Food for thought on health care reform

"Personal responsibility" is a politically loaded term. In the context of health care, Democrats accuse Republicans of using it to resist the expansion of insurance benefits, while Republicans counter that making comprehensive health insurance mandatory is paternalistic and potentially unaffordable for many people compared to other less costly options. While the fate of the different health reform blueprints recently passed by the Democrat-controlled House and the Senate remains uncertain, I think it's worthwhile to look at other innovative models of financing health care. You might be surprised to learn that two national grocery chains - Whole Foods and Safeway - are right on the cutting edge.

In August 2009, Whole Foods CEO John Mackey stirred up a small controversy by writing in a Wall Street Journal editorial titled "The Whole Foods Alternative to ObamaCare" (though Mackey later stated on his blog that the newspaper editor was wholly responsible for the provocative title) that his company's high-deductible health insurance plan was superior to both the typical employer-provided insurance model as well as government-sponsored insurance plans then under consideration by Congress. How does the Whole Foods plan work? Employees receive up to $1,800 yearly to deposit into a personal health savings account, which they can spend any way they like, paying full price for all medical services. If an employee's yearly health expenses exceed $2,500, catastrophic health insurance coverage kicks in. The lower premiums allow Whole Foods to provide insurance to more employees at lower cost, and employees pay only for the health care they need, rather than the health care that they might need. Personal responsibility in action.

Safeway has taken the philosophy of encouraging its employees to make intelligent health choices to another level. Based on the principle that the majority of health care expenses result from unhealthy behaviors such as phyiscal inactivity, poor diet, and smoking, in 2005 Safeway began offering insurance premium discounts of up to 50 percent to employees who passed a nicotine screening test and achieve weight, blood pressure, and cholesterol goals. Although the program is voluntary, enough employees have joined in that Safeway's obesity and smoking rates are now 70 percent of the national average and their per capita health care costs have not increased for the past 4 years, according to Safeway CEO Steve Burd.

It's not clear if either the Whole Foods or the Safeway insurance plans will survive health care reform unscathed; the Whole Foods plan, after all, is based on catastrophic insurance, which could be erased by any reform bill that requires comprehensive coverage for all eligible persons. And some argue that imposing financial penalties for lifestyle choices is tantamount to discrimination. But both of these examples tell me that personal responsibility for one's health may be one of the missing ingredients in the current conversation on reform.

Guest Blog: Cleft

Jon Neher is clinical professor of family medicine at the University of Washington in Seattle and associate director of the Valley Medical Center Family Medicine Residency Program. He is editor-in-chief of the newsletter Evidence-Based Practice and a frequent contributor of essays on medical education to Family Medicine. The following poem was first published in Pulse Magazine.

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As Caroline was born
the doctor saw
the split
from lip to nose -
purple rimmed,
going down deep -
Deep enough
to hurt
generations.

And the imperfect doctor,
tired of wounds,
tired of divisions,
saw the small
wholeness
Chose that moment
Chose tenderness
Saying simply
She is beautiful.

And the imperfect mother,
tired of pain,
held her child,
touched the tiny,
ragged face
Chose that moment
Chose acceptance
crying softly
She is beautiful.

- Jon Neher

After the health care reform bill passes: what next?

One of the best episodes of the final season of the NBC television series "The West Wing" was a special live (though probably scripted) debate between the Democratic candidate Matt Santos, played by Jimmy Smits, and the Republican candidate Arnold Vinick, played by Alan Alda. At one point, responding to a question about health care, Santos makes a policitically astonishing admission: "I don't like my health plan. I don't think it goes far enough. But it's my plan because I think it's what I can get through the Congress."

It's not hard to imagine that President Obama feels much the same way about the watered-down Senate version of the real-life health reform bill, which cleared a major procedural hurdle last night with no votes to spare and is expected to pass before Christmas. Even administration officials interviewed on yesterday's talk shows expressed only muted praise for a bill that, far from being a "government takeover" of health care, creates no new public insurance option, would still leave 23 million uninsured in 2019, prohibits importing inexpensive medications from Canada, and most critically, does little to control costs. It's a classic compromise solution that pleases neither end of the political spectrum, and, perhaps as a result, is opposed by a majority of the American public.

In spite of all that, this bill is apparently what can get through the Congress, so when the New Year arrives, it will be time to think carefully about next steps - to think about how to turn a bloated $1 trillion insurance subsidy and consumer-protection statute into true "health reform" that provides reliable access to (rather than just coverage for) quality primary care for all and bends the cost curve that threatens our and our children's generations with a staggering national debts as far as the eye can see. I have some ideas, of course, but I'd like to hear what you think the next steps should be.

