Doctors for America Blog

Less Access at Greater Cost

Tue, 29 May 2012 07:28:30 -0400

I always try to be sympathetic when my physician colleagues ask for fair financial reimbursement for their services. After all, our days are long, stressful, and the job entails years of training before those first bills can even be sent. But when docs push for increased reimbursement under a false flag of improving patient access, and patients are placed in potentially coercive situations, I cry foul.

Meet H.R. 1700/S. 1042 – The Medicare Patient Empowerment Act. It would allow us docs to contract with patients and balance bill them for amounts above and beyond the currently well defined Medicare reimbursement schedule. That might be an amount that is close to, or even exceeds, standard fee-for-service schedules…long ago inflated to sometimes obscene levels to compensate for much lower contracted rates with private insurers …or just something much closer to those contracted rates. Rolled out about a year ago, the proposed bill is now being pushed by the American Medical Association and some state medical societies.

How would this work? Let’s say I’m in a small primary care office. I could decide that only new Medicare patients need to contract to pay me more (never mind the waiting room mêlée that will eventually occur when the patients start talking among themselves) or require all my established Medicare patients to contract. Either way, two things happen. Some patients, perceiving that I am man’s-best-doctor, will gladly, or based on fear that their health may be threatened, sign up. Some will have money to burn; others really can’t afford it but will sacrifice financially in other areas including necessary health expenditures (i.e. dentists, prescription drugs). But in my neck-of-the-woods, where many primary care docs are accepting new Medicare patients, most of my existing patients will say “love you doc…but” and burn a path in the carpet leading to the records transfer staff.

But what about a family doc practice in a place with high overhead costs…like downtown LA or Manhattan…or Sun Belt locales where offices can be knee deep with seniors every January. Medicare reimbursement rates can be a burden in such places. Getting into an office requiring contracting will be financially impossible for many seniors and drive them to already overloaded non-contracting offices. And many seniors, already established in newly contracting offices, will be fearful to leave even though they really can’t afford to pay their Medicare Part B premium, medi-gap insurance premium, co-pay, deductible plus a bill balance. So, a worsening of access problems for most seniors in areas already with problematic access.

And don’t even think of balance billing if you are a doc in a mega-multispecialty group of one or two hundred physicians or employed within a big health system. Once thousands of patients in a community are affected, it will not be long before the media finds tearful, 89 year-old Mrs. Jones, complete with walker and portable O2, complaining that she can no longer see her beloved doc of oh-so-many years. That group will rapidly reverse its contracting decision and its administrators will put in longer hours than their docs as they backpedal and apologize.

Surgical specialists? Some of these docs will jump on this contracting idea in a heartbeat. Established and respected ophthalmologists or orthopedist, long feeling that perceived meager Medicare rates undervalue their expertise and experience in removing cataracts or replacing joints, will gladly ask for more cash from patients and get it from many. More offices will want to get in on the gravy-train producing more access problems for lower income seniors.

Does the AMA really think this legislation will increase access? I think not. More likely this is a bone being thrown to members and state societies disgruntled by its well reasoned support of the Affordable Care Act. This legislation has nearly zero chance of getting through the currently constituted US Senate. But it is an example of attempts at Medicare reform that we will see more of, particularly if Obamacare falls, that restricts access to the folks most in need or shifts costs to populations least able to pay.

Civic Responsibility, Power

Fri, 25 May 2012 10:35:38 -0400

Did you know that physicians usually vote at a rate lower than the adjusted rate for the general population? And did you know that we always vote at a rate lower than lawyers? Overall, physicians vote at a rate 8.7% lower than the general population (41.5 vs 50.1%) and 22.1% lower than lawyers (41.5 vs 63.7%). Also the lag in physician voting rates hasn't changed since the 70's.

Why is this? I'd like to think we have as great a sense of civic responsibility as lawyers. Theories about why we don't vote at as high a rate as other professionals include:

We feel that because our work has a greater social purpose, we aren't as obligated to participate in the civic process.
We feel disenfranchised as we have less power in the daily runnings of our health care organizations, so feel our vote is less important
Our professional organizations have focused their discourse less on sociocultural purpose and more on internal affairs, such a reimbursement and professional development.

