February 5th, 2009 by Dr. Val Jones in Health Policy, Opinion
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Merrill Goozner has been speculating about who will be nominated as the new Secretary of HHS. He reviewed his most likely candidates (David Cutler or David Blumenthal), and threw in a “dark horse” potential nominee: Ken Thorpe (whom I’ve interviewed several times on this blog and spent time with during Obama’s inauguration ceremony).
Tommy Thompson told me that the nominee is likely to be a current or former democratic governor (such as Kathleen Sebelius or Howard Dean).
But I’ve been pondering the “long shot” question and think that Goozner may have missed a more obvious choice – someone who works with Ken Thorpe at the Partnership to Fight Chronic Disease: former Surgeon General Dr. Richard Carmona.
Here are the 10 reasons why Richard Carmona would be a smart choice for Secretary of HHS (in random order):
1. He was confirmed by the senate as Surgeon General in 2002 and lived under their scrutiny during his term of service, meaning he has no hidden secrets, tax or nanny problems likely to embarrass Obama and could be confirmed rapidly – perhaps in under a week.
2. He has forged extensive good relationships with both parties over the course of his tenure as Surgeon General and is known internationally.
3. He has been the CEO of a large, public health system (including hospitals, Medicare and Medicaid clinics, nursing homes, and emergency medical systems in Arizona).
4. He has been a paramedic, nurse, and physician and understands the healthcare system from the inside out.
5. He has a track record of leadership in prevention, preparedness, health disparities, health literacy, global health and health diplomacy. He has worked on both sides of the aisle, including assisting Senator Kennedy with issues of disability and socio-economic determinants of health.
6. He is Hispanic, which adds additional diversity to the Obama leadership team.
7. He has experience managing local, state and federal health programs, including significant experience in immigration and border health issues.
8. He demonstrated competency and leadership as manager of the US Public Health Service of over 6000 uniformed public health officers both nationally and internationally.
9. He has extensive military experience, and is a combat-decorated Vietnam veteran. He maintains a strong relationship with military surgeons general and the department of defense.
10. The fact that he is a political independent might actually provide a middle ground for parties with differing agendas in health reform.
Is point number 10 a deal breaker? It may be, but Obama could look farther and do much worse. And while the clock is ticking and credibility is paramount (as Maggie Mahar wrote, “Reform needs to be overseen by someone who is perceived as being above suspicion—purer than Caesar’s wife”) I think the Obama/Biden team needs to take a closer look at Dr. Carmona. He’s actually the most experienced, low risk candidate under discussion – and could truly hit the ground running at HHS. And wouldn’t it be nice to have a physician who is also a health policy expert with advanced managerial experience at the head of the healthcare reform table?
February 4th, 2009 by Dr. Val Jones in Audio, Expert Interviews, Health Policy
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Many Americans have been surprised and disappointed by Senator Tom Daschle’s withdrawal as HSS Secretary nominee. I asked Tommy Thompson, former Governor of Wisconsin and the 7th U.S. Secretary of Health and Human Services, what he made of this. You may listen to our full conversation by clicking on the podcast arrow, or read a shortened summary below. Enjoy.
[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2009/02/tommythompsondaschle.mp3]
Dr. Val: Tom Daschle’s withdrawal as HHS Secretary nominee has been a real shock for most people. Some are saying that without Daschle’s influence, healthcare reform will take a back seat to other economic priorities this year. What do you think?
Thompson: I don’t think that will happen because we’re in such dire need of reform that even without Tom Daschle there’s going to be a tremendous transformation of the healthcare system this year. Two healthcare bills are already undergoing the legislative process, and one is ready to be signed into law – the expansion of SCHIP, the insurance plan to cover poor children. The second bill involves the expansion of COBRA, which allows unemployed individuals to buy in to their previous employer’s health insurance plan.
But beyond this, the new stimulus package has 20 billion dollars set aside for health IT infrastructure – to create an electronic medical record for all Americans and beef up broadband access. There will also be a lot of money set aside for preventive health initiatives – to help Americans become healthier so they won’t need as many medical services.
