QD: News Every Day--dry, boring health care reform? Think again.

ACP Internist's daily digest of news and events continues with how health care reform issues play out in real life, how the next generation of doctors view primary care careers, and how hospitalists are changing primary care.

Health care reform
Health care reform debates might at times seem esoteric, appealing only to economists and actuaries. For political wonks, the issue is about balancing what's possible vs. what's achievable. But the impact of reform plays out in real life and upon real lives, as profiles in Maine show. There, the need for health care reform has never been more acute. (New York Times, CBS News)

H1N1 influenza
Just in time for Christmas: flu vaccines. Drugmaker Sanofi-Aventis expects to ship 75 million doses to the U.S. market by late December, their CEO told reporters. (Reuters)

If a smartphone made its way onto your holiday gift list, an app in development could diagnose colds and flus by how the user sounds when coughing into it. (Daily Telegraph)

Primary care shortage
An internal medicine resident in San Francisco relates his eyewitness accounts of how a lack of primary care plays out in multiple care settings. A University of Alaska Anchorage student chooses to answer the call. (Los Angeles Times, The Northern Light)

Hospital medicine
Winneshiek Medical Center finished its first year with a hospitalist program. The results:
--$72,000 profit,
--decreased emergency room transfers to other facilities of 15%,
--decreased patient length of stays and an increase in observation stays by 65%,
--steady patient satisfaction of 88%, with better discharge timing,
--happier inpatient nurses, and
--approval from primary care doctors and emergency room staff.

But hospitalists aren't universally appreciated. Marcy Zwelling-Aamot, ACP Member in Los Angeles, calls them a "substitute" brought in when patients most need their existing primary care doctor. Her editorial decries all the barriers that create a wall between patients and doctors. (Decorah Newspapers of Winneshiek County, Iowa, Press-Telegram of Long Beach, Calif.)

In case you missed it ...
Do we need health care reform or health insurance reform? More than health care politics, doctors are fed up with insurance companies--paperwork, arguing on the phone, fights for what patients need. Some say they'd take pay cuts if there was a model that let them practice medical care differently. In Connecticut, internists discuss the issue in terms of health insurance reform, not health care reform. (Philadelphia Inquirer, Greenwich Time)

An Indiana health clinic is letting those who can't afford care pay for treatments by volunteering elsewhere in the community. (NPR)

Labels: H1N1, health care reform, health insurance, hospital medicine, primary care shortage, QD

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posted by Ryan DuBosar at 10:28 AM   0 Comments

Denied health insurance

One difficult part about being a doctor is the realization that I am part of a corrupt industry that I cannot influence. Such strong words about American medicine? Well, I have encountered yet another patient who is denied health insurance for underwriting reasons that are just plain unfair.

Maryanne has run out of COBRA, the temporary continuation of health insurance that is guaranteed when a person loses their job. It only lasts 18 months and, in case you didn't know it ... we are in a hell of a recession and there are a lot of people who are unemployed.

Maryanne, age 41, was turned down by Blue Shield of California after submitting all of her health records because she (and I quote) "did not meet the underwriting acceptance criteria:
--migraines treated with Imitrex, Aleve, seen in emergency department once 2009
--thyroid adenoma treated with Synthroid
--deaf"

This is pretty outrageous. One migraine headache that required an over-the-counter pain killer and a recognized pill that works for migraine is hardly a rare health condition. Some 30 million Americans have migraine headaches.

She is deaf since childhood and functions completely normally by lip reading. Of course, being profoundly deaf does affect her ability to get just any old job in this economy, doesn't it?

She does have a thyroid enlargement that will likely need further investigation. These are easy to work up but, without insurance, the cost can be exorbitant and probably more than an unemployed person can comfortably pay.

Another one has joined the 47 million uninsured. There is no safety net for Maryanne or millions of others who are living with the anxiety of being uninsured.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: headache, health insurance

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posted by Toni Brayer MD at 8:00 AM   1 Comments

QD: News Every Day--The disconnect of health reform

ACP Internist's daily digest of internal medicine in the news continues with the disconnect on health care reform, a larger analysis of who was hospitalized for H1N1, and more on the primary care shortage.

Health care reform
Americans want health care reform to change, but they don't want to pay for it.