I'm not sure any of these is the major reason physicians don't vote. I think the real reason we sometimes don't vote is just time. It can be hard to make it to the polls on Election Day. This has certainly been an issue for me. On two occasions, I wound up held up taking care of patients and couldn't get to the polls. But this is relatively easy to prevent, so take a moment today to do two things:

1) Make sure your voter registration is up to date. I got a reminder from our local election commission to do this recently and thank goodness, because I had forgotten to update my address when I moved. Here's a site you can visit to check your registration in any state.

2) Request a mail in ballot. They aren't calling them absentee anymore, thank goodness. I love going to the polls and voting, it gives me a sense of pride to cast my vote. But I've decided to sacrifice this personal satisfaction to be sure that my vote actually counts. The way I see it, you don't fill out a mail in ballot because you are an absentee in the voting process, you fill it out because you think voting is incredibly important and you don't want to not fulfill your obligation.

So get out your vote as a physician! It is our obligation as citizens first, but also as professionals in our society we set the example for others and should be participating in civil discourse. And, while I don't want to start any professional battles, really, we can't do better than lawyers?!

Cross-training Doctors: Improving Patient Care and Job Satisfaction

Thu, 24 May 2012 07:30:52 -0400

“What about combined Psychiatry/Family Medicine/Neurology/Internal medicine programs? Should I try to do a triple board program in psychiatry/child psychiatry and pediatrics?”

Every April, I field such questions from a slew of rising fourth year students who have become, to their surprise (and sometimes dismay), passionately interested in psychiatry. Psychiatry is a shortage specialty and psychiatric issues rank high among the challenges facing medical care systems here and around the world. For example, major depression has steadily advanced up the ladder of the World Health Organization’s ranking of conditions accounting for years lost to disability (YLD) and disability adjusted life years—to the point that major depressive disorder now accounts for the highest number of YLDs and is fourth leading contributor to DALYs worldwide. Together, alcohol, illicit drug and tobacco use are responsible for 9.1% of the total burden of disease around the globe. These numbers translate into millions of years of productive life loss, and billions of dollars of money inefficiently spent on medical consequences of preventable diseases. Don’t get me started on obesity…

While stress related illnesses, changing habits or adapting to chronic illness aren’t solely psychiatric concerns , within medicine , psychiatrists are uniquely qualified to address them with patients, and to enhancing the capacity of generalists and members of the allied health professions to diagnose and, sometimes, treat psychiatric, psychosocial, and behavioral problems.

Nevertheless, until now I have discouraged students from signing up for combined training programs. Even doctors who are eager and well prepared to deal with complex medical/psychiatric/behavioral problems cannot overcome the barriers of mental health “carve outs” and discriminatory reimbursement. Those who want to integrate psychiatry with another specialty may find themselves unable to bill for psychiatric services. If someone wants to integrate another specialty with psychiatry, problems of building and supporting the necessary teams are as daunting as problems of reimbursement and access. Graduates of combined programs struggle to find positions that allow them to practice both specialties once they leave training. Many default to practicing only one or the other, wasting precious skills acquired at considerable cost.

My advice is changing. Certain organized systems of care, in particular the Veteran’s Administration, have pioneered programs that make optimal use of psychiatric expertise at the interface of psychiatry and medicine/pediatrics/neurology. Provision 2704 of the Affordable Care Act has done much to encourage the creation of medical homes and accountable care organizations, places where the cost savings and increased professional satisfaction of providing integrated care quickly become apparent. At a recent meeting of the American Psychiatric Association, multiple presentations on integrated care attracted standing room only crowds. Many demonstration projects are sustained by grants; despite their obvious benefits, exciting new models for integrated care will not survive unless the system of payment for services evolves to make them viable.

Like my students, psychiatrists of every level of experience don’t want to give up being physicians in order to practice our unique specialty. We are eager to use our basic medical training throughout our professional lives, and to offer the fruits of what we have learned as specialists to our students and colleagues. For the first time in decades, I can now tell students this dream is becoming reality. Come next spring, when a student sidles into my office and says, with some embarrassment, “Dr. Frank, I think I want to be a psychiatrist…um…er…what do you think about a combined program?” my answer is going to be “Go for it, kid!”