Of course, Senator Kennedy is pushing for a “play or pay” plan modeled after Massachusetts’ law. There will be a lot of pressure to get this done quickly due to his ailing health. So you can bet your bottom dollar that the healthcare system that we know today is going to be changed so considerably that I doubt if you’ll recognize it a year from now.
Dr. Val: Do you have any idea who might replace Tom Daschle as HHS Secretary nominee?
Thompson: I’ve been hearing a lot of names. Governor Kathleen Sebelius from Kansas is very much in the running. Howard Dean’s name has also come up. Overall I do think it will be a governor or former governor who gets the position.
Dr. Val: What sort of person would have the skills for the job?
Thompson: I think a governor is the ideal person for the job because they already have experience running both state and federal programs – both initiating and managing them.
Dr. Val: Do you think that being a physician could be an advantage as well?
Thompson: There are so many physicians in the department that I don’t believe that being a physician adds or detracts from the position. Being the Secretary of HHS is an administrative position and although doctors have many skills, I’m not sure that running a large agency of over 67,000 employees with a budget of over 600 billion dollars is something that most doctors have the experience to do well.
Dr. Val: Do you think Daschle made the right choice to withdraw?
Thompson: Tom Daschle is a friend of mine. I think he’s an honorable person and I think he would have made an outstanding Secretary of HHS. I’m sorry he’s withdrawn, but the debate about his taxes was splashy enough to be affecting the stimulus bill and diverting attention from it. So I think overall it was probably the right thing to do.
Dr. Val: What’s the most important thing for the American people to know about the Daschle case?
Thompson: They should know that there is no double standard between people in power and those not in power. All of us are equal in the eyes of the law, and we’re a country of laws, not of men. We’re all responsible for our own personal decisions, and that includes paying our taxes.
***
See KevinMD’s excellent round up of further thoughts about Tom Daschle.
February 4th, 2009 by Dr. Val Jones in Humor, True Stories
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My friend and fellow blogger David Kroll just wrote an interesting post about the use of “doctor” as a title for a wide range of expertise, including medical. The discussion reminded me of the usual misunderstandings associated with my title…
Typical Val conversation with lay strangers:
Dr. Val: “Hello, I’m Dr. Jones…”
Person: “Oh, hi Dr. Jones. What kind of doctor are you?”
Dr. Val: “A medical doctor.”
Person: “Oh, so you’re like, a pediatrician?”
Dr. Val: “No, my specialty is rehabilitation medicine.”
Person: “Oh, my uncle has a drug problem. He’s been in and out of rehab for years. I’m so glad that there are people like you willing to help addicts.”
Dr. Val: “Uh… Well, actually my specialty is focused on physical rehabilitation – like patients with spinal cord injuries, amputations, strokes, car accidents, etc…”
Person: “Oh, so you’re a physical therapist?”
Dr. Val: “No, I’m a physician. But I work closely with physical therapists.”
Person: “So you’re a REAL doctor?”
Dr. Val: “Yes, I went to Columbia Medical School…”
Person: “Well, you don’t LOOK like a doctor.” [See example here]
Dr. Val: “Uh… thanks?”
***
Dr. Val: “Mom, why don’t people believe I’m a medical doctor?”
Dr. Val’s Mother: “Well, you picked an oddball specialty, dear.”
Dr. Val: “What’s oddball about helping the disabled population?”
Dr. Val’s Mother: “Well, you know ‘rehabilitation’ usually conjures up ideas of drug rehab.”
Dr. Val: “Yeah, my specialty has the weakest PR in all of medicine. Nobody knows what we do.”
Dr. Val’s Mother: “At least people don’t think you’re a hypnotist.”
Dr. Val: “What?”
Dr. Val’s Mother: “Did I ever tell you about the time I was on an elevator with someone at a Spanish literature convention?”
Dr. Val: “Uh…”
Dr. Val’s Mother: “My tag said ‘Dr. Sonia Jones, member of the American Association of Hispanists.’ A woman in the elevator with me was staring at my name tag and finally blurted: ‘Are you here with the convention?’ And I said, ‘yes.’ And then she responded: ‘Could you hypnotize me too?!'”
