I oppose Obamacare; I support the Affordable Care Act

Tomorrow, more than three years after being signed into law, and more than a year after surviving a Supreme Court challenge, the Affordable Care Act, more commonly known as Obamacare, finally begins to fulfill its promise. Most of this country has long since taken sides, despite appalling gaps in popular understanding of what the law means, what it does, and what it doesn't do.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy is a mess. The trillions in debt that the U.S. has run up over the past 5 years will hurt my generation and future generations, and if Republicans can be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. He is a perpetual campaigner, preferring theatrical gestures to the backstage grunt work of governing. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that includes morally repugnant death panels staffed by faceless bureaucrats who will decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that says that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that will regulate the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieves the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discourages irresponsible health care "free riders" and provides support for people of modest means to purchase private health insurance in regulated open marketplaces. It tells insurers that in exchange for new customers, they can no longer discriminate against the old and sick and make their profits off the young and healthy. Finally, the ACA rewards physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may or may not improve health.

The ACA has flaws. Since it doesn't do much to narrow the income discrepancy between different types of physicians, it may overwhelm the capacity of primary care as millions of uninsured patients look for family doctors for the first time. The ACA's provisions to discourage overuse of unnecessary medical services are limited and probably inadequate to the scope of the problem. But it's worth noting that these problems all predated the law. We don't have enough family physicians and other primary care clinicians, specialists make too much money in comparison, and overdiagnosis and overtreatment are already rampant today. That the ACA takes on these issues at all is a small victory of sorts.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, who was the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for people of all political persuasions to set aside the overheated rhetoric about Obama and Obamacare and focus on making the ACA work, starting tomorrow.

Guest Post: Why clinical questions are only a starting point

Dr. Robert Bowman is a Professor of Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. He blogs at Basic Health Access and Clinician Specific Medical Education.

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People come to family physicians with some indication or faith that we can help them. As the learned “high priests” of medicine, we can answer their questions in various ways. The following 5 ways that Christians perceive that God answers prayers also provide a framework for how we address clinical questions.

"No, I love you too much."

Daily we see patients who already have answers to their questions. They come to us for many reasons. One reason is so that we can confirm their impression. If we do so wrongly, we contribute to their problem. We also know that what some people are asking is wrong. For this and for other presentations, we have to say “No, I love you too much.” This can be difficult for physicians who want to please all of their patients or improve their “patient satisfaction” scores.

"Yes, but you will have to wait."

We gather information and then do exams, tests or sometimes treatments. Haste can help answer a clinical question, but a hasty answer can be wrong. Hundreds of hasty diagnoses or treatments have been proven wrong in later years. For 20 years we were pushing an unproven test for prostate cancer screening when we should have been saying: “You will have to wait.”

Those on the front lines of care recognize that some diseases and conditions go away. Patience is needed. When people come in with fever, chills, and headache within 24 to 48 hours, chances are that this will resolve with little consequence. Deciding who can wait or not is a clinical decision, but one that does not necessarily lead to a diagnosis. We fail to measure much of clinical decision making. Those who measure immediately will find many clinical questions unanswered. This is about the patient, physician, interaction, the state of the science, and limitations in each of these areas. Immediate diagnosis and treatment can be wrong and harmful – but sometimes delays can be harmful. Outside players (legal, payers, practice pressures, daily situations) exert influences that can impede optimal decisions and care.

"Yes, but not what you expected."

This is always a tough situation as people have already moved their minds down one path. It takes time and effort on our part to erase this path so that they can move down another. Our treatments often do not work and some are harmful. Even with correct diagnosis and treatment, some patients find that our treatments are too inconvenient or expensive to continue and may or may not tell us.

"Yes, and here’s more."

