Forces calling for Healthcare Reform Now are gaining momentum. I share their sense of urgency—assuming that they are talking about the “reforms” needed to create an effective, affordable, patient-centered health care system.  But if they simply mean “universal coverage,” I have to disagree.

Giving every American a piece of paper labeled “health insurance” will bail out a health insurance industry desperate for customers. And it will help drug-makers, device-makers, and medical-equipment makers.  But it will not solve patients’ problems.  What Americans need is not health insurance, but rather effective health care.

A stunner of a story in yesterday’s Washington Post makes it clear that today we are pouring money into a health care system that does more for the health care industry than it does for patients.

“We're not getting what we pay for," Denis Cortese, president and chief executive of the Mayo Clinic, told the Post’s Ceci Connolly. "It's just that simple."

"Our health-care system is fraught with waste," added Gary Kaplan, chairman of Seattle's cutting-edge Virginia Mason Medical Center. According to Kaplan: “As much as half of the $2.3 trillion spent today does nothing to improve health.” 

“Not only is American health care inefficient and wasteful,” declared Kaiser Permanente chief executive George Halvorson, “much of it is dangerous.” 

This is a startling indictment, and one that health care reformers should heed.

“There is a broad consensus on what should be done,” writes Connolly, a health care journalist who knows her subject well. The system needs structural reforms which include  “realigning financial incentives, coordinating care, researching what treatments work best…and most daunting but perhaps most important, saying no to expensive, unproven therapies.”

Therapies that have not been fully tested harm tens of thousands of Americans each year. Consider this: 10 percent of all drugs approved by the FDA from 1975 to 1999 were later withdrawn from the market or “black-labeled” to warn of risks.

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Assume that you are a 40-year-old man. What do you think the chances are that you will die of a heart attack or stroke in the next 10 years? (Please forgive the morbidity of the question; there is a purpose to this pop-quiz.)  The answer: just 4 out of 10,000 according to Drs. Steve Woloshin and Lisa Schwartz, authors of Know Your Chances. The odds that you will die in an accident before reaching your 50th birthday are 50 percent higher: 6 out of 10,000. 

Nevertheless, many men remain convinced that they are at great risk of dying from vascular disease, particularly as they get older. In truth, even at age 60, the odds that a heart attack or stroke will end your life over the next decade are only 37 out of 10,000.  Over that span, you are three times as likely to die of another cause—with the chance of a fatal accident (5 out of 10,000 ) just as high as the chance of a stroke.

Moreover, for reasons we do not fully understand, the incidence of heart attacks is declining. “Fifty hears ago, heart attacks were a scourge. Everyone knew a working-age man who’d dropped dead from one,” writes Dr. Nortin Hadler in his new book, Worried Sick. Today “the decline in mortality from coronary artery disease is well documented.”

There is one exception:  If you are a 60-year-old smoker, the chance of a fatal heart attack or stroke in the next ten years climbs to 67 out of 10,000, and your chance of dying of lung disease rises to 59 out of 10,000.

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Much of the newest issue of Health Affairs is dedicated to putting hard numbers to the rapid proliferation and over-use of diagnostic imaging technology like computed topography (CT) and magnetic resonance imaging (MRI) scans. This research warrants special attention:  quantifying the “imaging boom” provides an important contribution to understanding  America’s health care woes.

The Scope of Growth

The lead article from Health Affairs comes from Laurence Baker and Scott Atlas at Stanford and Christopher Afendulis at Harvard. The research team notes the explosion of imaging machines in recent years, estimating that “the number of CT units [in the United States] grew more than 50 percent between 1995 and 2004” and that “the estimated number of MRI units more than doubled.” As this technology has become more widely available, it’s been used more often: the number of MRI procedures per 1,000 Medicare beneficiaries increased from 0.3 in 1985 to 173 in 2004. Use of CT scans more than doubled from 235 per 1,000 in 1995 to 547 per 1,000 in 2005. Baker et al. crunch the numbers to find that, over the years, each new MRI unit on the market led to 733 additional MRI procedures, adding $550,000 to Medicare spending annually. Each new CT unit on the market prompted 2,224 additional CT scans and tacked on $685,000 to the yearly Medicare bill.