February 4th, 2009 by Dr. Val Jones in Primary Care Wednesdays
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Dr. Val’s note: My friend and co-blogger Alan Dappen is going to prepare a series of posts to expose the convoluted billing and procedural tactics that primary care physicians adopt to survive the ever decreasing reimbursements that would otherwise put them out of business. Below is his introductory post – others will follow each Wednesday morning here at Better Health. Enjoy!
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The Doctor’s Huddle
By Alan Dappen, M.D.
On the great gridiron of healthcare, the team of primary care providers is leaning inward, supportively embracing one another. They have huddled together for 15 years, calling plays against their opponent, the Insurance Team. The two-minute warning has sounded and the Physician Team is losing. The Physician’s play book pieces together strategies culled from cocktail party conversations, doctor conventions, office staff meetings, back hallways of hospitals, online blogs, and a plethora of practice management magazines; routinely circulated offering grand strategies to teaching doctors how to tackle the Insurance Team. The rising mantra is “Hit them again! Harder! HARDER!”
This game began in the 1980s, when concerns that rapidly inflating healthcare costs would consume all the U.S. gross national product within the foreseeable future unless something was done. Insurance companies lobbied regulators and advertised to the public not to socialize healthcare. Most people sighed relief when laws were passed granting insurance companies broad powers to regulate the price of care. Little did these politicians realize that they inadvertently were “socializing” care by handing the keys to the health care gold mine to Team Insurance’s privatized, for-profit model.
Up until this point, the healthcare system had experienced 40 years of run-away costs. Patients with insurance hadn’t worried about the costs of care. Inside of this cash rich environment, many important innovations occurred but employers, who subsidized most of the cost, questioned the sustainability of paying for it. All the while, physicians, hospitals, pharmaceutical companies, and medical suppliers eagerly reassured the patients: “Since you aren’t worried about the price, then no one else should worry about it either. We’ll pass the bill to the insurance company–they pay what we ask.”
This modus operandi came to a screeching halt in the late ‘80s, when the aforementioned game began, and Team Insurance was allowed to fix prices via preferred provider contracts. Insurance providers understood that the key to these contracts was not to change the rules for patients, who needed to perceive their care as virtually free so that they would continue to seek care.
Instead, Team Insurance spelled out new game rules in contracts for physicians, where the physicians “negotiated” to accept roughly 50% of their customary rate in order to be listed in the insurance company’s Preferred Provider Directories. These rules were never acceptable to physicians. Docs refusing to sign contracts rudely were awakened by the new world order when 95% of their trusted clients refused to return until they could say, “Yes we are preferred providers.” And, “Yes, all you have to pay us is your co-pay.”
Patient expectations remained unchanged. Quality of service, patience, time to explain oneself, attention to wellness, review of multiple issues, meaningful personal relationships, prescriptions, detailed explanations of risks and benefits of treatments, reviews of other possible ideas in a differential diagnosis, labs, call backs with results, and introductions to specialists were never connected to a price for patients before. After all, haven’t physicians had spent 40 years reassuring patients, “Don’t worry your silly little head about the price.” This time the boomerang came right back at physicians who suddenly were demanded to deliver all the same service for half the price.
The power of “owning” the patient for a $20 co-pay is not lost upon the insurance team. Every year, as they hand out new contracts, these insurance companies congratulate their preferred doctor players for their work, quality, and dedication and try to not rub in the following truth, “We own the doctor and we own the patient. Any doctor who dares not sign our next annual contract for less money will find themselves without patients. Remember, for the patient the big thing that counts is that you can say yes to the $20.00 co pay. Now sign on the dotted line.”
Every “negotiated” dollar saved from paying Team Physician means smiles all around for Team Insurance and their fans (shareholders.) Price fixing initially did control costs, but only for about five years. The U.S. now is back on the trajectory of health care pricing doubling every 7-10 years.
So what’s going on in those primary care huddles? The game plays are called out: “More work, less money, patient demands, protection from malpractice, keep smiling … Somehow we’re going to make somebody cough up our money …Hit them again harder! Let’s do it! On one, break.”
Up next, I’ll show you some of the plays physicians have put into place to survive. And why you the patient might feel like the football. Play along, with us. Hup one, Hup two, hike!