Meanwhile, the Economic Policy Institute, a think tank focused low- and middle-income Americans, points out that Medicaid and the SCHIP held in check the number of children who would have gone without health between 2000 to 2008. Children without insurance dropped 1.7% between 2000 and 2008, while adults less than 65 without insurance rose 3.1%. By contrast, children with public coverage grew 8.8%, compared to a 3.5% increase for the adult population under 65.

H1N1 influenza
Health officials now say that 46% of 1,400 adults hospitalized with H1N1 influenza did not have a chronic underlying condition, according to the largest analysis to date. The study looked at adults and children hospitalized from April through August in 10 states at medical centers participating in a special disease surveillance network. Anne Schuchat, FACP, who heads the CDC's National Center for Immunization and Respiratory Diseases, said the larger analysis looked at underlying conditions not previously examined. Among adults, 26% had asthma, 10% had diabetes, 8% had some other chronic lung disease, 8% had weakened immune systems and 6% were pregnant.

Primary care shortage
A financial advisor chimes in with his analysis of why primary care doesn't pay, including input from his own internist. The doctor says, "The average income of a primary care doctor in Massachusetts is about $86,000. Why do I do it? Because I love it."

The medical home
Profiles of practices trying the patient-centered medical home include Greenhouse Internists in Mt. Airy, Pa. and the Adirondack Regional Medical Home Pilot, which also an effort to stop the loss of primary care practitioners in the region. And for a lighter note, don't miss ACP Internist's own Stacey Butterfield's report from the MGMA meeting in Denver.

In case you missed it ...
In Minnesota, the Vitality Project prompted one town to build sidewalks and bike trails; restaurants, groceries and schools to push healthier foods; and employers to give workers time to exercise. The experiment added an average 3.1 years to the longevity of about 2,300 residents who calculated their lifespans by answering 36 lifestyle questions.

Labels: diet, exercise, flu, H1N1, health care reform, health insurance, health policy, patient-centered medical home, primary care shortage, QD

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posted by Ryan DuBosar at 11:53 AM   0 Comments

QD: News Every Day on insurance coverage, primary care shortage and H1N1

ACP Internist's daily digest of internal medicine in the news continues with who's covering the uninsured, students weighing in on why they eschew primary care careers, and H1N1's widespread but less lethal path.

Covering the uninsured
While the number of uninsured people rose slightly from 2007 to 2008, more people were covered by government programs as employer-sponsored coverage continued to decline, according to the U.S. Census. The ACP Advocate reports census figures showing that 15% of the population was uninsured in 2008, increasing from 45.7 million to 46.3 million. However, coverage by private plans fell from 67.5% to 66.7% and coverage by employers fell from 59.3% to 58.5%. Government coverage rose from 27.8% to 29%.

Primary care shortage
Medical students weigh in on health reform, and have their doubts. Also, they won't go into primary care. "When it's a difference of $200,000 in your paycheck, it's tough," one student said.

Flu update
The H1N1 pandemic has been more widespread than lethal, notes the Harvard Health Letter. The virus seems to cause fewer cases of serious disease than expected. Harvard experts discussed the latest at a forum, with video posted online. In short, estimates for the death rate for H1N1 range between one death for every 2,000 symptomatic cases and one death for every 14,000 (0.007%). In comparison, the death rate for seasonal flu is roughly one death for every 1,000 to 2,000 cases. Seasonal flu infects roughly 5% to 20% of the population annually, whereas pandemics infect 25% to 40%. This H1N1 epidemic may not rise to pandemic levels.

In case you missed it ...
Doctors drive medical consumption, not patients. Illness and patient preference play a much smaller role. NPR reports on one epidemiologist's lifelong work. Meanwhile, a Newsweek columnist weighs evidence-based medical treatments against clinical judgment. It's the age-old question: How does a study impact treatment of the patient sitting before a doctor, seeking a cure?

Labels: epidemiology, evidence-based medicine, flu, H1N1, health insurance, medical education, primary care shortage, QD

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posted by Ryan DuBosar at 12:34 PM   0 Comments

American values and health care

I read a good post from the New York Times about Health Care Reform and 'American Values' and it got me a thinkin' ... just what are American Values when it comes to health care? Usually I get a little anxious when I see "American Values" in a sentence, because what usually follows is something about rugged individuality, pulling oneself up by bootstraps, getting the damn government out of our lives and those damn immigrants and welfare mothers who won't work and want to live off others.