Guest Blog: The Limits of Medicine

Frances Wu is an assistant director of the Somerset Family Medicine Residency Program in Somerville, NJ. She enjoys teaching, seeing patients and volunteering with the student-run clinic at Robert Wood Johnson Medical School and with the Human Rights Clinic for HealthRight International. "I think that my career in family medicine has given me so much to live for and to write about that I can hardly contain it. I'm working on a novel this year with the impossibly concurrent themes of love, death and the healing power of laughter." The following poem was first published in Pulse: Voices from the Heart of Medicine.

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THE LIMITS OF MEDICINE

I can not change the color of the sky.

The texture of the rain, the distance of a star

must needs be fixed by ancient ritual

unaccepted by our modernity.

I can not change the length of your night.

The number of hours, the days of your life

are set by stern fate, impassive to sighs,

unsympathetic, and cold to your plight.

I can not count the breaths that are left.

Day into day, year into frightened morn,

only you, in your heart can know

the obscurity of the sand that now sifts.

I can not make a single tear move;

Its salt will wend its way to the earth

that calls with an irresistible force,

one that will not soon leave off.

I have been roundly trounced

by movements and thunderings greater

by far than my hand's grasp;

and for their final victory, I apologize.

- Frances Wu

"The health care problem no one's talking about"

As the U.S. Senate inches closer to passing its version of a health reform bill, general internist Thomas Bodenheimer and colleagues from the University of California, San Francisco argue convincingly in the December issue of the Journal of Family Practice that expanding health insurance coverage without expanding of primary care capacity will not lead to improved health outcomes. In addition to a shrinking supply of family physicians, they identify eight additional "barriers" to patients accessing primary care services that must be addressed if health reform is to achieve its potential:

1) Panel size - family physicians, especially those in rural locations, are caring for more patients than they can effectively manage.

2) Capacity - shorter visit times necessitated by large patient panels negatively affect care quality.

3) Distance - many patients live too far from the nearest family physician to access regular primary care.

4) Medicaid/Medicare issues - Medicaid and Medicare fees are often considerably lower than those of private insurers, in some cases, paying physicians less than the actual cost of providing services. Consequently, many practices limit the number of patients with these types of insurances that they accept.

5) After-hours care - is often unavailable.

6) Scheduling - most practices are unable to schedule timely (same day or next day) appointments for non-acute issues.

7) Virtual visits - insurers do not pay for patient encounters via telephone or e-mail, leading to missed opportunities or unnecessary office visits for equivalent services.

8) Troubles with team care - although registered nurses, pharmacists, medical assistants, and other allied health workers that can be trained to perform routine medical tasks and free up physician time, most insurers do not acknowledge (or pay for) non-physician services.

There is no single solution to all of these issues, nor will every solution be right for every practice or every community. But the recent experience of Massachusetts in providing universal health insurance coverage tells us that making primary care more affordable will not make it more accessible; in fact, it is likely to do the opposite. As Dr. Bodenheimer and colleagues conclude, "Unless Americans have greater access to primary care, we fear, the U.S. health care system will undergo significant change without substantial improvement." Regardless of whether a health reform bill passes Congress before Christmas, policymakers must understand that they remain very far from the finish line.

Cultivating new models of health care

I'm a big fan of surgeon-author Atul Gawande, and I eagerly devour each of his new pieces on health and health care reform in the New Yorker. So it was somewhat surprising how difficult it was for me to digest his most recent essay, "Testing, Testing." In a nutshell, Gawande argues that it's okay for the Senate version of the health reform bill to have no "master plan" for controlling the skyrocketing cost of care because health care is to agriculture as family physicians are to family farmers. Huh? This sounds like a bad analogy-type question from the SAT, not a serious argument. But it would be a mistake to dismiss Gawande's suggestion that farming and health care have more in common than one would initially think:

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. ... Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county.

Other notable physicians have recently proposed that primary care practice could be revitalized with the help of a "primary care extension service" analogous to the successful U.S. Agricultural Extension Service. In a plenary address at the 2007 spring conference of the Society of Teachers of Family Medicine, family physician Kevin Grumbach noted:

Just as family farmers were once the nation’s major agricultural providers but are now an endangered species, we know that 75 years ago the majority of physicians in the US were general practitioners, but by the end of the 20th century, family physicians and other generalists had become a distinct minority of physicians. Just as family farmers find that few of their progeny are becoming farmers, we find half as many US medical school graduates are entering family medicine residency programs now as were a decade ago. The dominance of a reductionist paradigm in medicine has devalued the work of primary care and its integrating function for whole-person care.

