Monday, April 14, 2014

Lack of Listening is the Core Problem in American Health Care

The Crisis in Primary Care – Part 4
There is and will be a need for many more primary care physicians (PCPs).Why? There is a shortage now and it will be exacerbated in the coming years for at least four reasons. The population is growing, the population is aging and there will be more individuals with health care coverage as a result of the Affordable Care Act (“Obamacare”). I believe that the need will be much greater than the estimate of 52,000 in 2025 as proposed recently in the Annals of Family Medicine. The authors did not address this fourth and particularly important reason driving a need for more PCPs.  If PCPs actually cared for only a reasonable number of patients, perhaps 500 to 1000 (depending on demographics) rather than today’s common 2500+,  such that they no longer were seeing 24-25 or more patients per day in their offices, then the need for more PCPs would be much greater. With fewer patients seen per day, the PCP can then spend the time needed to listen, to prevent, to coordinate and to think – four key activities that they often are not able to do effectively today. This drives a need for substantially more PCPs.
The need is not to graduate more total medical students but to make primary care desirable as a medical professional career. This means overcoming the current non-sustainable business model so that graduates once again will select primary care.
Here is an example of the value of a primary care physician being able to take the time needed to thoroughly listen to a patient and assess the situation. The PCP saw a lady one day that he had known for many years. She was always very enthusiastic and very articulate. One day she came in for a routine visit. The PCP noticed that her speech patterns were slightly different than he remembered from the past. No one who did not know her well nor anyone who had only a brief conversation would have recognized her speech as changed. She was unaware and felt fine. The changes were subtle but they were clearly changed in his mind. The rest of the history was unremarkable. He did a neurologic exam which was also unremarkable. But he was certain that something was amiss. So he ordered an MRI of her brain. Her insurer refused because she had no specific indications with an otherwise normal history and examination. He had to call multiple times and explain his rationale; finally the insurer relented. The MRI showed a primary brain lymphoma – treatable, probably curable. 
The message is simple. The PCP knew his patient well and because he had the benefit of an extended visit time he was able to notice the subtle changes in her speech pattern. His skill combined with a long history with his patient and adequate time made all the difference and probably saved her life. 

Compare that experience to the following story sent me recently.  

“My mother's "real world" story is mostly about a cardiologist but touches on the very problem you describe about PCPs in a brief but pointed way.  

“I took my mother to the cardiologist this week. He spent a good amount of time with her, mostly listening, trying to figure out her medical issue. Once he thought he'd hit upon what was causing the problem and the solution (which happily, did not involve a drug or surgery but behavior modification), he said he'd call her internist who she has been seeing for many many years to tell him about the discussion. My mother waved her hand dismissively and said, "He doesn't know me." The cardiologist looked surprised and a little confused but I understood. My mother was saying that her internist had not spent time listening to her and getting to know her unique situation like this cardiologist had done. 

“My usually non-compliant and defiant mother called me the morning after her appointment to report she had done what he recommended and would continue to do so. His unhurried gentle questioning, sympathetic listening and obvious desire to figure out how to help her is what made my mother trust him. I felt that my mother had actually consulted with a physician - a healer.” 

There is both a good and a not so good side to this story. The good is obviously that the cardiologist listened to her and then developed a plan of action – with her and her daughter - that she could accept and follow. The not so good or even most unfortunate is that she felt her PCP that she had visited for many years didn’t really know her – because he did not listen.  

When doctors do not have enough time to really listen the result is that they do not listen. A study from 1984 of primary care physicians observed throughout patient visits revealed that the doctor interrupted the patient within 18 seconds on average. Relating to this article, Koven commented on KevinMD “In only 17 (23%) of the 74 visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement.”  This is not only remarkable but a sad commentary on the short visit and the lack of attention by physicians to actually listening to the patient.
This lack of listening is the core care problem in American healthcare today. It is prevalent, pervasive and getting worse, not better. It is the inadequate income per patient (by whatever payment system – fee for service, capitation, etc. -- is used) that is driving the lack of listening. Today the PCP sees too many patients for too little time each. Until the payment system is corrected and, in return, doctors get back to listening, healthcare will not be true care and certainly not healing. Call this a future combination of shared rights and responsibilities – the doctor earns a decent income in return for offering superior care to a reasonable number of patients. This would be a good balance all around. And although primary care would cost more, the total cost of care would come way down. 