Family physicians have more to offer than just diagnosis and treatment. Because of our tens of thousands of patient care experiences, we have experienced the impacts upon others and how they responded and what helped. The context of neighborhood, family, and individual past experiences is a rich database. Teaching of medical students and residents adds to the reflection, discussion, learning, and management. Ideally we have experienced the disease and condition and can speak with regard to practical matters, with evidence as a foundation. It helps to have access to pharmacists, behavioral professionals, and nurse educators who can step in and connect patients to needed care. But adding more can be difficult with financial margins so thin, with penalties for serving patients in settings where margins are thin, with fast rising costs of delivery, and with stagnant reimbursement. 

"Yes, and I thought you would never ask."

This is what we tend to focus on too much. People come in and we make the diagnosis and treatment together and have great agreement and all are pleased about expectation, diagnosis, treatment, and outcome. We like to measure this outcome since it is easy to measure. Much of what we do in family medicine, though, is in the first four answers rather than this last one. Saying no, getting people to wait patiently, or redirecting wrong impressions is often more important to individual outcomes than is the clinical question. Unfortunately, current designs for training and practice support make responding "Yes, and here is more" difficult unless we personally sacrifice to provide more care.

Family physicians generally do not experience the immediate rewards of diagnosing an inflamed appendix with confirmation during removal at surgery. But we do see the negative consequences of focusing on short-term outcomes at the expense of long term approaches to health, where the "clinical question" may only be a convenient starting point.

Conservative Medicine: Who needs to read it?

"Don't just do something, stand there." This deliberate rephrasing of "don't just stand there, do something" reminds me that the typical impulse of a physician to take immediate action in the face of clinical uncertainty can sometimes lead to a worse outcome than exercising patience, collecting more information, and waiting for any harmful conditions (if present) to declare themselves in time.

However, as I explained in this week's MD Global Health podcast, powerful monetary and psychological incentives present throughout the health care industry push physicians, advocacy groups, and medical institutions to aggressively seek out and treat persons with "underdiagnosed" diseases, expand the definitions of existing diseases (e.g., pre-osteoporosis, or low bone density), and sometimes, create new diseases (e.g., restless legs syndrome) out of whole cloth. Recognizing that these issues are often exacerbated by expert consensus recommendations of dubious quality, a distinguished international working group recently proposed a short list of questions that, if properly implemented, could permit clinicians and patients to evaluate financial conflicts of interest in clinical guidelines.

Conservative Medicine will not only outline a list of problems that result from overtesting and overtreatment, but offer a set of solutions in the areas of medical education, public policy, regulation, and patient advocacy. Who needs to read it? I believe that my book will appeal to a broad audience of health professionals, journalists, policymakers, and ordinary people with and without defined health problems who wonder if they actually need "preventive health care," and if so, how much.

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This is the sixth and final entry in a series of brainstorming posts about a book that I am writing titled Conservative Medicine.

Mindful communication, physician burnout, and patient satisfaction

Are mindful clinicians happier clinicians, and do they communicate better with patients? A pair of studies published this month in Annals of Family Medicine aimed to answer one or the other of these questions. Mindfulness, defined as "purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings," is being increasingly recognized as having a protective effect against clinical burnout. In the first study, an abbreviated mindfulness intervention in 30 primary care clinicians was associated with reduced burnout and improved measures of mental health 9 months later. In the second study, clinicians with higher self-rated mindfulness were found to engage in more patient-centered communication and have higher patient satisfaction scores.

These studies are particularly important to family physicians like me because other surveys have shown that we (and general internists and emergency physicians) are at much greater risk of experiencing early career burnout than other medical specialists. This isn't only a professional issue, it's a public health issue; since the U.S. primary care shortage is expected to worsen over the next decade due to low student interest, health insurance expansion, and population growth, we need "all hands on deck" now more than ever. (I'll tackle the issue of credentialing primary care nurse practitioners in a future post, but for now suffice to say that at best this is only part of the solution.)

Not long ago, to fulfill the requirements for a Master of Public Health degree, I reviewed the limited literature on interventions to reduce burnout and improve well-being in primary care physicians. The structured abstract is below, full paper available upon request.

Background: Burnout in primary care physicians may have negative effects on personal health and patient care.

Purpose: To review the prevalence of burnout in primary care in the U.S. and other Western countries; causes, determinants, and negative effects of burnout in primary care physicians; and interventions to reduce burnout.