These are striking numbers, and the shock persists when you put diagnostic imaging in the context of other medical services. In another Health Affairs study, Ariel Winter and Nancy Ray from the Medicare Payment Advisory Commission (MedPAC) note that between 2000 and 2005, the volume of services per Medicare beneficiary grew by 31 percent (in other words, the average Medicare patient in 2005 received 31 percent more care than she did in 2000). In contrast, the volume of diagnostic imaging (including MRI and CT scans, x-rays, and ultrasound) grew by 61 percent—twice as fast as broader physician services. More services means more payments, and this increase has been coupled with a doubling of Medicare spending on imaging services, from $6.4 billion in 2000 to $12.3 billion in 2006.

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Below, a story and a poem from Pulse, a very special online magazine that uses stories and poems from patients and health care professionals to talk honestly about giving and receiving care.

Pulse was launched by the Department of Family and Social Medicine at Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York, with help from colleagues and friends around the state and around the country. The magazine’s contributors are doctors, nurses, psychologists, social workers, patients, students, editors and writers.

I count its editor-in-chief, Dr. Paul Gross, as a friend. Here Paul describes how Pulse was born:

“While leafing through a medical journal some years ago, it struck me that the scientific studies that filled its pages bore only a slight resemblance to my experience of the practice of medicine. For one thing, the patients in the studies seemed to enjoy swallowing pills. They remembered to take them and didn’t seem to mind their accompanying side effects…

“For another, the studies assumed that the pills were readily available—and affordable…

“These journals had glossy images of smiling patients who were now leading active lives thanks to antidepressants or anti-inflammatory agents. My experience with these same pills was a little different: many didn’t work nearly as well as advertised…

“The health center where I worked at the time wasn’t making things easier for patients, who complained about doctors (myself included) who made them wait and telephones that rang and rang unanswered.

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In my previous post, I discussed how the realities of primary care—the “hamster wheel” of 15-minute visits with sometimes-difficult patients suffering from complex, chronic conditions—can burn out idealistic primary care physicians (PCPs). Increasingly, disillusioned PCPs are leaving the field. A recent survey from the Physicians’ Foundation reports that one-half of PCPs would leave medicine if they thought they could do so. 


Well-intentioned doctors choose primary care because they love the idea of working closely with patients and building lasting relationships over time. But the low reimbursement rates force them to see as many patients as possible in a given day, and the frantic pace of their work often de-humanizes their practice. They are pushed to practice “assembly line” medicine.  Understandably unhappy with this state of affairs, many think to themselves, “this is not why I wanted to become a doctor.”

Ideally, as Thomas Lee, an associate editor of the New England Journal of Medicine, recently put it, PCPs should go home every night thinking “this is what I was meant to do.” This seems like a high bar to reach, but we’d be a lot closer to it if our system recognized one simple fact: no physician is an island.

The Importance of Teamwork

Primary care can’t be a one-man (or a one-woman) show. There’s simply too much to do. In a recent commentary for the New England Journal of Medicine¸ Dr. Thomas Bodenheimer of the University of California-San Francisco notes that “it would  take a primary care physician 18 hours per day to provide all recommended preventive and chronic care services to a typical” cohort of patients.

Making the time-crunch even worse is the fact that PCPs often take on duties that have little to do with the actual practice of medicine. In a recent comment over at Theresa Chan’s Rural Doctoring blog, a PCP named “Doctor Jen” describes the diversity of responsibilities that she faces over the course of a day. “Today,” she begins, “I saw a young woman who brought a list with 17 issues to be addressed…I also saw a newly diagnosed cirrhotic gentleman who is really struggling emotionally with his diagnosis, an 88 yr old lovely woman who needed medical clearance to take a driver's test, and a poorly controlled bipolar client who can't get a psych appt for 3 [months] because he's not suicidal.”