My next post in this series will address the “paradox” inherent in today’s American medicine.

Monday, April 7, 2014

Why Is There A Critical Shortage of Primary Care Physicians?

Primary care physicians (PCPs) are becoming extinct.  It’s true. Not many medical students choose primary care as their career path. Older PCPs are retiring early. Many others are closing their practices or seeking employment at the local hospital. And there has always been a shortage of primary care physicians in rural and urban poor areas. Today only 30% of all physicians practice primary care (compared to about 70% in most other developed countries and about 70% in the United States fifty years ago) and this percentage is shrinking at a steady rate.  

This my third post in this continuing series  

Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000 primary care physicians in active practice, will need an additional 52,000 PCPs by 2025. Good luck. This is based on growth of the population (requiring 33,000 added PCPs), the aging of the population (10,000) and the added number of individuals that will have health insurance as a result of the Affordable Care Act (8000). The number needed almost undoubtedly is substantially higher. And if you accept my premise to be detailed in a later post that a primary care physician (or nurse practitioner or physician assistant) should be caring for only about 500-1000 individuals rather than the current typical 2,500+, then the need is truly much, much greater.  

About 25,000 new graduates enter medical practice each year. This represents an increase of about 3% per year while the general population has been growing about 1% per year. Today there are about 29 physicians for every 10,000 population although they are not necessarily distributed evenly across all population areas or groups.
With these numbers one could argue that there is no shortage of doctors. Indeed with the opening of new medical schools and many others increasing class sizes, there should be another 3000 added to the graduating class each year rising to 5000 by the end of the decade. But most graduates enter specialty care rather than primary care training driving the ratio of PCPs to specialists of 30%-70% ever wider. Adding further to the specialist roles (except those with known shortages like general surgery) will only add to health care costs rather than increase quality.
There is good data to support the notion that a primary care-based delivery system increases quality of care and decreases costs compared to our current specialist-based delivery system.
Critical to how many PCPs are trained are two key factors. One is how many trainee (residency) slots are available to train primary care physicians. Medicare pays hospitals to train medical school graduates during their residency. Currently, Medicare pays teaching hospitals $9.5 billion each year to subsidize the training of the next generation of physicians with residency programs that range from three to seven or even more years after medical school graduation. Medicare has kept these “slots” it will cover flat since 1997 and has given no indication of raising this as of yet. But even more importantly are the absolute numbers of PCP vs. specialist slots available. There are simply many many more specialist slots available. Medical centers want to train specialists. They represent assistance to the faculty or staff physicians and they bring an aura of quality to the hospital. No good professor and chief of, say, neurosurgery at an academic hospital would not want to have his or her own training program. It is a matter of pride. Absent a training program, the best will not chose to work for that medical center and will choose to practice elsewhere. This is a serious conundrum for the medical center that needs the specialty program to drive more revenue. And Medicare has been willing to pay for these specialty training programs over the years while not increasing funding for primary care training.
There is a recent study covering 2006-2008 residency training and Medicare payments. Lin, commenting on the article on KevinMD, noted by separating out those 20 hospitals that trained the most and the 20 that trained the least PCPs, respectively, among all teaching hospitals in the USA, “the top primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates of their hospitals (41%) and received $292.1 million in total Medicare graduate medical education (GME) payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates from their hospitals (6.3%) and received $842.4 million.”  In other words, the hospitals that got the most money trained a larger proportion of specialists; perfectly logical if that is where the money is. But this makes little sense in an era of serious primary care physician shortages that will certainly worsen in coming years.
The other problem is that primary care is not seen as a desirable career path today. There are multiple reasons. Primary care physicians earn about one half of what a specialist earns. Specialists are generally seen to have a higher level of prestige in the community – “I was sent to Dr Jones, the surgeon.” Most medical school graduates have large debt loads so earning more means paying it off sooner. And with a large debt, it is harder and scarier to take out a loan to start a practice that brings in fewer dollars. But the primary reason is that medical students realize that PCPs are in a non-sustainable business model, one in which they must see far too many patients per day, accept unpleasant burdens with insurers, be on call many hours and yet not be able to offer  what they know would be better care. They see it as a no win situation and so avoid primary care even if that might otherwise be their preference.
Less prestige, high debt loads and a knowledge that PCPs work in a non-sustainable business model forcing them to see an excessive number of patients per day in order to meet overhead and still garner an income about one half that of the specialist is, combined, enough to discourage medical school graduates from selecting primary care as a career.
The next post in this series will focus on the PCP’s need for time – to listen, to think, to prevent, to treat, to coordinate.

