December 17th, 2008 by Dr. Val Jones in Primary Care Wednesdays
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By Alan Dappen, MD
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Alan Dappen, MD
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Believe it or not, this headline paraphrases the recent lead article from the American Medical News, covering a comprehensive, white paper published by the American College of Physicians (ACP). The article reviews the state of primary care physicians. The conclusion: since primary care doctors are essential to control the spiraling costs of health care, a bailout is necessary to shore up their rapidly shrinking ranks.
To understand why they argue a bailout is needed, we must look at what caused the crisis. Primary care doctors are drowning in red tape, as my partner Steve Simmons mentioned last week. Over the past 20 years have come bureaucracies and regulations with acronyms like OSHA, CLIA, HIPPA, CPT, ICD-9, P4P. Drops led to trickles: more complex certification and increasing malpractice risk. Then trickles formed streams of data that is required of practitioners: quality reporting, management reports, productivity measures, electronic medical record systems, billing reports. Finally, the flood of information needed to stay in compliance with Medicare, Medicaid and insurance regulations swamps primary care providers.
The creative and intellectual focus of primary care physicians has been diverted to understanding this new world order of business contracts, negotiated rates, billing details, payment denials, coding, and non-compensated services. This is no game. It means the difference between medical practices staying afloat or going under. There are now thousands of reasons a doctor can lose money by getting fined, sued, or refused reimbursement.
Family doctors and internists have grown weary. They feel underappreciated by their patients, undervalued by the specialists, underpaid by the insurance company, overworked to meet expenses, and overexposed to malpractice risk. U.S. medical graduates entering family medicine residencies dropped by 50% over 10 years and are now filled mostly by non-US trained physicians. American medical graduates now rush to specialties where they make better money, gain higher status and/or achieve better control of their work schedules. To keep primary care doctors in adequate supply, so the argument goes, system subsidies and readjustments are needed.
Outsiders easily “get” what went wrong the auto and financial industries. These industry execs standing in line for handouts make most of us angry. They refused to do so many things to avoid their plight: innovate, stand up to wrongs, worry about sustainability, take responsibility, invest in a new future, even ”bending the truth” and turning a blind eye was fine as long as there were profits. They say that Americans didn’t want “the truth.” They want us to believe that they are victims of circumstances beyond their control. What should we think of primary care doctors who put themselves on the same playing fields as these execs asking for a bailout?
Internists and family doctors are the backbone of a vibrant healthcare system that is cost-effective [see later blog post to learn why]. But, for far too long we in primary care have piggybacked on the insurance systems, relying on them to pay the bills, even when the costs of administering that is more expensive than the care provided in most cases. This has slowly weakened our doctor-patient relationships and our advocacy for patients, thus compromising our power and professionalism. By casting its lot with third party payers, primary care essentially has announced that it wants someone else to fix the problem of affordable care.
I feel that the solution to primary care is simple. We should not be looking for a bailout. Instead, primary care doctors must step up to initiate change. Personally, I stopped waiting for someone else to rescue me or tell me how to do my job, promising they could make me happy. The restructuring I’m suggesting to revitalize primary care is that patients retain control of the funds they (and their employers) have been giving to the insurance companies for their day-to-day care (which now account for about 30% of total costs), and directly purchase the services they need from doctors who serve them best. Doctors in Oregon (www.greenfieldhealth.com), New York City (www.hellohealth.com) and Northern Virginia (www.doctokr.com) already have set up such practices. These doctors have developed innovative business models that deliver better care to patients at much lower cost. But these will only spread on a large scale if patients understand the value of these new business models, and flock to support them.
More details about the changes needed can be found on our website or by listening to our story with “The Story” on National Public Radio, and in this blog in the coming weeks.
Until then, I remain yours in primary care,
Alan Dappen, MD
December 16th, 2008 by Dr. Val Jones in Opinion
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For some reason, people just love to misrepresent the issues underlying the Wyeth vs. Levine case. I have written extensively about this case here and here because I found it so amazing that the media has bungled the story so badly – and that no one is really calling them on it.
In case you don’t recall – Ms. Levine was the victim of medical malpractice. An anti-nausea drug (phenergan) was injected into (or very near) her artery by accident (the potential consequences of such an error are clearly indicated on the drug label). Tragically, the resulting chemical reaction with the oxygen in her artery caused such severe tissue irritation that her arm eventually had to be amputated. Ms. Levine settled out of court for $700,000 with the clinic where the injection occurred. Unfortunately the story doesn’t stop there.
