Give thanks for small primary care practices

When I was in high school, a national hardware retailer opened a new franchise down the street from the mom-and-pop hardware store that had served my neighborhood for many years. Since the new store had the advantage of larger volumes and lower costs, it seemed to be only a matter of time before it drove its smaller competitor out of business, the way that big bookstore chains and fast-food restaurants had already vanquished theirs.

But a funny thing happened on the way to the inevitable. By the time I left for college, the new hardware store had folded, and the mom-and-pop operation had moved into their former building. How did this small business manage to retain its customers and win new ones without prior loyalties? The answer was quality of service. I remember visiting both stores when a classmate and I were working on a physics project. At the mom-and-pop store, the owner himself happily held forth for several minutes on the advantages and disadvantages of various types of epoxy adhesive. At the national hardware chain, the staff consisted mostly of kids my age who didn't know much more about glue than I did.

Six years ago, an editorial authored by White House officials in the Annals of Internal Medicine blithely predicted that small primary care practices would eventually be absorbed by "vertically integrated organizations" as a result of health reforms. The editorial prompted the American Academy of Family Physicians to send the White House a letter defending the ability of solo and small group practices to provide high-quality primary care. Despite the migration of recent family medicine residency graduates into employed positions, researchers from the Robert Graham Center estimated that up to 45% of active primary care physicians in 2010 practiced at sites with five or fewer physicians.

The limited resources of small practices seem to put them at a disadvantage relative to integrated health systems and Accountable Care Organizations. Small practices have less capital to invest in acquiring and implementing technology such as patient portals, and fewer resources (dollars and personnel) to devote to quality improvement activities, such as reducing preventable hospital admission rates. Nonetheless, like the small hardware store of my youth, some small practices are not only surviving, but thriving in the new health care environment. Dr. Alex Krist and colleagues reported in the Annals of Family Medicine in 2014 that eight small primary care practices in northern Virginia used proactive implementation strategies to achieve patient use rates of an interactive preventive health record similar to those of large integrated systems such as Kaiser Permanente and Group Health Cooperative. An analysis of Medicare data published in Health Affairs found that among primary care practices with 19 or fewer physicians, a smaller practice size was associated with a lower rate of potentially preventable hospital admissions.

In addition to providing superior service, solo physicians or small groups can create their own economies of scale by pooling resources and collaborating with other practices in areas such electronic health record systems and quality improvement. For example, Dr. Jennifer Brull reported how her practice and four others in north-central Kansas succeeded in improving hypertension control rates in an article and video in Family Practice Management.

These examples illustrate that the demise of the small primary care practice has been greatly exaggerated. Whether small practices can continue to flourish in the era of health care consolidation and questionable quality metrics remains an open question, but I do know this: the small hardware store in my home town is still thriving, a quarter century later.

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This post first appeared on Common Sense Family Doctor on September 22, 2014. Happy Thanksgiving, everyone!

Repeal Obamacare; sustain the Affordable Care Act

On the Election Day that made Donald Trump the next President of the United States, I traveled to Lancaster, Pennsylvania to give a lecture. Long a conservative political stronghold, Lancaster County was dotted with "Make America Great Again" campaign signs, forecasting Trump's comfortable 47,000 vote margin there, which ended up being more than two-thirds of his 68,000 victory margin in Pennsylvania, one of the states that effectively decided the election. Ironically, Lancaster is where I trained to become a family physician from 2001 through 2004, and it is the place where I first recognized that the health care system our country had then was not up to the task of caring for all the people. Lancaster, which started me on my path toward advocating for reforms that ended up in the Affordable Care Act, voted overwhelmingly for a candidate who has promised to repeal it.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy has been a mess. The trillions of dollars in debt that the U.S. has run up over his term will hurt my generation and future generations, and if Republicans should 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. 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 included morally repugnant death panels staffed by faceless bureaucrats who 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 said 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 regulates 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 politically conservative law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieved 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 discouraged irresponsible health care "free riders" and provided support for people of modest means to purchase private health insurance in regulated open marketplaces. It told insurers that in exchange for millions of new customers, they could no longer discriminate against the old and sick. Finally, the ACA rewarded physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may not improve health.