Until next time, I remain yours in primary care,
Alan Dappen, M.D.
February 2nd, 2009 by Stacy Stryer, M.D. in Opinion
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By Stacy Beller Stryer, M.D.
After my blog last week discussing the recent increase in Haemophilus influenzae B (Hib) cases in Minnesota, I received a comment from “Indian Cowboy,” who is a blogger and fourth year medical student. While Indian Cowboy admits that he isn’t completely against vaccines, he does question their safety and says that, “if my (future) patients were to ask me specifically, scientifically, what the risks of vaccines are, I would be forced to shrug my shoulders and say I actually have no idea.” He suggests that pediatricians, in general, are not open and honest with their patients about any side-effects associated with vaccines. Furthermore, Indian Cowboy comments that he is a member of the “current generation of medical students,” where evidence-based medicine is important. Does this mean that we old-timers (yes, I am an ancient 45 years old), don’t practice medicine based on results of quality studies and proof of what actually works?
That is far from the truth. My colleagues and I practice medicine based on what has been proven to work and not just what we learned on a whim. We continue to read reputable journal articles and other medical literature, often discussing treatment changes based on new research. And I do not know any pediatrician who makes a blanket statement that vaccines are 100% safe. Personally, I spend a fair bit of time talking to parents who question vaccine safety. I tell them that anybody can have a reaction to a vaccine, just like anybody can react to an antibiotic, food, or something in the environment. I also discuss more common side effects of vaccines, such as fever, redness, and irritation at the injection site. In addition, I mention that there are very rare, more serious side effects associated with some vaccines, such as seizures and encephalitis. I am certainly not the only honest pediatrician in the United States. In fact, reputable organizations such as the Centers for Disease Control (CDC), which are major advocates for vaccines, clearly state on their website that no vaccine is 100% safe or effective.
Just as importantly, and an absolute necessity is discussing that the risk of becoming seriously ill or dying secondary to a vaccine is much lower than the risk of developing a serious illness or dying if a child becomes ill with one of the infections for which they could have been vaccinated. Parents must be aware of the benefits of receiving these vaccines. And they should know that vaccines are one of the greatest medical discoveries of the 20th century and have increased life expectancy and quality of life significantly.
Back to Indian Cowboy – he also comments that we really don’t know much about vaccine safety because studies only last days or, at most, a couple of weeks. This is also far from the truth. Before a vaccine is licensed, the Federal Drug Administration (FDA) requires testing. Once the vaccine is being used, the CDC and FDA look for any problems and investigate them through the Vaccine Adverse Event Reporting System. It’s true that this system depends on pediatricians and parents to report side effects. This was recognized as a problem, so in 1986 a National Childhood Vaccine Injury Act was developed which, among other things, required experts to intensively review any possible adverse effects of vaccines. In 1990 the Vaccine Safety Datalink project was developed, where researchers gained access to the medical records of over 5.5 million people to evaluate for common and rare side effects associated with vaccines. All of these different safety methods have led to changes in vaccines to make them safer. In 2000, children began to receive the inactive polio instead of the live polio vaccine due to the rare risk of developing polio from the oral vaccine. More recently, the pertussis vaccine was changed from a whole cell to an acellular one because of the increased risk of rare neurological side effects.
I could continue, but the bottom line is that immunizations have been tested extensively for safety and continue to be monitored by reputable, quality organizations. There is an abundance of information available on safety for every vaccine. It is true that we cannot assure parents that their child will not develop a severe allergic reaction or a rare side effect to a vaccine. And we cannot say that we are 100% sure that vaccines do not affect the brain or the immune system, such as we cannot assure them that they will not get into an accident when they step into a car or that they will not be hit by a car when they cross a street. But we can reassure them that the chances of such an event are rare and that the benefit of receiving the vaccine far outweighs the risk of not receiving it.
I certainly hope that the one case of epiglottitis and pertussis that Indian Cowboy saw last year makes him realize not only how serious these infections can be in infants and children, but also that he only saw one case of each whereas, without immunizations, he would have seen many more and, most likely, a few deaths.