Monday, March 31, 2014

Causes of the Crisis in Primary Care

The Crisis in Primary Care –Part 2

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

In my last post in this continuing series on primary care, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – stress related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office. With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit – most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time – time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise – and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example may need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least. But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

But with little time to listen and think, the action step of many PCPs, as with the patient described last time, is to send the patient to a specialist. Indeed, according to an article in the Archives of Internal Medicine, about nine percent of all visits to PCPs result in a specialist referral, far far higher than truly necessary. This is up from about five per cent a decade earlier; 41 million referrals per year then compared to 105 million in 2010. Something needs to be done. The push for accountable care organizations, medical homes, population health and a switch from fee for service to a salaried or capitated system are noble but unless the PCP is given time and enough of it, these changes – no matter their apparent utility – will prove valueless.

Meanwhile, fewer and fewer medical school graduates choose to enter primary care. They are smart and see that PCPs are very busy and very frustrated. They know that given the PCP’s average income it will take many years to pay off their high educational debt load.

PCPs are looking for ways out of their dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital. But the hospital wants the physicians to earn their keep. That means high productivity. So it is still 24 – 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, not from the government insurances (Medicare, Medicaid), nor will it come from the Affordable Care Act. It will likely be in the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care with lessened frustrations for doctor and patient alike.

For starters, many PCPs need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technologies. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some PCPs have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection (one estimate of this is $58 per patient visit!) they can charge a quite reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or of a set amount for all care for the year, a retainer-based (concierge) approach. In each of these models and others the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and thus begins to ask questions, to challenge and in general to bring down the costs of care while receiving a higher level of quality along with greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by PCPs today in an effort to overcome the current non-sustainable business model so that they can not only give better quality of care but reduce their sense of frustration and increase their patients’ satisfaction.

In the posts to follow I will review what primary care is all about; the characteristics of a good primary care physician and a true healer; who does primary care and why and why not; the critical role of the PCP in managing chronic illnesses; the need to listen and think – both requiring time; the use of teams in the primary care doctor’s office; the importance of care coordination, wellness promotion and disease prevention; the current non-sustainable business model; what approaches are being taken to overcome the current business model; and finally how primary care can once again take its rightful place as the backbone of the American healthcare system offering superior quality, outstanding service and greatly reduced overall costs.

The next post in this series will address the critical shortage of primary care physicians.

Monday, March 24, 2014

The Meaning And Depth of the Primary Care Crisis

The Crisis in Primary Care – Part 1 of a Series

The primary care physician (PCP) should be the backbone of the American healthcare system. But primary care is in crisis – a very serious crisis. The first statement is my considered opinion and I will attempt to convince you of its truth. The second sentence is a simple fact.

Accounting for only 5% of all health care expenses, the PCP can largely control the “if and when” of the other 95% and hence can be the one to best affect quality of care and the totality of costs. This crisis limits the effectiveness of the primary care physician such that care quality is nowhere near what it could be or should be and the costs of care have skyrocketed.