The ACA has flaws. It didn't narrow the income disparity between different types of physicians or encourage more medical students to choose careers in primary care. It didn't prevent pharmaceutical companies from arbitrarily jacking up prices on old but essential drugs. Its provisions to discourage overuse of unnecessary medical services were limited and inadequate to the scope of the problem. But it's worth noting that all of these problems all predated the law. We don't have enough family physicians and other primary care clinicians, drugs in the U.S. cost more than anywhere else in the world, and overdiagnosis and overtreatment have been rampant for years. That the ACA took on these issues at all was a small victory.

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, 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 thoughtful Republicans to look past their leaders' overheated rhetoric about repealing Obamacare and focus on strengthening and sustaining the ACA, starting now.

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A slightly different version of this post first appeared on Common Sense Family Doctor on September 30, 2013.

When treating addiction, the words we use matter

In a JAMA editorial last month, Director of National Drug Control Policy Michael Botticelli and former DHHS Assistant Secretary for Health Howard Koh wrote that it was time to change the language health professionals and researchers use to refer to patients who suffer from addictions. This isn't simply an exercise in political correctness. Stigmatizing terms that "describe [patients] solely through the lens of their addiction or their implied personal failings" have been shown to negatively influence mental health clinicians' attitudes: someone described as a "substance abuser" was considered less treatable and more likely to be blamed for his or her condition than a "person with a substance use disorder." Similarly, they recommended describing someone with a history of having abused substances as "in recovery" rather than "clean." Botticelli knows his subject perhaps better than any previous U.S. "drug czar" (another term he prefers to not use), being in recovery himself from alcoholism.

I've written before about the failure of our criminal approach to drug misuse and the problems that misuse of legal pain medications have created for patients who suffer from chronic pain. Abetted by pharmaceutical companies whose sales representatives convinced many doctors that opioids were safe and non-addictive, the medical profession handed out powerful drugs like OxyContin as freely as Halloween candy, with devastating consequences.

Those consequences were more devastating in some communities than others. For almost every imaginable medical condition, members of racial and ethnic minorities receive less care and have poorer health outcomes, and addiction is not an exception. An article titled "Deconstructing Addiction" in NYU Physician began by describing two men in their 20s who sought treatment for heroin addictions and severe mood swings. One was diagnosed with bipolar disorder and prescribed antipsychotic medications and supervised methadone treatment. The other received an antidepressant and buprenorphine. Why were their medical plans so different? The first man was "a Latino living in a poor section of Brooklyn," while the second was a "middle-class white man from suburban Queens." Helena Hansen, an NYU psychiatrist and medical anthropologist, has worked to unravel the complex web of social and political forces that created these care disparities:

Methadone, she learned, was initially presented to the public as a tool for lowering crime in black and Latino communities. Accordingly, methadone clinics were mostly located in those areas. ... By the start of the new millenium, media reports warned of an epidemic of OxyContin addiction sweeping suburban and rural America. Buprenorphine maintenance, Dr. Hansen found, was aimed expressly at this new, overwhelmingly white cohort of substance abusers. ... When buprenorphine came on the market, ads portrayed the typical user as a white, middle-class dad who'd become addicted to painkillers after a back injury and wanted to return to coaching the son's baseball team. Even now, many buprenorphine providers accept only private insurance or out-of-pocket payments - unlike methadone clinics, which rely mostly on Medicaid reimbursements.

Although this two-tiered approach to treatment was not intended to create inequality, Hansen emphasized, it rapidly became incorporated into the structure of medicine and perpetuated stereotypes about white versus nonwhite patients with substance use disorders:

For addicted people in private care, most of whom are white, therapy is designed to minimize stigma and get the patient back to work or college; buprenorphine is used as a means toward these ends. Addicted people in public care - which covers most poor and nonwhite patients - are administered methadone under stringent supervision, steered into perceiving themselves as permanently disabled, and prescribed psychotropic medications that may further compromise their health.

On a related note, I've given some serious thought recently to going through the certification process to prescribe buprenorphine. Few family physicians currently possess a Drug Abuse Treatment Act (DATA) waiver to do so, not because the process is particularly onerous (eight hours of mandated education, half live and half online), but because most feel poorly trained and equipped to manage the psychosocial needs of these patients. I can't get a psychiatrist to see my few patients with mental illness that I consider beyond my capabilities unless they can pay cash; my heart sinks when I ponder how to arrange necessary care and social services for patients with substance use disorders. Working for a health system connected to a tertiary medical center, living in a city where the doctor to population ratio is one of the highest in the country, I rarely view myself as the health care option of last resort for anyone. But the need for accessible addiction treatment is great, and it isn't being met.