Data Sources: Electronic searches of PubMed (2003-present) and hand searches of reference lists of key studies and reviews. The full text of 48 citations was reviewed for randomized controlled trials, cohort and cross-sectional studies, and descriptive studies relevant to one of the content areas. 17 studies were included: 4 on prevalence, 6 on causes, determinants, or negative effects, and 7 on interventions.

Data Synthesis: Burnout consists of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. The risk of burnout is higher in the presence of work overload and perceived lack of control over one’s workload. 46 percent of surveyed U.S. physicians reported at least one symptom of burnout; primary care physicians had among the highest rates. Family physicians from 12 European countries commonly reported emotional exhaustion (43%), depersonalization (35%), and reduced personal accomplishment (32%), with higher rates in younger and male physicians. Burnout was associated with a higher frequency of self-reported difficult patient encounters, but was not associated with medical errors, lower quality of care, or patient dissatisfaction.

Descriptive studies of physicians with reputations for “resilience” identified several themes that may prevent burnout. A multi-component intervention to improve physician control over work environment, staff efficiency, and patient care satisfaction was associated with a statistically significant reduction in emotional exhaustion. Limited evidence exists for the effectiveness of individual-level interventions to reduce burnout. A yearlong continuing medical education course in mindful communication was associated with decreases in all 3 burnout dimensions. Short-term cognitive behavioral interventions reduced emotional exhaustion and general psychological distress.

Patient-centered health care means sometimes saying "no"

Many commentators on U.S. health care, including me, have written that our existing models of care are far from patient-centered. In a 2009 Health Affairs piece, former CMS Administrator and Institute for Healthcare Improvement president Donald Berwick took this one step further by observing that instead of revolving around the needs and wants of patients, health systems are generally designed to meet the needs of clinicians. He related an episode during which a close friend who was having chest pain requested that he accompany her to the cardiac catheterization laboratory for emotional support and to help explain the procedure's results afterwards. The nurse and cardiologist both rejected his friend's request, giving no explanation other than "it's just not possible." (And I remember, with dismay, hearing these exact words from a physician when I wanted to accompany my newborn daughter to the hospital nursery for her first bath.)

After tracing the recent history of "patient-centeredness" as an aim of various groups devoted to improving health care quality, Berwick proposed what he called an "extremist" definition of patient-centered care:

The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care.

To me, this definition sounds hardly revolutionary, and more like common sense. The sticking point for most clinicians, of course, is "without exception." Does this mean that clinicians should be required to fulfill patients' all-too-common requests for tests and procedures that have little clinical benefit or are likely to lead to harm? Well, in many cases, such as antibiotics for colds or imaging for acute low back pain, most of us already do, despite knowledge of potential adverse consequences. But perhaps these seemingly irrational requests occur because the health professional hasn't done enough to explain the risks and benefits of various options, or more importantly, understand what those risks and benefits mean from the patient's perspective.

This topic leads me a study about getting to "no" published in JAMA Internal Medicine, in which trained actors posing as patients visited the offices of internists and family physicians, and, after complaining of vague symptoms of fatigue, requested a specific medication for depression that they said they had learned about in an advertisement. In the majority of these encounters (111 out of 199), doctors simply fulfilled the request, even though the information that the actors gave clearly did not meet criteria for the diagnosis of depression. Of the 88 who did not, 31 either gave no reason for saying no or deflected the request by ordering (unnecessary) tests or prescribing a sleep aid. In the remaining 53 encounters, the doctor attempted to further explore the content of the request or suggested a referral to a mental health counselor to accomplish the same end.

Although the study's authors did not explicitly endorse a particular approach to saying "no," it seems to me that the last one, which one might call the "patient-centered" strategy, is the most likely to benefit the physician-patient relationship and prevent harm in the long run. I'm not saying that this negotiation is easy, and it certainly isn't the sort of thing that is routinely taught in medical school or residency (which explains why more than half of the doctors in this study found themselves unable to say "no" to an inappropriate request). It's only what family physicians do, day in and day out - and like many other aspects of primary care practice, we need to learn how do it better.