This crisis is the most pressing and frankly most urgent issue in health care delivery today. Healthcare delivery must be restructured – now - so that everyone but especially older adults with multiple chronic illnesses can obtain quality, compassionate, cost effective care. And this means having a committed primary care doctor who has the time along with the knowledge and experience to deliver the care needed.

This is the first of a series on the crisis in primary care that will appear over the coming weeks and months.

To be effective, the PCP needs, of course, to be well educated, well trained and up to date. This is necessary but not sufficient. He or she can be more effective with an appropriate team approach that puts the patient in the center of the equation – the patient centered medical home concept. He or she also needs to be a deep listener and needs to think extensively. Listening and thinking require time and for those patients with one or more chronic illness, the PCP needs to quarterback all of the other providers involved with the patient’s care. This also takes time. Time is the element that has been lost in the past decade or more for the PCP. Without the time to listen, the full picture of a person and their illness does not emerge. Without time to think, the diagnostic process suffers immensely. Without time to listen, the PCP is no longer a healer but rather a well-paid care giver. Without time to think, the PCP is quick to send the patient off to a specialist. Without time, the opportunity for outstanding preventive care is diminished. And without time to coordinate all of the specialists and other providers that are required for someone with a serious chronic illness, the care becomes disjointed, quality suffers and expenses rise.

A patient story may help elicit the meaning and the depth of the problem.

Monica is 68, married, retired, on Medicare and in generally good health. She has a PCP who she sees intermittently. She began to have a strange sensation in her right chest described as a sort of shooting sensation, almost electrical or vibrational in nature that stretches from high up in her right mid chest down as a narrow line over her rib cage and just onto the abdomen. It seems to be immediately under the skin. It starts intermittently and ends at no set time. There is nothing she has found to make it start nor stop. She visited her PCP and offered this description, adding that she was concerned that maybe it was her heart. The doctor asked additional questions and did an exam and an electrocardiogram. All were normal save the description of the sensation.

The PCP was now about out of time for that 15 minute visit. Here was a fork in the road, two paths to choose between. Given that Monica was concerned about her heart, the PCP chose the path to send her to a cardiologist for further evaluation. The cardiologist found nothing abnormal but nevertheless suggested a stress test and an echocardiogram. Both were normal. The cardiologist suggested since the sensation crossed over to the upper abdomen, maybe it would be a good idea to see a gastroenterologist. The GI doctor found nothing. Nevertheless he ordered a CT scan of the abdomen. All was normal except that in her uterus there was a small cystic structure. The radiologist read it as a probably benign cyst but – feeling the need to be cautious –recommended Monica visit a gynecologist. The gynecologist also said it looked benign but just to be on the safe side, she could remove it. Monica would be out of the hospital the same day and feeling fine in a day or so! The cyst was just that, a benign cyst. Monica still had the strange sensation in her chest and no one had found an answer for her.  But given that it seemed to run in a line with an electrical sort of feeling the gynecologist suggested that maybe it was a nerve issue. So she visited a neurologist who of course found nothing, commenting that nerves run around the chest, not up and down.

Monica illustrates the problem so common today in primary care. The PCP did not truly listen to the patient. And he did not stop and think the issue out carefully. He had no time because there was a waiting room full of patients and he needed to see about 24 to 25 each day. So instead, he took the easier path and referred the patient to a cardiologist since this seemed at least logical given that the strange sensation was in the chest and the patient was personally concerned about heart disease. Had he followed the other side of the fork in the road and had listened long enough and then thought about it he would instead have concluded that the patient was hypersensitive to minor – albeit real – sensations. He would have offered reassurance that it did not represent a life concerning ailment. He would have said that it was real but of no concern. He might have offered a few weeks of a low dose anti-anxiety medication, offered further reassurance and told her to return in two weeks for a follow-up. At the follow-up he would have explored the issues producing anxiety or stress in her life – financial, marital, a disruptive child, an overbearing in-law. Had he done so he would have soon discovered that Monica was deeply concerned and feeing guilt about a family issue. What Monica really needed was assistance to overcome her sense of guilt and shame – not months of specialist hopping. Anxiety and stress are often components associated with a physical symptom and these can only be addressed with more time to carefully listen and then time to respond with suggestions.