Reflections from the Field: Our Happiness is Our Health

Wed, 23 May 2012 12:29:22 -0400

I have just returned home from an emotionally exhausting shift at Pacific Free Clinic in San Jose. As is often the case, it was last patient of the day, a gentleman who spoke perfect English, who left a lasting impression on me and challenged my emotional capacity. RS, as the patient will be called, was a 48-year-old man who presented with an onslaught of medical issues. Highest on the list was an ongoing, lifelong struggle with depression that had been exacerbated in the past 2 months after he ran out of his antidepressant medications. RS expressed feelings of hopelessness, frustration, lack of motivation, and a general anger towards the world. His traumatic past and current situation was certainly a key contributor, if not a direct cause of his depression. His father had been abusive all his life—abusive towards RS and abusive with alcohol. He had grown up around violence in a world filled with hatred and fear. More recently, his mother committed suicide after succumbing to her own struggles with depression. His sister, who he described as ”borderline mentally retarded,” was a continual source of stress to the point that RS was forced to sever their relationship.

More recently, the sources of stress in his personal life have mounted. In 2009, he lost his job after a 15-year run at the same company . Since then, he has been both unable and unwilling to find work. He expressed feeling defeated, which has crippled him emotionally and rendered him helpless for pursuing work. Yet, at the same time, he admits that unemployment was the driver of his anxiety and frustrations with the world. His wife is currently employed, and his son and daughter are busy finishing their senior year of high school. He is left alone at home each day, by himself, to ruminate, to agitate, and to self-medicate. He has always taken to alcohol during tough times, but he admits that this time it is worse than before. He can easily finish a bottle of rum each day, and he takes to the bottle each morning as soon as he wakes. He explains that he is simple bored of life—there is no more joy and all he can think to do with his free time is drink in an attempt to forget it. It pains him to think of his wife at work all day while he is at home, being “useless” and unable to provide for his family. In essence, he feels robbed of his masculinity and ashamed by his inability to take action. Although his family provides a source of joy and pride, his frustrations and alcoholism are self-isolating and a strain on his relationships.

I feel helpless, as I am not adequately prepared to deal with this emotional burden to help the patient explore his illness. I try to narrow the scope of the discussion and focus on the more manageable health issues—his high blood pressure, high cholesterol, and back pain—even though I empathize that he is here in a desperate attempt to reach out for a human connection. I am a stranger, and the anonymity of our interaction provides a sense of safety to unload emotions. I realize that this depression is limiting his ability and willingness to take care of his other health issues and to tackle his addiction.

I imagine that RS is not the only patient who is suffering from severe depression due to unemployment. People are very much defined by their job. This provides a sense of purpose, pride as a provider, and a reason to get up each day. Loss of a job, especially for the family breadwinner, is a devastating experience that wrenches the soul. The economic situation in this country has forced many people, and then patients, to face this reality. It would not be surprising if unemployment were discovered to be one of the primary reasons for the recent uptick in the prevalence of major depressive disorder here in the United States. People need a reason to live, just as much as they need food, water, shelter, etc. RS is a very competent individual who is capable of managing his other chronic conditions. He has a handle on all of his medications, he is capable of caring for himself, and he is cognizant of the lifestyle changes that he must adopt in order to control his blood pressure, lipid levels, and potentially high glucose levels. He understands that he has an addiction to alcohol is ruining his relationships and jeopardizing his physical health. It is quite clear that the major roadblock to addressing all of these issues is his mental health. This serves as another reminder of how much remains unknown about the inner workings of the mind and how critical it is to treat mental health in order to optimize physical health.

Unfortunately, there is only so much help that we can offer at a one-stop free clinic. The key was to get RS to focus on two to three conditions on his list that were most concerning to him and that we could address right there in our limited time. With no job, and hence no health insurance, RS had run out of antidepressant medication. As soon as the medications ran out, he noticed increased anxiety and, in turn, increased drinking. It was easy enough to provide him with a new dose of the antidepressant medications. In addition, we referred RS to Valley Medical Center for follow up with a psychiatrist and continued care with a primary care physician. He had lab work performed to monitor his cholesterol and to check for elevated blood glucose levels as a screen for diabetes. We feel confident that providing a mechanism for continued care through a primary care clinic will at least help to coordinate RS’s complex and multifaceted health issues. Although this action plan was comprehensive given our limited resources, this does not fix the problem of course. This is a case that demonstrates the powerful impact of the broader economic and social situation on the mental health of the population. This speaks to the larger problem that we as a society face in facing and adequately treating issues of mental health. Perhaps if we could better understand the impact of mental health disorders on physical health, this would motivate us to study and allocate health care resources more equally. Until then, patients like RS will force an uphill battle, searching for motivation and encouragement to deal with their health problems while their minds tug in the opposite direction.