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This post is slightly revised and updated from a post that was originally published on Common Sense Family Doctor on February 22, 2010.

Job Posting: Robert L. Phillips, Jr. Health Policy Fellowship

The Department of Family Medicine at Georgetown University School of Medicine is currently seeking qualified applicants for its one-year fellowship in Primary Care Health Policy. This is a unique, full-time program that combines experiences in scholarly research, faculty development, and clinical practice. Fellows have the opportunity to interact with local and federal policymakers in Washington, D.C. and conduct health services research projects with experienced mentors at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. They will join a dynamic group of faculty (including me) at one of the flagship departments for urban family medicine on the East Coast. Past Robert L. Phillips, Jr. Health Policy Fellows hold leadership positions in federal health agencies, community health organizations, and academic institutions. Applicants should be graduates of an accredited residency program in Family Medicine or expect to graduate in 2014. Please contact me at KWL4@georgetown.edu for additional information.

Guest Post: Why the Direct Primary Care Model would benefit poor patients (2 of 2)

This is the second of two guest posts by Dr. Marguerite Duane. Part 1 is posted here.

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What about specialty care? In the Direct Primary Care model, physicians have more time to spend with their patients to diagnose and treat problems appropriately; therefore, specialist and emergency visits, surgeries and hospitalizations are all significantly reduced. Also, specialists are willing to reduce their fees when they are guaranteed timely payments without insurance processing delays.

So, if direct pay models could provide affordable, personalized primary care for the poor, why are more physicians and/or practices in underserved communities not moving to this model? I think there are two main reasons:

1. Physicians may mistakenly believe that poor people can’t afford direct primary care because they do not appreciate that these models are different from concierge medicine. Concierge medicine usually involves cost-prohibitive retainer or membership fees that guarantee 24-hour physician access. However, these fees often do not cover actual physician visits, which may still be billed separately. On the other hand, monthly membership fees in direct pay models of primary care are far more affordable, typically costing less than a monthly cell phone bill. More importantly, these fees cover physician visits.

2. It may be difficult for patients and physicians to move to direct pay models of care because they are trapped in the current insurance model. Physicians are accustomed to being paid by insurance companies, so they provide and document the "care" that insurance companies require in order to be reimbursed appropriately, rather than the care that patient actually needs. Many poor patients are accustomed to being covered by Medicaid which allows them to access care without co-payments, so in their mind it is “free.” However, since fewer and fewer physicians accept Medicaid, patients “spend” a lot of time and effort just searching for care rather than receiving the care they need. While change is difficult, physicians and patients alike must move beyond their dependence on health insurance for primary care, because with the insurance company as the payor, the patient will never really be at the center of care.

Patients who pay for primary care through direct pay models can choose physicians who provide high quality, satisfying care. The smaller patient panel sizes facilitated by this model of care make it possible for physicians to form stronger relationships with patients who benefit from the extra time and attention.

Insurance is designed to cover unpredictable, undesirable or expensive events. Primary care is none of these. In my view, Direct Pay practices are viable primary care options for patients of all income levels.

Guest Post: Why the Direct Primary Care Model would benefit poor patients (1 of 2)

Dr. Marguerite Duane is the past medical director at Spanish Catholic Center of Catholic Charities of Washington, DC; a member of the Folsom Group; and co-founder of the Fertility Appreciation Collaborative to Teach the Systems (FACTS). She will attend the Direct Primary Care National Summit in October. This is the first of two guest posts. Part 2 is posted here.

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When most people hear the term Direct Pay Primary Care, they presume that it refers to a high cost, “concierge” care model for the wealthy and is not a realistic option for poor people. That presumption couldn't be farther from the truth. Here’s why.