But I have listened to about ten thousand patients over the past 25 years, and I have a good idea of what these Americans want for health care. They are the silent majority ... the people who work, study, raise their kids and seldom call into a radio talk show. They don't have time to go to town hall meetings and shout slogans.

They range from age 17 to 101 and most of them are middle class. They come in all races ... Asian, black, white, Pacific Islander and mixes of all.

Some are wealthy enough to have multiple homes and private planes.
Some are uninsured and watch their health care spending very closely. Most were thrilled to get Medicare and I've never heard a complaint from a Medicare patient.

Here is my list of what these Americans think about health care:
--They do agree that everyone should be covered for basic health care and would pay higher taxes if they could believe that there would not be fraud and waste. (The recent banking meltdown has destroyed all confidence that government can regulate or be independent from special interests.)
--They want choice of physicians and hospitals.
--They are sick of insurance companies and all feel like they have been screwed in one way or another. They are shocked at how little insurance companies pay toward the doctor visit and the way those fees are discounted.
--They are technocentric and want tests, imaging, referrals and think "more is better" when it comes to health care. They think tests are cures. Because of the perverse incentives, the "more is better" philosophy benefits doctors and hospitals, but not necessarily patients.
--They fear losing insurance if they have it.
--They are confused about the current reform debate and mostly fear losing whatever coverage they now have, because they know how impossible it is to get by without any coverage at all.

There are no such thing as "American Values" because we are a diverse group of people. But we all have certain things in common. We want to be healthy. We don't want to be screwed by anyone (big business or the government).

We want to be able to manage our own health care but we don't want to have to decide between numerous health plans every year with pages of information that cannot be understood. We are tired of not knowing where all the trillions of dollars really are being spent.

We want to know the price of a service up front, and we want a trusted physician to help us decide if that is how our money should be spent. We want smart, committed physicians to know us, and not hurt us.

Sounds American to me.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Labels: health care reform, health insurance, pay-for-performance

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posted by Toni Brayer MD at 8:00 AM   2 Comments

A totally different vision of health reform

Often the phrase "consumer-driven health care" is a cue to hold on to your pockets because there's an unexpected bill headed your way. But in the cover story of this month's issue of the Atlantic, David Goldhill makes an interesting argument about the benefits that a truly consumer-driven system could provide. Or, at least, he's pretty convincing on the idea that it couldn't be any worse than things are now. His plan's not going to be enacted anytime soon and has some flaws (boy, does he hate hospitals), but it's definitely an interesting read.

Labels: health care reform, health insurance, health policy

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posted by Stacey Butterfield at 1:14 PM   0 Comments

Internist asks patients to leave co-pay ... for the next patient

James S. Braude, ACP Member, of Atlanta, has started asking patients to leave a dollar (or any other amount) in an envelope at the front desk after a visit. That donation is applied toward the visits of patients without insurance--Dr. Braude comps the rest of the cost. The local TV report is here:



(The text version is here in case video is restricted on your computer.)

In May ACP Internist polled its readership how they handled uninsured patients, and doctors spoke of a variety of ways they help their patients who don't have insurance.

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 8:00 AM   0 Comments

Making sense instead of noise

Tired of all the people yelling about health care reform? This little article from the Wall St. Journal provides a nice respite. It uses both logic and morality to explain why a totally free-market approach to health care coverage doesn't work. Even the comments section is surprisingly civil.

Labels: health care reform, health insurance

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posted by Stacey Butterfield at 12:00 PM   1 Comments

Internists, FPs alike trying to help their patients through the recession

The economy is prompting internists and family physicians to increase charity care, discount fees and offer free screenings, according to a survey by the American Academy of Family Physicians.

ACP Internist reported its own poll results earlier in May asking internists how they handled patients who couldn't afford to pay. ACP members reported they most commonly offered free care or reduced payments (66.7%), offered free samples for prescriptions (61.1%) or referred to community clinics (34.7%).

Nearly 90% of the AAFP crowd reported their patients expressed concerns over their ability to pay, 58% had seen more appointment cancellations and 60% had seen more health problems caused by patients forgoing needed preventive care such as such as pap smears, mammograms and colonoscopies, or failing to return for follow-up visits or refills.

Also:

• 66% were discounting fees, increasing charity care, providing free screenings, and moving patients to generics;
• 54% have seen fewer total patients since the recession began in January 2008;
• 73% saw more uninsured patients;
• 64% of respondents reported a decrease in the number of employer-sponsored/privately insured patients; and
• 87% saw more patients with major stress symptoms since the beginning of the recession.