But this was not the way it was to be for Monica. She was shipped from doctor to doctor, test to test, even an operation yet with no one really listening enough to figure out her problem. All each specialist could do was say it wasn’t in their “organ system” and left her with a sense of floundering and without a sense of closure from any physician. Each one said it wasn’t in their sphere – not the heart, not the stomach, not the nerves, etc. And the “surgery went fine.” But she still had the unpleasant sensation. So it resulted in far less than adequate medical care and obviously cost a king’s ransom. Neither was necessary. But that is what all too often happens today. And, I assure you, Monica’s saga is not uncommon.

Monica’s experience is all too common and results largely from the PCP’s lack of time – time to listen and time to think. The result is less than adequate care, certainly not humane care, not healing care and very high costs.

In the next post, I will address the causes of this crisis in primary care.

Thursday, February 20, 2014

How Many Patients Should A Primary Care Physician Care For?

The answer is probably about 1000 or less. But most primary care physicians (PCPs) have a panel of perhaps 2,500 patients and often more.  Why the dichotomy?

As insurers have held the line on physician reimbursement in the current fee-for-service system, PCPs have found that they must increase the number of visits per day in order to meet overheads yet still maintain their personal income of about $175,000 per year.  In order to see more patients, usually 24-25 per day or more, they must no longer visit inpatients in the hospital nor see their patients in the emergency room.  And they have shortened most visits to about 15-20 minutes which means 8-12 minutes of “face time.”  Too little time for someone with multiple chronic illnesses on 5-7 prescription medications and possibly impaired by age with reduced vision, hearing and memory.

Further, there has been a major shift over the years form mostly seeing acute illnesses to a much larger proportion of patient with chronic illness, often complex and often with multiple chronic diseases. These diseases are difficult to manage, last a lifetime (some cancers excepted) and are inherently expensive to treat. These patients often need to be seen, over time, by many specialists. Someone, preferably the PCP, needs to coordinate this team of caregivers to assure quality, safety and in so doing keep expenses down..

Baron published an article on how a primary care physician spends his or her time. He is part of a Philadelphia area internal medicine group practice with an active caseload of 8840 patients divided across the equivalent of four full-time physicians each working 50-60 hours per week. The office has 3.5 full time support staff per physician. Each physician handled 24 telephone calls, 17 emails, reviewed 20 laboratory tests reports, 11 imaging reports and 14 consultation notes and processed 12 prescription refills each day in addition to seeing patients. It is clear from this report that the PCP spends a lot of time in clinically relevant work not directly associated with a patient visit – which is the only activity that generates an insurance reimbursement. Not noted was the very substantial time spent in non-clinical requirements such as insurance forms.

So what is an appropriate number of patients under care or number of visits per day?  The answer, of course, is that “it depends.”  It depends on the type of patient, their reason for the visit, their impairments and their personal needs, to name but a few. 

I have completed multiple in-depth interviews with many PCPs.  Most were in private practice; some were in an academic setting.  Most accepted fee-for-service insurance; some were retainer-based PCPs.  Some had been in practice for decades, others for a few years.  About three-quarters were men, the remainder women.  Of the 21 questions, one asked the ideal size of the PCPs patient panel. Their responses varied but here are some generalizations.  PCPs, they said, should have no more than about 1,000 patients under care, perhaps less if the majority are geriatric with complex chronic illnesses and perhaps up to 1500 if most were basically healthy.  But, in order to meet overheads, most of these same PCPs had closer to the 2,500 panel size.  The exceptions were retainer-based PCPs with about 500 and a salaried PCP in a retirement community with 400 patients in his panel.  These physicians felt they were able to give much better care to these smaller sized panels of patients. The retirement community PCP had strong data to support his contention, e.g., reduced hospitalizations and markedly reduced unplanned 30 day readmissions to the hospital. One of the retainer-based physicians participated with MDVIP, an organization which has developed similar data on substantially reduced admissions.

