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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Some facts to chew on: The prescription drug industry is projected to reach $842 billion in global sales in 2010. Over the last ten years, 80 percent of the drugs that have entered the U.S. market are “me too” drugs that are no more effective than those we already use. Meanwhile, across the ocean, Sub-Saharan Africa accounts for 60 percent of the world’s 250-500 million malaria cases every year and 75 percent of the global population that goes blind from the infectious eye disease trachoma.  Both diseases can be treated through various drugs and antibiotics which pharmaceutical companies have the capacity to manufacture.

The billion-dollar question: how can we get drug companies to focus more of their formidable resources on producing drugs to combat these tropical diseases? The Food and Drug Administration (FDA) thinks it has the answer: a “priority voucher” program which grants drug companies accelerated approval for products targeted at wealthy countries as a reward for developing drugs that address tropical diseases. The program, established through a 2007 Congressional amendment to FDA legislation, essentially offers drug makers a deal: prove that you have, say, a new anti-malarial drug, and get your next blockbuster antidepressant fast-tracked for FDA approval. At first glance, this may seem like a sly bargaining chip to help the Third World; but in reality, the priority voucher program leaves much to be desired.

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While some argue that we must have health care reform “Now,” others (including HealthBeat) have argued that “doing it right” will take time.

In the white paper released today Senate Finance Committee chairman  Max Baucus seems to take both sides of the argument. On the one hand: “Congressional leaders and the public must be realistic about the timeframe in which the fiscal success of reform is measured. “

On the other hand:  “If we fail to act  we will double our current national expenditure on health care from $2 trillion to $4 trillion, continue to witness the plight of tens of millions of our citizens without health insurance cost shifting to those who do, continue to tolerate poor quality . . .  We must choose to invest now."

Is this simply political double-talk of the “Look Before You Leap”/“He Who Hesitates Is Lost” variety?

Not at all. Baucus’ multi-part plan would unroll over time “hopefully . . . in about three years.” (You can hear him offer this time-frame in his press conference on C-Span).  Over this period, he would create a Health Insurance Exchange that would insure that “affordable, high quality and meaningful health insurance options are available to all Americans.” The insurance offered through the exchange “would need to meet certain requirements established by a new Independent Health Coverage Council,” Baucus explains.

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Today, Senate Finance Chairman Max Baucus issued a “Call to Action” for Health Care Reform. And it is shockingly honest.

The bombshell in the plan is that it would require every American to purchase health insurance. There would be sliding subsidies for everyone under four times the Federal poverty level ($70,400 for a family of 3), but there would be no exemptions.

The individual mandate is necessary because Baucus is barring insurers from charging higher premiums or denying coverage outright to people with pre-existing conditions. (Today, in the vast majority of states, insurers can shun the sick–or charge them whatever it chooses).

As HealthBeat has explained here, if you insist that insurers must cover everyone, old or young, sick or healthy, at the same price, you must have the individual mandate. Otherwise, many young, healthy people would wait until they became sick to join a pool—safe in the knowledge that an insurer could not charge them more—and expect people who had been paying premiums into that program for years to now pick up their medical bills. If that happened, ultimately only the sick and the elderly would buy insurance—and prices would levitate to a point that virtually no one could afford it. 

What Baucus doesn’t mention is that community ratings are likely to hike premiums in many states because suddenly, the very sick will be included in the insurance pool. As Time magazine reported in 1994: In 1993, [when] New York State tried community ratings, “thirty- year-old males watched their premiums soar 170%, according to the Council for Affordable Health Insurance, while men aged 60 enjoyed a 45% cut. The rate hike for 30-year-old women was 82%, and women twice their age saw rates slashed by a quarter.”

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Here we go again.   If you haven’t yet heard the news from the American Heart Association meeting that was held in New Orleans yesterday, here is Bloomberg’s report on a medical breakthrough that, some say, will “change the way we practice medicine.”

Bloomberg, Nov. 9: “AstraZeneca Plc’s Crestor [a cholesterol-lowering medication] slashed the risk of heart attack, stroke and death by nearly half in people with normal or low cholesterol in a study, potentially opening a way to save the lives of thousands of seemingly healthy people.”