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 11:40 AM   0 Comments

Your Thoughts Exactly: Handling patients who can't afford to pay

With the economy uncertain and unemployment rising, ACP Internist readers reported they are facing patients in their offices who are ill, but unable to pay for health care. The situation has left many physicians with the unexpected dilemma of how to treat such patients while also trying to manage a practice. Or worse, patients may not seek health care at all, an option suspected by virtually all respondents in our latest poll, Your Thoughts Exactly: Caring for unemployed/uninsured patients.

Results were collected anonymously throughout April. The results are not scientific and do not reflect any ACP policy, and are reported for their news value only.

When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
Options (respondents could choose more than one; n=73)

• I've offered free care or reduced payments. 66.7%
• I've offered free samples for prescriptions. 61.1%
• I've referred them to community clinics. 34.7%
• I've reduced or eliminated co-pays. 18.1%
• I've deferred billing. 16.7%
• I've had to refuse care to delinquent patients. 6.9%
• I've let the front desk handle it. 6.9%

Among those who offered other options, hospitalists who responded are generally able to refer to their own facilities. One reported, "As a hospitalist I try to take care of them as I do the others ... but I have the devil's own time getting consultants to see them, and arranging outpatient follow-up is often difficult or impossible."

Another respondent said, "I have the luxury of practicing in an academic setting where most of these decisions are made for me. I would hate to be faced with the situation of not providing care due to inability to pay. I can say that since our institution has implemented a co-pay policy, attendance at our resident teaching clinics has fallen off dramatically. I see a future where residents graduate with even less ambulatory care experience than they're already getting."

Office-based practitioners are setting up payment plans, steering patients toward low-cost or no-cost generic options through their local chain pharmacy or grocery. A few have some sort of sliding scale for payments; others suggested downcoding services, even comprehensive exams, so the overall cost would be less.

"I provide them information on how to shop for their prescriptions, explain the excessive cost of needless over-the-counter products, attempt to keep the costs of tests and other health care to a minimum, refer to the physicians who will provide the same level of care and concern that I have whenever possible; I also refer to the state."

Many are referring to local support groups or working at free clinics--in one case the doctor opened a free clinic. Many physicians are doing more chronic care management by phone, which as one person said, "I have done it in previous recessions."

Nearly all (72 of 73 doctors, or 98.6%) said that they know or suspect their patients are skipping needed care, while the other respondent replied he or she wasn't sure. Among the patients suspected of skipping care, they were thought to be rationing medications or not coming back for follow-ups. "I suspect this is a much bigger problem than any physician actually knows about," one physician added.

One doctor suggested a way to prevent losing patients to follow-up: "Be sensitive to proud patients who do not want to admit they are having financial troubles."

Labels: health insurance, primary care, recession

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posted by Ryan DuBosar at 3:23 PM   0 Comments

A helping hand or a snatch and grab?

Walgreens has announced a new plan that could be good news for patients but trouble for primary care providers. Under the Take Care Recovery Plan, patients who lose their jobs can get free basic care from the stores' minute clinics. That is, as long as the patients were clinic customers before they lost their jobs.

It's hard to criticize any program that provides care to the uninsured, but this plan does seem designed to use fear of the recession to lure insured patients away from their doctors' offices. Will this lift some of the burden of unpaid care from internists, or realize the concerns of the anti-minute-clinic crowd? Tough call.

Labels: health insurance, primary care

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posted by Stacey Butterfield at 2:27 PM   0 Comments

Insurance insurance (no, that's not a typo)

Worried that the recession might lead you to lose your job and therefore your health insurance? Relax. UnitedHealth is here to ease your mind with a new policy that will ensure your right to buy insurance in the future if you get sick, the New York Times reports.

Got that? They're not selling you insurance. They are selling you, a healthy person, the opportunity to buy insurance later, should hard times befall you and you get laid off, then stricken with illness. All for the low-low monthly cost of 20% of an individual policy premium. That's $50 a month for Richard A. Collins, the president of UnitedHealth's individual insurance unit.

Mr. Collins calls the policy a "hedge." (You know, sort of like credit default swaps.) It's a huge vote of confidence for heath insurance reform, no?

Labels: health insurance, recession

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posted by Jessica Berthold at 12:03 PM   0 Comments