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“Fat prejudice is the primary impediment to understanding—or wanting to understand what obesity is all about,” says a public health nurse who appears in “Fat: What No One Is Telling You,” a 2007 PBS home video documentary.

In the first installment of this post, I explained how little physicians know about what causes obesity—in part because, as this nurse points out, “blaming the victim has stood in the way of understanding.” Here, I am reminded of how, in the past, we blamed patients suffering from depression and other forms of mental illness. For centuries, this prejudice stood in the way of understanding that mood disorders are caused by a flaw in chemistry, not character

In “Fat,” patients describe how even some doctors treat them with contempt. “When I went to get a Pap smear, the doctor said, ‘You’re too fat; come back when you’ve lost weight,’” one woman recalls. 
The documentary also points out that “while everyone dies . . . it should perhaps come as no surprise that in our society, obese people are blamed for dying. If a thin patient comes into the hospital, has a heart attack, and dies, cause of death is labeled ‘heart disease’, a public health nurse who appears in the film tells the filmmakers. “If an obese patient has a heart attack and dies, cause of death is ‘obesity’.”

Nevertheless, despite the bias, today scientists have begun to look past the old-fashioned notion that obesity is merely a matter of gluttony, and have made real progress in beginning to understand a terribly complicated chronic disease.

Granted, obesity doesn’t look like “a subtle disease,” acknowledges Harvard’s Dr. Lee Kaplan, who heads the Weight Reduction Program at Mass General Hospital. Conventional wisdom says that if you put too much food in your mouth, and don’t exercise enough, you’ll wind up fat. Period.

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In a recent post, Health Beat described the policy strategies that must be employed in order to address the primary care crisis in the United States.  Here, I’d like to focus to the human side of the primary care crunch by highlighting the personal experiences of doctors. Moving from the policy to the personal adds an all-important qualitative element to our understanding of just why American primary care is in such dire straits. 


The Basics

That said, numbers still help set the stage: in 1990, 9 percent of graduating medical students planned to work in primary care/internal medicine; today just 2 percent are choosing primary care. Meanwhile, we know that primary care can help patients avoid expensive, unnecessary medical procedures; obtain regular preventive care; and manage the chronic illnesses that make up between 75 and 80 percent of our $2.3 trillion national health care bill. We can’t afford to run out of PCPs.

The usual reasons cited for the dwindling ranks of PCPs are money and time. Many PCPs make only 1/5 as much as the best-paid specialists. Lower salaries mean that PCPs need to see more patients to have incomes that are comparable to those of their peers. This imperative creates a “hamster wheel” as PCPs frantically cycle through patients who often are suffering from complex, chronic diseases.

No Time to Learn

It’s generally agreed that primary care is unpopular because medical students see the money/time crunch and tell themselves, “no way is that going to be my life.” But the Over My Med Body! blog, which until recently had been maintained by a medical student named Graham, offers a slightly different perspective. According to Graham, students aren’t necessarily mapping out their whole lives when they select a field and apply for residencies—they just want the chance to develop their analytical acumen and grow as doctors. The hamster wheel doesn’t give them that opportunity. 

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The film opens with a fetching red-head puffing away on a treadmill. She’s perspiring, but she’s smiling gamely into the camera. “It’s not an average work-out, but I wasn’t an average weight,” she explains. “I have to do above and beyond what any of you guys would have to do. I have to try twice as hard, sometimes three times as hard—just to maintain this level of…chubbiness.”

And she is right. She is chubby. By 21st century mainstream (and magazine) standards of beauty this young woman is probably 30 pounds overweight. The dimples, the pony-tail, the strawberries and cream complexion, and the undeniable on-camera charisma make her very appealing. But there is no doubt that most physicians would urge her to lose weight. 