Doing More With Less? The Closing of Chicago’s Mental Health Clinics

Tue, 22 May 2012 05:28:15 -0400

Yesterday marked the official end to the NATO Summit in Chicago, an event that dominated the news of our city, not to mention disrupted our traffic patterns and weekend plans. While leaders from fifty countries gathered to discuss global security and economic issues, the real news of the summit was four days of protests. Demonstrators marched the streets for a wide gamut of causes and viewpoints—“End the war,” “Tax the rich,” “Capitalism has outlived its usefulness!”—mostly global themes that inspired ideological fervor.

But one group of Chicagoans used the international spotlight and took to the streets to highlight a local problem: the closure of a half-dozen Mental Health clinics by the Chicago Department of Public Health that served that uninsured and Medicaid patients. The city once had 12 health clinics that provided mental health services to about 5,100 underserved patients. Last fall, however, Mayor Rahm Emanuel and the CDPH announced that they would close six of these clinics and fully fund only two of them, lay off over 50 staff, transfer care of insured patients to private mental providers, and save $3 million by consolidating services.

After the first two planned clinic closures occurred, community organizations rose up in outrage. A series of protest rallies and vigils were organized over the next several months. The Mental Health Movement, a coalition of groups including Southside Together Organizing for Power (STOP) and the American Federation of State, County, and Municipal Employees (AFSCME) union local. A sit-in at one of the slated to shut down, the Woodlawn Mental Health Center, led to dozens of arrests in April.

And yet, by the beginning of May, the City had closed the remainder of the clinics.

So on Friday, to kick-off the NATO protest weekend, a group of citizens took their message all the way to the top, to Mayor Emanuel. They rallied not at his office in City Hall, but at his home, and went door-to-door to recruit allies in his politically progressive neighborhood.

The closures came on the heels of Illinois’s cuts to in Medicaid payments to mental health provider across the state. That decision was made by Governor Patt Quinn, faced with a $8 billion state deficit and growing.

Yet, for a mayor also facing huge budget shortfalls, Mayor Emanuel said it’s not about the money. Instead, he claimed that psychiatric services would be enhanced and be more efficient because 1) they would now be available at all city clinics for 3,000 uninsured patients; 2) these patients would receive more time with their city-employed providers, because 1,100 insured patients, including Medicaid recipients, would be referred to over 60 community-based, non-profit, private mental health providers; and 3) $500,000 in grants would available to augment these private clinics. And starting in 2014, Medicaid eligibility would expand to more uninsured patients due to implementation of Affordable Care Act.

The CDPH commissioner, Dr. Bechara Choucair, re-iterated the financial and expansion logic to a crowd gathered at the University of Chicago’s Urban Health Initiative summit (the UHI has itself earned controversy, trying to resolve the challenge of preserving access and capacity while managing limited resources). The focus, Choucair stated, needed to be on the most vulnerable, uninsured patients with mental illness who would clearly have no recourse in the private sector, about 80 percent of those who seek the city’s help. Choucair has also tried to meet with protesting groups to explain this strategy.

But consumer groups decry that closing down clinics subtracts services and that capacity needs have been clearly under-calculated. More than that, capacity is not the same as access. One article estimates that transportation to the remaining fewer clinics will mean extra bus trips and 4 extra miles for poor patients. Hispanic patients previously benefited from Spanish-speaking providers at the Northwest Mental Health Center but may now have to travel to other city or private clinics that have fewer language services. Finally, continuity between patient and provider, the relationship that is vital to mental health care, is disrupted.

These advocates have already stated the transition period is going poorly, reporting that patients falling through the cracks. Commissioner Choucair objects to these claims, saying that the department has been monitoring patients closely during the transition, for the very reason to make sure these gaps in care don’t occur.