I like that last phrase: “seemingly healthy people.”  As we all know, there are no truly healthy people. Even if you think you might be healthy—you’re worried. You know there is probably something wrong with you.

Here, I can’t help but think of “The Last Well Person.” This was the title of an “Occasional Note” that Tennessee physician Clifton Meader wrote for The New England Journal of Medicine in 1994. His fiction was set in the not-too-distant future, and focuses on a 53-year-old professor of freshman algebra at a small college somewhere in the Midwest. He is…you guessed it, the very last healthy American.  Using advanced medical screening, physicians have found something wrong with everyone else. 

Now medical science is catching up with Meader’s science fiction.  It’s beginning to look as if all of should be taking Crestor, or some other cholesterol-lowering drug (a.k.a. a statin) even if we don’t have high cholesterol.

The trial of Crestor  reported at the AHA conference yesterday, showed the effect of the drug on patients who did not suffer from high levels of “bad” cholesterol—but did show high levels of a protein called CRP.  It turns out that CRP is a marker for inflammation. It is tied to heart risk even in “well” people with no additional symptoms. At the moment, Crestor is approved by U.S. regulators only to lower bad cholesterol. Now, it appears that it also reduces inflammation, and other statins may have the same effect.

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Recently, Time magazine listed the retail DNA test as its best invention of 2008 (thanks to Kevin M.D. for the tip). The best?  Maybe one of the most worrisome.

Time specifically highlights the do-it-yourself DNA testing kit from 23andMe, a California-based corporation named after the 23 pairs of chromosomes in each human cell.  The company sells $399 DNA kits that consist of a test tube in which you spit and send to the company’s lab. There, over the next 4-6 weeks, researchers extract DNA from your saliva and map your genome, putting the results online. You can access the results through the web and navigate a guide to your genes that estimates “[genetic] predisposition for more than 90 traits and conditions ranging from baldness to blindness.” 

Admittedly, this sounds pretty cool. As Time gushes, “in the past, only élite researchers had access to their genetic fingerprints, but now personal genotyping is available to anyone who orders the service online…” But look closer at the commoditization of DNA testing and the novelty wears off pretty quickly.

By pinpointing specific genes associated with certain diseases, a 23andMe gene read-out can inform a user of his or her susceptibility to those conditions. It turns out this is a lot less useful than it might seem. For example, Time reports that one test showed that the husband of 23andMe’s founder has a rare mutation that gives him an estimated 20 percent to 80 percent chance of getting Parkinson’s disease. The couple’s child, due later this year, has a 50 percent chance of inheriting this mutation, and thus his dad’s risk of Parkinson’s.

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Long-term, Health Beat still expects that President-elect Barack Obama will reform healthcare. Originally (before the economic melt-down) he said that he hoped to roll out reform by the end of his first four years in office. Now, as Maggie indicated yesterday, he seems to be signaling that full-scale reform will have to wait until his second term. But there are steps that he can take to begin paving the way for reform in 2009.

For one, he needs to give Americans a chance to understand why a public sector health care plan, open to all Americas under 65 years of age, would be a good idea.  This plan would serve as a voluntary alternative to private insurance. People who didn’t want to enroll in the public plan could stick with their private insurer or move to one contracted with the National Health Insurance Exchange—the new government organization which, in addition to managing the public plan, would help to connect people with plans that adhere to certain government-specified regulations.

This so-called “public competitor” model, in which the government (a) introduces a new health care plan to compete with private insurers, and (b) tightens regulations on the health insurance market, has made its share of enemies on both the Left and the Right. Staunch single-payer advocates bristle at a reform package that still includes a role for private insurers, while conservatives view an expansion of the government’s role in health care as evidence of “socialism.”

Given the orthodoxies at work on both sides here—More government! Less government!—these complaints aren’t surprising. But both camps should understand that the National Health Insurance Exchange (NHIE) is a means of giving both single-payers and free-marketeers a health care system close to their cherished principles—without making health care reform an unnecessarily daunting and divisive endeavor.

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