Five years ago, I became medical director of two community health centers that serve an almost exclusively poor and uninsured population. More than 90% of our patients earn less than 200% of the federal poverty level (about $47,000 for a family of 4 in 2013). So if our patients have so little money to spend, how could direct primary care work for them? With direct pay models, actual health care costs can be kept much lower and made much more affordable. Also, since direct pay models typically care for smaller patient panels, patients have more time with their primary care team to address the myriad of life issues that affect their health.

Some direct pay models charge patients a monthly or yearly membership fee that covers all primary care office visits and even some basic or in-house lab tests. For example, at Qliance in Seattle, depending on the patients’ age, members pay a fee that ranges between $54 and $94 per month, which includes:

• 7-day a week access to the Qliance health care team
• Same or next-day appointments for urgent care
• 30 to 60 minute office visits
• Phone appointments and electronic visits
• After hour phone access to a physician for urgent medical needs
• Basic x-rays onsite at no additional charge

This care would cost my family of five $3,780 annually, less than a quarter of the $16,000 our employer-sponsored health insurance actually costs. Patients can then purchase a separate catastrophic health insurance policy for significantly less than a traditional insurance plan that also requires co-payments for primary care. Monthly membership models work particularly well for patients with chronic conditions, eliminating the potential financial disincentive of paying a fee for each office visit.

But how will poor patients pay for labs or specialty visits? It may surprise you to learn how inexpensive most basic lab tests are when they aren’t paid for by insurance middlemen. Here is an example of tests at my community health center for a patient with diabetes:

Lab Test                        Actual Cost to Us           Patient Paid

Hemoglobin A1C                 $8.72                             $10
Lipid panel                        $3.47                             $5
Metabolic profile                $4.21                             $5

This patient would pay $20 for lab tests that actually cost $16.40. While a profit margin of $3.60 may seem small, it worked for us because neither the clinic nor the lab had to pay anyone to process insurance claims or send follow-up reminders for un-paid bills months later.

Conservative Medicine: Why is now the right time for it?

Forty years ago, Dr. Jack Wennberg and colleagues at Dartmouth Medical School published the first of a series of groundbreaking studies of medical resource utilization and practice variations that would eventually become the Dartmouth Atlas of Health Care. They found huge variations in how often elective surgeries such as tonsillectomies were performed in different parts of New Hampshire, even in neighboring cities and counties. These geographical variations could not be explained by differences in the demographics or health of patient populations, and outcomes in areas with more surgeries per capita were no better, and sometimes worse, than in those with fewer surgeries. Subsequent studies identified similar unwarranted variations in many other procedures and treatments paid for by Medicare, leading to a consensus among policymakers that the U.S. health system spends hundreds of billions of dollars each year on medical care (termed "waste") that has no health benefits and often harms patients.

To my profession's credit, physician organizations are finally taking unprecedented steps to confront the problem of waste in medicine. The American Board of Internal Medicine Foundation's Choosing Wisely campaign, which asks each partnering group to identify 5 commonly performed tests or treatments that should be questioned by physicians and patients, has signed up more than 50 specialty organizations to date, with more to come in the next several months. Next week, screening and diagnostic experts from all over the world will gather at Dartmouth to discuss strategies for Preventing Overdiagnosis, a problem that is largely created by physicians looking too hard for diseases with imperfect tests that lead to many false positive results and more invasive procedures, such as biopsies. (Even if the tests themselves were perfect, they are often performed in patients who could not possibly benefit from the results, such as patients with terminal cancer.)

But if the problems of medical waste and overdiagnosis are familiar to doctors, most patients are still in the dark about the basics. For example, how is someone without medical training expected to know the difference between a test that might help and a test that is potentially harmful (and, since many tests meet both criteria, weigh the benefits and harms and make a decision that accurately reflects his or her preferences)? When should you suspect that your doctor is testing or treating too aggressively and ask for a second opinion? How do you know if you may have been overdiagnosed? What components of a complete physical are supported by good evidence, rather than simply relics of medical tradition? Does a physical really need to be done annually, or at all?

These are the sorts of questions that I plan to answer to the best of my ability in Conservative Medicine. Now is the right time for this book, but in many ways, the topics of this book are timeless.

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This is the fifth in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.