What frustrates protesters the most are the Mayor’s and CDPH’s claims that the closures will lead to more, not less, mental health service, through the consolidation of services and use of the private sector. It’s a claim that Dr. Lora Chamberlain found preposterous: "Rahm spins it. Somehow, out of less he's going to make more. He thinks nobody can add. They are cutting services when we have a greater and greater need." Her sentiment was echoed in a letter by 50 mental health providers to the City and to the Media harshly decrying the logic as “Orwellian” and complaining that CDPH staff had been “intentionally dismissed and excluded from the Commissioner's narrative.” The problem, they say, is not one of inefficiency in services, but of sheer inadequacy of resources, for which they have been demanding redress for years.

The providers and others claim that the City listened to the advice of The Civic Federation, a non-profit private research group that comments often on state and local budget problems, who suggested the City consider closing clinics because they were “dead meat anyway,” in anticipation of a private sector expansion under the Affordable Care Act.

Did the advent of future federal health care dollars through Medicaid expansion usher in a sort of reverse “crowd-out,” i.e., the closure of public services in anticipation of the expansion of Medicaid coverage for private services?

The Chicago Reporter has written skeptically about the Civic Federation and its recommendations, and in an interview with University of Chicago expert Colleen Gorgan, found them rather weak. For one, private clinic support and future Medicaid expansion does not solve the capacity problem because the closed clinics are in already medically underserved areas, as designated by the Dept of Health and Human Services, where few private providers practice. Second, the states administer Medicaid, and Illinois’s cuts to mental health care signal that future budget problems will persist, ACA or not. For non-profit providers, they will simply have to scale back on services due to an inevitable shortfall, not likely made up by the half-million dollars promised by the City. Ironically, if the city’s clinics had stayed open, they would have qualified for more Medicaid dollars from the ACA.

With regard to mental health care, is “doing more with less” valid? It’s not likely that outpatient mental health services are over-utilized. Instead, it is clear that less care and poor continuity lead to the use of the emergency department and the jail system for mental health problems, which are more expensive and less healthy. Cook County Sheriff Tom Dart has weighed in against the closings, frustrated that many criminals should be patients instead of behind bars and many victims could have been spared the crimes committed by the mentally ill.

Chicago’s and Illinois’s problem with mental health services highlights the dilemma that deficit-strapped governments’ have with maintaining health care services. With unsustainable rises in health care costs, they look to public-private partnerships to save money without having reliable forecasts that the market can adequately serve. Progressives believe that minimum safety nets already fall short because all the variables of a comprehensive health care system are rarely estimated correctly, but their requests for increased funding is naïve to budget realities. Unfortunately, despite the fervor of thousands of NATO summit protestors’ marching and chanting on idealistic themes of equal opportunity and protecting the poor, slashing public services for the most vulnerable still provides the least resistance for policymakers faced with practical reality. As Dr. John Grohol, founder of PsychCentral.com writes: “Illinois, like many states, [found] it easiest to cut public mental health services first, because mental health has few lobbyists that work on behalf of the population most affected — the poor.”

Who do you believe?

Fri, 18 May 2012 07:14:46 -0400

One week ago, the editorial page of the Wall Street Journal (WSJ) decided to pick a fight with The Institute of Medicine (IOM). In response to the new report, “The Weight of the Nation,” the WSJ accuses the IOM of politicizing obesity. They use familiar language as most opponents of health reform do, maligning the recommendations for new regulations or taxes to attempt to combat our exploding epidemic of obesity. The editorial is light in the department of suggested alternatives to the IOM recommendations, with one mention of “entitlement reform” and another of “end to subsidies for…corn,” but the general tenor of the piece is all too predictable. The WSJ takes the position of criticizing the IOM report – a product of years of research and consensus building among our country’s most reputable obesity experts – with tropes of over-regulation and accusations of partisanship.

I would encourage you to watch the companion documentary to the report. It has 4 parts, each about an hour in length. It describes in detail the obesity epidemic in our nation and suggested solutions – highlighting successful programs across the country.

What the WSJ seems to want its readers to do is ignore science and support their own partisan view of government policy. Already, there is research that shows interventions in California Schools banning sugary sodas and instituting new nutrition standards is working, leading to 158 fewer calories consumed per student per day. By reducing calorie intake among students to this degree, it will result in 16 fewer pounds gained per year (3500 calories per pound of fat in humans)! The WSJ cites conservative economists at the Mercatus Center of George Mason University to diminish the efficacy of soda taxes. Yet there is ample evidence that raising cigarette taxes has dramatically reduced teen smoking rates.