Later in the film, we learn that she exercises three hours a day.  And when her mother was dying of cancer, this thirty-something nursed her and learned a great deal about nutrition. Dedicated and determined, she eats healthy meals and sticks to a strict exercise regime.  Why, then, is she “chubby?”

Doctors don’t know.  That is one of the first things you learn in “Fat: What No One is Telling You,” a 2007 documentary that is, by turns, entertaining, moving, and eye- opening. (The PBS home video, directed by Andrew Fredericks, can be rented on www.netflix.com or purchased on www.amazon.com).

The questions are endless, a narrator tells the audience. “Is it her genes, her childhood, a flaw in her character, stress, sadness, a lost love, processed food, television, seductive advertising, lack of sleep, a government that subsidizes corn, sugar and beef?”

All of the above may well contribute. But taken together, they still don’t constitute an answer. Doctors cannot help the vast majority of obese people lose weight–and keep it off—because doctors don’t know what causes obesity.

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Niko Karvounis and Maggie Mahar

By now you know that Senator Max Baucus (D-MT) has offered a “Call to Arms” for health care reform by way of a 98 page policy document. There is much to think about in Baucus’ proposal, so you might have missed the section where he talks about increasing payments to primary care providers at the expense of compensation for specialists. But in the future, keep your eyes peeled for developments around this proposition—because supporting primary care is going to be a complex and controversial undertaking.

Baucus rightly recognizes that primary care is “undervalued” in our health care system. The Medicare reimbursement schedule—which is the model for private insurers rates—pays a lot more for removing a wart than it does, say, for talking to patients about their medications. Doing something to a patient (procedural care) is compensated much more than is doing something with a patient (cognitive care). The result is that generalists, including family practitioners, internists, primary care providers (PCPs), geriatricians and palliative care specialists make a lot less than proceduralists.

Today the average annual salary of a radiologist is $354,000, and at the high end they make $911,000.  Orthopedic surgeons pull in $459,000 to $1.352 million; cardiovascular surgeons average $558,719 to $852,000.  By contrast, internists report average salaries of $176,000; after years of experience, they can hope to make $245,000.  In the middle of her career, the typical pediatricians can expect to earn $175,000; later, she may move up to $271,000.  The average family practitioner may gross $204,000, at the high end he can look for $299,000. 

Following the recommendations of an April Medicare Payment Advisory Commission (MedPAC) report, Baucus wants to restructure the reimbursement system to place more value on primary care. Part of this plan is to offer bonus payments to PCPs by making a list of services that qualify as primary care services (“evaluation and management visits”) and boosting payments to doctors who deliver these services. These increased payments would be “budge-neutral”—meaning that hikes in PCP payments would be coupled with corresponding cuts in some specialists’ payments.

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Over at Colorado Insurance Insider, Louise hosts Health Wonk Review, highlighting some of the best healthcare post of the past two weeks.

Many focus on what the new administration will or won’t do about healthcare reform.  At the Covert Rationing Blog, Dr. Rich offers a particularly entertaining—and shrewd—assessment of the future of health insurance companies. 

Unlike many observers, Dr. Rich understands that the insurers are desperate to see universal coverage as soon as possible because they need new customers—Now. Insurers assume  that any reform plan will follow Obama’s model and include them, giving Americans a choice between public  sector insurance and private sector plans. With the government providing subsides for low-income Americans, this means that insurers could look forward to tapping that pool of 47 million Americans who are now uninsured.

Of course, if the reform plan regulates insurers (as it must), they won’t be able to “cherry-pick” their customers. Nevertheless, Dr. Rich speculates (and this is the part that is, I think, particularly shrewd) that insurers were looking forward to “one last, huge windfall, in the form of government-provided premiums for some significant chunk of millions of uninsured Americans. Then, a couple of years later and having realized their final gains, they would get out of the health insurance business altogether and let the feds have the whole mess.”

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