I asked the same question on a LinkedIn group.  Many responded as did the PCP interviewees.  Here are some specific comments: “Patients are not products on an assembly line that must all fit into specified compartments as business models dictate.”  “Time is what affords the physician the ability to utilize all of his or her experience and medical expertise in the most efficient manner to benefit the patient.”  “Time is the one component necessary to be effective.”  Another response was that PCPs who decline insurance and have the patient pay directly can actually charge less because their overhead declines so dramatically, perhaps by about $58 per patient visit.  A third stated that PCPs need to develop and properly manage an office team and delegate responsibility and authority accordingly.  Data collection and data entry for example can be done by non-clinicians and much preventive care can be handled by nurses and nurse practitioners, thereby freeing up substantial time for the PCP to interact with patients – time to listen and time to think. 

An article in the Annals of Family Medicine by Altshuler and others sought to estimate a reasonable sized patient panel for a PCP with team-based task delegation consistent with the patient centered medical home model.  Using published estimates of the time needed by a PCP to provide preventive, chronic and acute care they modeled how panel sizes would change if some portion of the work in each of the three categories was delegated to team members.  If there was no delegation of work, as has been typical in PCP practices for decades, the data suggest that a patient panel size of about 983 is the maximum, not too far from my own estimate of 1,000 based on the various interviews.  They then assumed varying levels of delegation to the team.  Their model panels with team-based delegation ranged from 1,387 to 1,947 patients.  This analysis suggests that a primary care physician can care for more than 1,000 patients provided he or she practices as part of a well-oiled team-based medical home practice.  It does not address the question of whether the team can practice true “population health” meaning that the PCP and his or her office team reach out proactively to all members of the patient panel to address high quality preventative care rather always being reactive by waiting for the patient to arrive at the office with a problem. 

PCPs (and all doctors) need time with the patient if they are to be effective and to be trusted.

Something needs to change if PCPs are to get back to providing the level of humane, comprehensive care that patients want and doctors wish to offer. The current reimbursement system short changes the patient and frustrates the physician. Insurers should look to new approaches that pay the PCP to actually spend time with the patient – time to listen, time to prevent, time to treat, time to coordinate chronic care, time to think and time to interact with their colleagues, especially regarding more difficult situations. This can be with fee for service, capitation, bundling, etc. or by the PCP no longer accepting insurance and expecting the patient to pay directly by the visit, the month or the year. In whatever manner, the new paradigm must create time for the physician to spend with the patient so as to listen and think about both the patient and his or her condition.