The vast majority of the IOM report and documentary focuses on combating childhood obesity. They do so because science tells us that obese children are much more likely to become obese adults. But logically, adults have the ability to make their own choices in an informed way, whereas children are impressionable – most children are not going to turn down soda, pizza and French fries in the school cafeteria. If the last several decades have seen the deterioration in the nutritional value of school meals, and we are now waking up to the devastation of our waistlines, I would hope that we care enough about future generations to do something about it.

It comes down to: who do you believe? I choose to believe the dedicated scientific experts of the Institute of Medicine rather than the Wall Street Journal Editorial Board. I will let you judge who has partisan motivations and who has ambitions to better the health of our nation.

Towards an Ethic of Physician Responsibility

Wed, 16 May 2012 10:10:55 -0400

By now we are all familiar with the statistics: the United States spends a disproportionate amount of money on health care for results that are, at best, comparable to countries that spend far less. Whatever your diagnosis of this problem, whether it is a result of misaligned incentives, under-investment in primary care, or government interference, and whatever your prescribed treatment – Accountable Care Organizations, increasing access or unleashing the free market – there is one inescapable common denominator. If any reform is to be successful, physicians must have more knowledge of and be more responsible for costs in our health care system.

Physicians in the United States have historically been granted a substantial degree of autonomy. We were slow to develop a system of private insurance, largely because physicians saw private insurers as a threat to their independence. Likewise, the United States was, until recently, one of the few developed nations without a national health policy providing universal coverage, in large part due to opposition from physician's groups. Even the Affordable Care Act avoids the overt government involvement of a single payer plan, instead preferring a lighter touch that defers to doctors and hospitals

This deference to the autonomy of physicians gives the medical community a moral obligation to address the challenges that face our industry. As a profession, physicians cannot stand idly by while costs in the health care system – costs which are largely under their control – grow to consume an ever larger share of economic output, pricing ever more people out of the system. Whether you believe in the power of free markets or the necessity of government intervention, the case for practicing more efficient and less wasteful medicine is clear.

Of course, nearly any physician you ask will acknowledge the importance of this goal. After all, who stands for wasteful spending? And yet, at an absolute minimum, in excess of twenty percent of our health care dollars are wasted. The question then is not whether physicians should commit themselves to eliminating waste, but rather what are the obstacles standing in the way of this commitment?

The primary obstacle is one of education. A recent study showed that physicians don't understand basic cancer screening statistics. They mistakenly valued less important indicators like increased early detection and improved survival times over more definitive indicators, such as reduced mortality, when evaluating whether a screening test was worthwhile. Another study looked at oncologist's readiness to assess the cost-effectiveness of various treatments and found them unprepared. They were inconsistent in how they weighed the cost of expensive new therapies against the benefits they provided in additional months of life, first saying a treatment adding one year to a patient's life would be worth $100,000, and then later, when presented with a hypothetical patient, endorsing much higher levels of spending.

Many would pause here claiming that it is not the physician's role to assess the cost effectiveness of the tests and interventions they provide. They argue that physicians ought to do whatever their patients wish, regardless of the costs incurred. Wasteful spending in one area, however, leads inevitably to higher insurance premiums and higher taxes, and the costs we incur therefore fall upon society as a whole. For this reason, physicians should work to reduce these costs not only as stewards of our patient's overall well-being, seeking to provide the highest quality care that we can for our patient's dollars, but also as citizens of our nation, attempting to utilize limited resources in the most efficient way possible.

The other major barrier to the practice of cost-effective medicine is the problem of misaligned incentives. Because doctors and hospitals are mostly paid on a fee-for-service basis, rather than for entire episodes of care, they are rewarded for performing more tests and procedures instead of for providing quality care efficiently. This means that even if doctors are well informed about cost-effectiveness research it will be difficult to translate this knowledge into practice without damaging their own bottom lines.

We are beginning to solve this latter problem. With the Affordable Care Act's move towards Accountable Care Organizations and reimbursing physicians for the quality of care they provide rather than the quantity, the fee for service model will hopefully soon be a thing of the past.