Ms. Levine’s attorney counseled her to sue the drug manufacturer for inadequate label warnings (the potential hazard is in fact mentioned on the label six times – though it does not forbid IV administration of the drug, though it recommends a low dose and slow push). In a precedent-setting judgment, a jury in Vermont decided that the FDA-approved label was inadequate, and that it should have fully contraindicated administration via IV push. The jury awarded Ms. Levine $6.8 million and Wyeth contested the judgment, bringing the case to the US Supreme court in November, 2008. The case has not yet been decided, though it has been compared to deceptive labeling of “light cigarettes.”
How on earth is a drug that has been successfully administered (without harmful side effects and with good efficacy) over 200 million times in the U.S. equivalent to cigarettes (a known carcinogen with no therapeutic value)? It’s an exceedingly poor analogy.
To put it another way, if a nurse took an insulin syringe and injected it into a diabetic’s eyeball, causing blindness, should I say that the insulin manufacturer (because it did not forbid the injection into the eye) was engaging in deceptive labeling and should be at fault for the patient’s loss of vision? The PA who injected the phenergan into Ms. Levine’s artery, and our hypothetical nurse who injected insulin into an eyeball are the ones to blame.
But wait, it gets worse.
The attorney (David C. Frederick) who is arguing Ms. Levine’s case in front of the Supreme Court is being considered by our President elect for the position of Solicitor General of the United States. Yes, this very man who is engaged in a law suit that could potentially set a precedent that would allow all 50 states to set up their own mini-FDAs with the lay public (i.e. juries) deciding what drug label language should say.
The pro-Levine camp argues that a court ruling in favor of Wyeth would preempt consumers from being able to sue drug companies for damages related to incomplete disclosure of risks (such as the Vioxx case) but in reality, the Wyeth vs. Levine case has no bearing on pharmaceutical non-disclosure, since Wyeth did not hide the irritant risks of phenergan from the FDA. They have been known for decades.
So Wyeth vs. Levine is NOT about deceptive labeling or non-disclosure of risks – it’s about whether medically uneducated juries should have the power to set arbitrary drug labeling language standards in order to facilitate litigation against deep-pocketed pharmaceutical manufacturers whenever a patient is harmed in a case of medical malpractice.
I understand that many folks are frustrated with pharmaceutical wrong doing (and there are many cases of it), but this is just not one of them. In America, we are not supposed to bring pre-conceived notions to bear on law suits, but objectively review the facts in each case, separate from our general feelings about those involved. I do think that Wyeth isn’t getting a fair shake in the media because of the general mistrust/dislike of Big Pharma. But everyone has a right to a fair trial. I sure hope they get it.
December 16th, 2008 by Dr. Val Jones in Audio, Expert Interviews
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Dr. Joseph Heyman
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Alright I admit it, that was a rather provocative title. The truth is that at the end of a recent interview with Dr. Joseph Heyman, the chair of the board of trustees of the AMA, I was in fact chided for having left full time clinical practice. Dr. Heyman was rather avuncular in his tone when he stated,
You are robbing patients of the opportunity to have a good clinician like you involved in their care. I guess it reflects badly on our profession that the best and brightest are making alternative career choices – practicing clinical medicine is becoming unbearable.
No amount of protest on my part (about my volunteer work at Walter Reed) would convince Dr. Heyman that I hadn’t abandoned my profession to some degree. And it touched a chord with me too – because taking care of patients is very gratifying for me in many ways. It was with a heavy heart that I chose to become a medical journalist instead.
And so back to the interview with Dr. Heyman. We had an interesting discussion about the concept of medical tourism:
You may listen to our conversation here, or read my summary below.
[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2008/12/heyman.mp3]
Dr. Val: Is medical tourism about people coming to the U.S. for care, or about patients leaving the U.S. to get more affordable care elsewhere?
Dr. Heyman: Historically, medical tourism has been about patients coming to the United States to get high quality care. Nowadays, people are realizing that there are wonderful places overseas where they can seek treatment. If they don’t have a very exotic illness, or require a highly specialized procedure, they can get appropriate care overseas. Hip replacements are a good example of a standard procedure that can be performed without too much difficulty. It wouldn’t be as much of a draw for patients who need hip replacements to come to the U.S. Read more »
December 15th, 2008 by Dr. Val Jones in Expert Interviews
1 Comment »
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Skip Brickley
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Skip Brickley is the master mind behind the popular Consumer Health World conference series. He is a natural communicator, and a bundle of positive energy. I was pleased to have the chance to interview him last week about his provocative views on healthcare reform. Enjoy the conversation:
Dr. Val: Tell me about the importance of “community” in healthcare reform.
Brickley: I’ve been thinking about the healthcare problem in this country for many years. First of all, I believe that the wellness of a community is related to the economic health of that community. Therefore, improving healthcare is about improving the economic health of this country at the community level. Successful communities like Silicon Valley, Raleigh-Durham, and Cambridge, Massachusetts have similar underlying reasons for their success: they figured out what they’re good at, learned out how to monetize it, and then found the necessary support for a global reach. They involved all the key stakeholders (at the community level) in their singular purpose: educational institutions, government, consumers, businesses, and non-profit partners.