Thursday, December 19, 2013

Small Businesses And The Not So Affordable Care Act

The Affordable Care Act is not so affordable if you own or if you are an employee of a small business. Here is why.
Consider the owner of a small service business with one or multiple outlets (e.g., a large restaurant or a small chain of sit down restaurants, a chain of barber shops, a taxi company.)  The owner has more than 50 employees but the business is still “small” with less than 1000.  It is a service business where the usual wage is about $10 per hour or about $20,000 per year plus significant tips. Many of the staff have been with the company for decades and some prefer to work fewer hours for family reasons.  Let’s also imagine that the company has always offered a quality health insurance plan to those who work full time (greater than 32 hours per week).  The owner selected a plan that has a modest deductible of $200 per year, good catastrophic coverage and a maximum out of pocket expense for each employee of $1,000.  Company policy has always been for staff to pay approximately 50% of the premium.
At the company whose owner I talked with, both the company and a single individual are paying about $2,000 per year in premiums.  Most   of the full time employees are not enrolled.  Some have coverage through a spouse’s employer.  Others are young invincibles and choose to use their wages for other purposes. But the owner encourages all to participate who wish to or to sign a waiver that they chose not to do so. The health care policy is (and has been) consistent with the ACA/Obamacare guidelines for the various essential services that must be covered; it has never been a “substandard” policy. 
In 2014 all of the full time staff must, per the ACA, have insurance or pay a penalty tax.  That means the young invincibles will be required to sign up somewhere.  If they enroll in the company plan and pay their share of the premium, they will have less take home pay – perhaps a hardship.  But every time one more employee enrolls, the business will also have to pay its 50% share of that premium as well.  The owner is pleased that the employee is now covered but this is a new and substantial expense for the company. 
But that is not all.  Beginning in 2015, an employee cannot be required to contribute more than 9 ½% of wages for their insurance.  Since the full timers tend to earn about $20,000 per year, less for someone working say 32 hours per week, a $2,000 per year share of the premium exceeds the 9 1/2 % limit.  To avoid a significant penalty, the business will need to lower the employee contribution amount, adding further substantial expense to the company. 
So what’s the import?  Does it really matter? 
There is general agreement that it is good for everyone to have insurance.  But this company’s prices will have to go up to cover the new expenses.  And a price hike may make the business less competitive because other companies in this business may have less than 50 employees and hence are not affected by the ACA requirements.  What the owner will likely decide to do is preferentially hire part-timers even though having fewer employees who work longer hours each is otherwise preferable. 
So, in the end, all fulltime employees will have insurance; some employees forced to buy insurance will now have a lower take home pay with its consequences; the person who wants to work more hours will be pushed toward less hours with yet lower take home pay; and the customer will pay a higher price for the service. Is this affordable health care or is it is the law of unintended consequences? 

Sunday, November 3, 2013

Cheap Drugs From Canada– Good Idea?

The price of drugs comes from a perverse system and what you as a patient pay is equally perverse. Let’s consider a few examples.
Older people often develop actinic keratosis on their scalp as a result of years of ultraviolet rays from the sun. They can progress to skin cancer so it is good to treat them. A dermatologist can remove them with liquid nitrogen or the individual can apply a prescription drug that kills the cells in the AKs. The drug most commonly used for decades is an anticancer drug – 5-flurouracil or 5-FU. Applied topically it can be very effective. 5-FU was developed before I went to medical school which is now 50 years ago. It is obviously off patent and not difficult to manufacture. But the branded topical called Efudex costs about $300 retail. Wow! There is a generic but it is also expensive, albeit at half the price of about $150. It is a large tube and will last a long time but it is a lot of money none the less. It is not a high volume drug and there are only two manufacturers so the competition is minimal enough to keep the price high. And even with the generic, there is a large middleman profit between what the manufacturer sells it for and what the pharmacy ultimately charges you (or your insurer.)
Staying with dermatoligic issues, rosacea can be cosmetically bothersome with redness, papules, acne-like pustules on the face and coarsening of the nose (rhinophyma.) Its cause is unknown and there is no really good treatment. One approach has been to use an antibiotic called doxycycline taken orally in the usual “antibiotic” dose of 100mg. It seems to have an anti-inflammatory effect rather than an antibiotic effect in the skin and often can clear the face. It is a very inexpensive capsule at about 30 cents each. But it can also have an adverse effect on the bacteria in the gut and possibly lead to overgrowth of yeasts. A new approach is a 40mg capsule branded as Oracea which is both regular doxycycline and a sustained release form so that the blood level stays low and relatively constant over the day; perhaps it will have less likelihood of adverse problems. It has been tested and found to be reasonably effective for rosacea and hence approved for market by the FDA. But it is on patent and costs about $10 per dose or $300 per month– a drug that the patient will probably have to take forever to keep their face clear. That adds up – fast. Instead one might consider using the standard 100mg doxycycline but only for a few days whenever a flare-up begins. Low cost and limited side effects, if any.
Steroid creams are commonly used for rashes. I was once given a prescription for betamethasone for a small rash. Why betamethasone rather than over the counter hydrocortisone? “It is stronger and will work faster,” said my doctor. But, since I had a high deductible insurance policy, I had to pay the entire bill which proved to be a remarkable $67. An over the counter tube of hydrocortisone at the same pharmacy, enough to last a whole family for years and years, costs only $1.98. Sometimes it pays to accept a slower cure.
Let’s say you need an acid suppressor for reflux esophagitis [acid reflux or GERD.] There are multiple drugs called proton pump inhibitors on the market, some off patent and now over the counter and others still on patent and only available by prescription. They are all effective. The differences among them are minimal. Your doctor could tell you to go to the grocery store and pickup Prilosec for about $30 for a month’s supply. Or, he or she could give you a prescription for Nexium. It would cost about $150 for a two week supply. But your insurance will pay for it except for your co-pay of, say, $15. So your doctor will probably suggest Nexium since it will cost you less. But the overall system is paying out a huge amount more than necessary. What a perverse system. 