Equipping physicians with the knowledge needed to make this transition is a more difficult matter. The recent list of overused medical tests compiled by a group of medical societies led by the American Board of Internal Medicine Foundation was a good first step. The move by organizations like Costs of Care to bring price transparency to health care will aid physicians in making these cost-conscious decisions. Increasing the emphasis on cost-effectiveness in the education of medical students like myself will also be an important change. In the end, this transition will require the acknowledgment of physicians as a whole that understanding the costs of the care they provide is as integral to being a high-quality clinician as understanding the benefits.

Transforming the American health care system will not be easy. But no matter what your political persuasion, no matter what reforms you think are necessary, no reform can succeed unless physicians are ready and willing to eliminate wasteful spending and perform their jobs more efficiently. It is the single change upon which all others ultimately rest.

Celebrating Women and Health Reform on Mother's Day

Tue, 15 May 2012 07:05:06 -0400

On this Mother’s Day, I woke up with a sincere gratitude that comes with having three children who are healthy and thriving. I am also thankful for my own good health, as well as that of my husband’s. Before becoming a mom, I had taken much of my good health for granted as I assume most young people do. But once I began the journey of motherhood, it was an obstacle course of doctor’s visits, medical tests, ultrasounds, vaccinations, X-rays, E.R.visits, and hospitalizations. Becoming a mom is a huge wake- up call to what is good and what still needs improvement in our healthcare system.

Being in the profession grants me an advantage over many other families. Or so one would think. My first son was born during my third year of residency training, when the new childhood pneumococcal vaccine was introduced. It was held as a revolution in reducing the incidence of bacterial pneumonia and meningitis. Although I was able to provide it to my clinic patients, mostly Tenncare Medicaid families, I had to take my son to the health department to get this valuable vaccine at a reduced cost. Our private insurance hadn’t yet covered the vaccine, which was almost two hundred dollars out of pocket. That was the first time I questioned why the premiums I paid do not go back to the health care of my child.

My generation of physicians in training got to witness the effectiveness of this vaccine in evolution over a fairly short period of time. In the beginning of my residency, it was commonplace to see children with bacterial pneumonia and meningitis, often caused by pneumococcus. By the end of my training, we saw a significant decline in admissions for bacterial pneumonia. And for the first time ever, we had more admissions for viral than bacterial meningitis. The former often is benign but the later can be devastating. The vaccination was available for many of low income families, through Tenncare, the state’s form of Medicaid. And though it still is an ever changing endeavor in the dynamic field of medicine, it provided the necessary vaccine at the right time to the most vulnerable and made the biggest impact in the process.

On this Mother’s Day, I am grateful for the provisions in the Affordable Care Act that benefit moms and their families. That 80% of our paid premiums will go back to the actual health care is an honest way of getting what we paid for. Preventive visits, routine screening of hearing, vision and developmental delays, and vaccinations should be covered at no additional cost. Don’t we all pay enough for coverage - shouldn’t we get covered for what is most important for our families?

Celebrate this Mother's Day, and start of National Women's Health Week, by telling the important women in your life how the Affordable Care Act benefits them and those they love.

You can learn more about how the ACA benefits women and families by clicking here.

Happy Mother’s Day to all,

Anna Tran, MD
Texas State Director

A slower rise on the rise: a sliver of hope?

Mon, 14 May 2012 07:48:19 -0400

There has quite the discussion regarding the most recent health care expenditure numbers released by the Center for Medicare and Medicaid Services (CMS) in January. Health care spending increased by only 3.8 and 3.9 percent in 2009 and 2010, respectively. To put this in perspective, this seems disproportionately small relative to the prodigious growth in the 1980s and 1990s (13.1 and 11.0%, respectively). Furthermore, healthcare expenditures as percentage of GDP held steady at 17.9% for 2009 and 2010.

Naturally, it would be intuitive to attribute the recent recession to the plateauing in growth. Indeed, the recession was one of the most severe since the Great Depression. We saw the first decline in overall GDP in sixty years in 2009. The highest unemployment rate in 27 years translates into a larger loss of private employer-based healthcare coverage for consumers. Moreover, employers are increasingly more cautious of hiring in an economic downturn. With the lowest median inflation-adjusted household income since 1996, tightening household budgets further hamper consumers from affording the premiums for coverage and the deductibles and copays when seeking health services. Consequently, there is increasing impetus to postpone medical care, as demonstrated by the slowing growth in ER visits, outpatient visits, outpatient surgeries, and decreasing in median inpatient admissions in 2010. The recession has not only affected consumers and employers, but also the public arena, too. Tightening state budgets decreased growth in overall nursing home spending, which tends be a major expenditure for Medicaid.