So what's the solution? How can whole-person care survive in a specialist-dominated U.S. health system? By encouraging lots of experimentation, said Dr. Grumbach, and rethinking the essential functions of a family physician within a health care team. But most practices don't have the time, resources, or expertise to accomplish this practice transformation on their own. Financial incentives should help, but like Drs. Grumbach and Gawande, leaders from the Agency for Healthcare Research and Quality argued in a 2009 editorial that a government-supported extension service would speed the pace of innovation.

Admittedly, it's tough in these times to imagine that a government-sponsored anything could effectively control costs in health care or any other important sector of our failing economy. But regardless of the lack of political will on Capitol Hill, Dr. Gawande's latest article still provides food for thought about the best means of cultivating more effective models of health care in the U.S.

Ignore health reform scare stories

In a previous post, I argued that debates about the inclusion of a "public option" for health insurance in the reform bills taking shape in the U.S. Congress obscured the critical issue that elected officials have been reluctant to tackle: cost control. Extending insurance coverage to everyone is a moral imperative, but doing so will do little or nothing to hold down the rising price tag of health care, which is driven in large part by the proliferation of "care" that is unnecessary or harmful. In a New York Times editorial earlier this week, David Leonhardt observes that opponents of cost control use "scare stories" to falsely assert that cutting spending always means hurting patients:

Hospitals that practice more intensive medicine, to take one example, get no better results than more conservative hospitals, research shows. And while the insured receive better care and are healthier than the uninsured, the lavishly insured - those households with so-called Cadillac plans - are not better off than households with merely good insurance.

Yet every time Congress comes up with an idea for cuttting spending, the cry goes out: Patients will suffer! You're cutting bone, not fat!

How can this be? How can there be billions of dollars of general waste and no specific waste? There can't, of course. The only way to cut health care costs is to cut health care costs and, in the process, invite politically potent scare stories.

The trouble is, while disease advocacy groups such as the American Cancer Society can trot out endless legions of men whose lives have been "saved" by screening for prostate cancer, for example, you won't hear anything from the much larger numbers of men who have suffered permanent impotence or urinary incontinence due to surgery for prostate cancers that may never have affected their health. (A recent analysis in the Journal of the National Cancer Institute estimated that over 1 million additional men have been diagnosed and treated for prostate cancer in the U.S. since the introduction of PSA screening in 1986, and even under the most optimistic assumptions, only 1 in 20 of these men actually benefited from treatment.)

It's completely understandable that men who undergo treatment for cancer and suffer adverse effects from their treatment want very much to believe that their lives have been saved and that the harms they suffered were worth the cost. Doctors who detect and treat those cancers want to believe this too. In a phenomenon that has been called "a system without negative feedback," all of the incentives in U.S. health care conspire to encourage excessive testing and treatment for individual patients. Only by paying attention to health on the population level can we get a better perspective. Resources are limited, and given this fact, it makes no sense to squander resources on care that doesn't work, or care that hurts more people than it heals. Scare stories about cost control make for good headlines, but the story that scares me is what would happen if health reform passes without it.

Guest Blog: The Rudeness

Rick Kempa lives in Rock Springs, Wyoming, where he directs the Honors Program at Western Wyoming College. "The Rudeness," first published in the Bellevue Literary Review, dates from a time a few years ago when his mother, who is afflicted with Alzheimer's, lived with his family. His work has appeared in the journals ARS MEDICA and The Healing Muse, in the anthology Beyond Forgetting: Poetry and Prose About Alzheimer's Disease (Kent State University, 2009), and in his poetry collection Keeping the Quiet (Bellowing Ark Press, 2008).

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THE RUDENESS

Late in the evening, I hear her shout, "Now, that's a little rude, you know."

I look into her room. She is lying on her back, one hand raised above her head, fingers plucking and pruning the air. Her eyes are tightly closed, mouth working.

"Mom, can I settle you in?" I whisper.

She twists her body towards me, eyes still shut, flings out her hand, grasps a handful of my hair, lets go.

"Mom, what are you doing?"

"Oh, I'm reaching for a word."

"What word, Mom? Can you tell me?"

She grimaces. "Oh, you know ... those words ... I don't know."

Deftly, she probes the air, arm bobbing and weaving like a swan's neck. Sometimes her fingers curl into a loose fist around a space. She holds whatever she has found there, then rotates her wrist outward, unfurls the fist, pushes the platform of her palm skyward, coaxing it to fly, be gone - and resumes her searching.

And I am thinking that I do know, Mom. I too have had the best of them torn from my grasp by a whirlwind. I have chased their flitting shadows across the lawn, walked all afternoon, head hung, without them. I have carried their meanings in my pockets, flashed them at strangers - hey, buddy, have you seen ...? I have sat timidly at tables, seven blanks in the Scrabble rack of my brain, and stared into the faces of nameless friends. At night, I open my mouth - leap of faith! - trusting they will dart home, prodigal hummingbirds. Others arrive instead, grackles and starlings, a sorry tribe of stand-ins and has-beens.