If you are the one paying for the drug because you have a high deductible plan or no plan at all then you start to ask questions. Sometimes you can find a generic equivalent like the fluorouracil example but sometimes the generic is still expensive. That is you might start to look elsewhere. 

What about buying drugs from Canada? Same drug but at a better price. I checked and found the topical fluorouracil branded Efudex for $75 including $10 for shipping. That is a lot better than the generic price here of about $150 and way better than Efudex at about $300. For the doxycycline, using the same web checker, I found a 50mg dosage (albeit not sustained release) that costs about $17 per month. Oracea 40 mg capsules can be found in Canada for about $2.00 each if you buy more than 50 at a time. Both are quite a difference from $3600 for a year’s supply. Nexium can be found for about $1.00 a pill, way less than in the United States but it is just as easy to go to the local grocery store and buy Prilosec for much less still. As for betamethasone, it is $25 with a $10 shipping fee. A lot less but over the counter hydrocortisone is still only $1.98! 

But buyer beware. We have a very carefully monitored market in the United States through the FDA. We benefit greatly from its regulations and its careful scrutiny of each new drug before it can be marketed. IN the United States, the drug can be traced from the manufacturer to the distributor to the pharmacy to you so you can be certain it is the real thing. And companies that manufacture overseas must follow the same stringent requirements as in the USA in order to sell here. The FDA's concern is not to protect the drug companies profit from competition but to protect us (you and me) from the unscrupulous. The concern is that the drug bought from Canada (or elsewhere) may not actually be the drug it is said to be. Witness the highly expensive drug Avastin used to treat certain cancers. A counterfeit was somehow entered onto distribution in the USA from somewhere else- except that it was not Avastin. It was not a drug at all. A lot of unsuspecting doctors and patients were duped. So it behooves us to carefully balance the pros and the cons.  

Why does it cost less in Canada or other countries for the same drug? Because the other countries tell the drug company that it can only sell the drug at a set upper price limit. If that limit is still within the pharmaceutical manufacturer’s marginal cost per unit of drug, then they will agree and sell at that level. In America, we are effectively paying for the entire R&D cost of bringing a new medication to market along with the company’s marketing cost and still giving it a huge profit potential. Rather than import the drug from Canada, we should just expect the company to sell here for the same price as there. But they do not have to and so they do not. Right now, Americans effectively pay for the R&D costs of new drugs while others get a discount because their governments insist. So should ours. It would bring the price down and negate the need to look to Canada or elsewhere.

How to do that without imposing price controls or getting the government into further regulatory policies. I wrote in the Future of Health Care Delivery that the federal government should simply say that it (through it drug purchases via Medicare, Medicaid, the military and Veterans Administration) will only buy medications from drug companies that sell it for the same price here as overseas. The drug company still can sets whatever price it wants but since the government buys at least half of the drugs sold in the USA, it should have an impact and quickly.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).