Although I don’t agree with Hillary Clinton on her approach to healthcare reform, I think she’s right about starting at the community level. Our education system must teach people to value their health as their #1 asset, to provide them with the tools and training necessary to manage their personal finance, and to create ongoing programs to keep the community focus in the forefront. People need to feel that their health choices don’t just affect them, but it impact their entire community.
For example, when we realized that second-hand smoke could be deadly to others, we were able to enact legislation to ban smoking from common areas, and dramatically reduce the population’s overall exposure to cigarette smoke. We need to make that leap in healthcare too – for example, eating two Big Macs at a time is like second-hand smoking for those around you. Because that kind of lifestyle choice is going to cost your community a lot in the future when they have to pay for the inevitable health consequences of such behavior.
When the individual consumer has no contract in the health relationship, any health initiative is doomed to fail. Community leaders must rise up to help us change the culture of health in America. We must align healthcare with community economics – providing incentives for behavior change, and effective education to make people aware that bad choices affect us all. Cowtowing to the whims of consumers is what caused our current financial crisis – we need leaders who will do what’s best for communities, rather than follow faddish trends.
Dr. Val: What is “Health 3.0?”
Brickley: Health 3.0 is where the consumer and the provider engage online together. If providers don’t connect with consumers online, there will be no trust developed and the two groups will continue to exist in parallel universes.
Dr. Val: What inspired you to create the Consumer Health World conference?
Brickley: I wanted the conference to be a catalyst for change. I’m a conversation facilitator – and the event brings together key healthcare stakeholders so they can plan a multi-faceted, community-based approach to healthcare reform. If we can inspire communities to organize themselves around personal responsibility, teamwork between providers and patients online, and legislated incentives for behavior modification – all the while using the “Silicon Valley model” to encourage entrepreneurial, local economic development – we can reform healthcare and improve the health of this country, one community at a time. Consumer Health World stimulates discussion amongst the people who have the power to make these changes a reality. I can’t wait to witness the fruit of these discussions.
December 15th, 2008 by Dr. Val Jones in Opinion
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The “Health 2.0” movement is about “consumer directed healthcare” and proposes to empower patients with online tools and technologies to help them manage their care and take control of their health. Some Health 2.0 initiatives have been quite popular – though many suffer from lack of participation on the part of consumers. Having your own personal health record sounds great – but when you’re the one who has to manually enter the majority of the data into it, only the most motivated patients will participate. Access to online physician ratings is appealing – but when everyone wants to read the ratings, but no one takes the time to complete the ratings questionnaire, the value of the tool is lost.
Over the past few years there have been a number of regularly repeating conferences created to unify key stakeholders around healthcare’s digital agenda – Health 2.0, Health Care Consumerism, The Healthcare Globalization Summit, Health 3.0, New Media Expo, Blog World Expo, Health 4.0, the AMA’s Medical Communications Conference, and more. Thankfully, these disparate groups with overlapping agendas are beginning to consolidate – offering new mega conferences that simplify the learning and relationship-building process.
My observation as an attendee of several of these conferences is that providers and patients are still not coming together as they should. Online healthcare solutions tend to be created in a lopsided manner – either by consumer/patient groups without much provider input, or by providers/health plans/governmental agencies without much patient/consumer input. The result tends to produce two types of products 1) active online groups and tools that facilitate both helpful information and misinformation or 2) products that advance good concepts, but have low participation due to lack of user-friendliness.
The current conference version “arms race” (to attract the most powerful vendors and largest audience possible) is not terribly helpful. Whether you associate with Health 2.0, 3.0 or 4.0 – the bottom line is that the Internet is a powerful force in healthcare. It can provide many different kinds of tools that make valuable contributions to health education, care management, behavior modification, emotional support, and improved quality outcomes. In the wrong hands it can also mislead patients, promote snake oil, sensationalize health news, confound research efforts, misinform, and mislead.
There is no more critical time than this for providers and patients to join forces to guide the development of new online health initiatives. The successful execution of digital health platforms requires a patient-provider partnership – I can only hope that upcoming conferences will embrace this view more fully.
In my next few blog posts, I’ll provide you with some fascinating interviews with key opinion leaders from the recent Consumer Health World mega-conference in Arlington, Virginia. The interviews are as follows, so stay tuned:
1. Skip Brickley, founder of Consumer Health World
2. Joseph Heyman, M.D., Chair, Board of Trustees, the American Medical Association
3. Emme Levin Deland, Senior Vice president, Strategy, New York Presbyterian Hospital
4. Joseph Kvedar, M.D., Director, Center For Connected Health, Partners Healthcare