"It doesn't matter," I console her. "These other words will serve us well, or if we arrive at a place where there are none, the silence will not be so bad." But I know now, watching the fist of her mind clenching, unclenching around the space that once held words - the very best, the most perfect words - how wrong I am. This is the rudeness, this is what's unacceptable: that at first they were so gracious, so generous with themselves, and are now so spare.

- Rick Kempa

Healthy skepticism and improving health communication

In yesterday morning's hearing before the House of Representatives Energy and Commerce subcommittee on health, Dr. Ned Calonge and Dr. Diana Petitti, Chair and Vice Chair of the U.S. Preventive Services Task Force, admitted to a "failure in communication" of the Task Force's recently updated recommendations on breast cancer screening when it came to women ages 40 to 49 years. There was, and remains, absolutely nothing wrong with the science of the recommendations, which included advising against clinicians teaching self-breast examinations due to a lack of benefits (a conclusion also reached by the highly respected Cochrane Collaboration more than two years ago) and having mammograms performed every two years rather than every year, as is common practice in the U.S.

In an attempt to correct the widespread perception that the USPSTF had recommended against ALL women under the age of 50 having mammograms for screening purposes, the breast cancer screening page on the USPSTF website now includes a direct quotation from Dr. Petitti: "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values." Although adding this quotation was too late to quell the political firestorm that erupted in the wake of the new recommendation (which was only pushed out of the headlines by the debate over appropriate troop levels in the war in Afghanistan), it is an attempt to translate what had been a statement directed at clinicians for patients and their caregivers.

In an earlier post on this blog, I mentioned how researchers at the Dartmouth Institute of Health Policy and Clinical Practice had developed a book meant to assist patients with understanding health statistics and using data to estimate their personal risk of contracting a disease or experiencing a disease-related event. In an editorial in this week's Journal of the National Cancer Institute, Dr. Woloshin and Dr. Schwartz (writing prior to the release of the USPSTF breast cancer screening recommendations) argue that while headline-seeking journalists are to blame for some of the exaggeration of health risks and benefits, researchers, medical journals, and academic press offices are also responsible for this common phenomenon:

Important elements that journalists (and, really, all readers) need are sometimes missing or hard to find in the published articles. For example, in six high-profile journals, two-thirds of articles reporting ratio measures failed to provide the underlying absolute risks in the abstract. ... Nor are study limitations routinely highlighted in journal abstracts ... and sometimes are missing from articles altogether. ... Only half of the press releases reporting on differences between study groups provided absolute risks; less than one-quarter noted any study limitation. ... Can we really expect journalists to do a better job than the medical journals, researchers, or their university public relations offices?

Studies have shown that women consistently overestimate their personal risk of breast cancer diagnosis, breast cancer death, and the benefits obtained from screening mammography. For the record, a typical 40 year-old woman has 1.4% chance of being diagnosed with breast cancer over the next 10 years, and a 0.33% chance of dying from it (or 1 in 300). Regular screening mammograms reduce the probability of dying of breast cancer in a 40 year-old woman by 0.05%, to 0.28% (or 1 in 357), at the cost of a 1 in 3 chance of experiencing a false alarm due to screening. Whether or not the cost is worth the benefit lies in the eye of the beholder - which is why, despite all of the unnecessary hysteria, the USPSTF got it right.

Residency Procedures

The mantra "see one, do one, teach one" has long been thought to be essential to the training of physicians. But how would you like to be the patient on the receiving end of that training - a medical student or resident doing his or her first (or second, or third) procedure of a particular type? My anxiety about one such situation as a second-year Family Medicine resident at Lancaster General Hospital (PA) in 2002 led to the following tongue-in-cheek poem about the disparity between intellectual knowledge and hands-on ability.

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PROCEDURES

Have you ever been caught
Too close to a lamp
Unable to immediately turn
To evade the scalding heat?

That's where it starts
Your name in block letters
An article tacked up on a door
The thrill of recognition.

They can't see what you can
But the cost is prose burned
Into areas that ought to contain
Other things - for example,

Being on time for noon conference
The dinner you forgot to pack for that long night on call
The chapters of skin diseases you didn't read
So you have no idea what to do with the ugly mole on this man's back.

But ... perhaps he'll recognize you!
Perhaps he'll say, didn't you write that column in Central Penn Parent Magazine?
Your ignorance scrubbed away in a sterile field
Awaiting decisive excisions with number 10 blades

Then sent off to Pathology, where
Under the piercing gaze of microscopes
They'll dissect your pieces,
Label them separately,
Fix them in formaldehyde
So your slides may be admired for generations.

- Kenny Lin