Thus, there may be evidence to support the recessional effect in mitigating the acceleration of health care costs. But given the already evidenced deceleration health expenditures prior (7.6% and 4.7% in 2007 and 2008) to the official start of the economic downturn, could there be other potentially prominent factors contributing to the slowing? One can look as the Medicare expenditures as a likely indicator. Medicare utilization is typically unassailable to the effects of recessions given the federal government mostly pays for coverage. Regardless, inpatient utilization for Medicare beneficiaries in many states nonetheless dropped. Furthermore, nine states with 2010 unemployment rates lower than the national average demonstrated declines in health care utilization. Whether these states had an increasing unemployment rate during the economic downturn that is still considered absolutely low is another question. Growth in retail prescription drug spending has reached a historical low of 1.2 percent, emblematic of the increasing use of generic drugs, a dearth of in the introduction of novel drugs, and brand names such as Flomax and Lovenox coming off patent. There also has been an increasing prevalence of the high-deductible plans, which entails lower premiums but also increases cost-conscientiousness on the part of the consumer. Importantly, it is very possible the health care reform legislation process that ultimately led up to the ACA in 2009 and 2010 fomented an incipient nationwide dialogue on our complicated health care system that robustly affected consumer, provider, and corporate behavior. Lastly, the shift in provider culture to more coordinated care and quality measures, as evidenced by the inception of accountable care organizations (ACO) across the nation (with ACA provisions playing a major role in assisting providers set up ACOs) may not contribute significantly to 2010 figures due to its fledgling scope, but will prove most important in the future.

There is no doubt with the statistical trends we are witnessing, this is an encouraging moment for our society given Medicare and Medicaid expenditures precariously impact the long term solvency of our nation. However, it is important to keep in mind that a decrease in the rise attributed to a decrease health care utilization may not necessarily be a good thing. If decrease utilization precludes consumers from appropriately seeking care, we are only exacerbating the problem down the road. Ultimately, it may be too premature to confidently attribute the exact causes in the flattening in the growth health care spending. Nevertheless, it would provide a sliver of hope that taming the intractable rise in health care expenditures is not just a dream but also a reality.

Equal Pay for Equal Work

Fri, 11 May 2012 09:18:56 -0400

I love it when I see Medicaid patients on my schedule for the day. Working at a community health center, our doors are open to all people, regardless of their ability to pay. It’s hard to run a medical office when you get $20 for a visit, which is what our uninsured patients pay. So when a patient has Medicaid we know we’ll get paid a decent reimbursement for that visit.

On average, Medicaid pays 34% less for a primary care visit than Medicare, which itself pays less than private insurance. In contrast to my situation, many doctors won’t take Medicaid because it pays so much less than what they’re getting from their other patients with private insurance. The people covered by Medicaid - poor women, children, the elderly sick and the disabled - need more choices of where they can get their care, not fewer.

Which is why it was great news to hear earlier this week that because of the Affordable Care Act, in 2013 and 2014 Medicaid rates will increase to be the same as Medicare rates. This should get more doctors to participate in Medicaid which will expand access for this vulnerable population.

Just as important, it corrects an injustice. The message of the current payment structure is that society, by paying less for Medicaid than for Medicare, values the lives of the poor less than the elderly. It speaks ill of us when we short change vulnerable populations because they can’t afford lobbyists and devalue the providers taking care of them by paying them less for equal work.

For our clinic it will mean that we will be able to expand our services. We will finally be able to buy an audiometer to screen children for hearing problems. We can get more vaccines to vaccinate our diabetics. We can subsidize medication costs for those who can’t afford it. And, we can see even more uninsured patients with the extra money that we get.

The cost of all this is $5.5 billion dollars a year which is just over a 1% increase in the budget for Medicaid. It’s already paid for since it’s a part of the Affordable Care Act but there’s a showdown coming in 2015 when this pay increase is set to expire. Ideally, this pay disparity will be eliminated once and for all but that seems a dim prospect given the way this Congress operates. So when the time comes to fight, ask yourself this: Isn’t caring for your child worth at least as much as caring for your parents?