Can You Get a Prompt Appointment With Your Doctor?

Having trouble getting an early appointment with a doctor? It’s a common problem. Here is one company’s proposed solution.

It takes an average of 20.5 days to get an appointment with a physician, according to a study by Merritt Hawkins & Associates and related to me by the principals at ZocDoc, a startup company. That’s a long time. ZocDoc aims to fix that problem with a rapid appointment scheduled on line.

Perhaps your need is not urgent in the classical sense but imagine you were just told your mammogram was suspicious and that you should see a surgeon for a biopsy. Waiting three weeks just to be seen (plus another wait for the scheduled biopsy date) will seem like a lifetime of anxiety,  but a company called ZocDoc has set out to improve patients’ access to care by making the market for doctors’ appointments more efficient, to the benefit of patients and doctors alike.

But if the doctor is booked up what can you do except wait it out? It turns out that physicians have a 10-20% cancellation rate. Maybe someone’s serious problem got better on its own. Maybe they went to the ER instead of waiting. Or maybe he or she just forgot because the appointment was made so long ago. For whatever reason, the doctor has many last minute openings; but you don’t know about them.

Cancellations mean no income for that time slot, but the physician’s fixed costs of office rent, staffing, insurance, etc. don’t go away. So he or she would like to fill those empty time slots if possible. 

In response, ZocDoc has created a software system that works with physician’s scheduling systems. Basically, patients go online and insert the particular type of physician they need to see (e.g., primary care, ENT, dermatologist, etc.) as well as their location. ZocDoc scans the real-time schedules of the physicians meeting that search criteria and allows patients to instantly book an appointment online. ZocDoc tells me that 40% see a doctor within 24 hours and 60% will be seen within 72 hours. And, although ZocDoc does not presently put you on a waiting list, you can always check back on ZocDoc and see if an earlier time slot becomes available.

My only concern is that you as a patient are best served with a single primary care physician (PCP) with whom you have a long standing personal relationship. He or she knows you, your medical status and the issues of work and family. Going to a different PCP for a one time problem is not the best medicine – although I would agree that it is far superior to a long wait in the emergency room.

The specialist situation is somewhat different however. Usually, your PCP is the best person to make a referral. As your advocate, the PCP wants you to be well served with quality care and so will generally refer you to a specialist that the PCP knows by years of personal experience is not only competent but respectful of patients. And if the PCP is really on your side, he or she will personally call the specialist, explain the reason for the referral and, when appropriate, ask for an early appointment.

But if you can’t get to your PCP for many days and you just fell and have a swollen ankle, ZocDoc could presumably get you into an orthopedist’s office quickly. Or to a surgeon for that breast biopsy. Getting to see that orthopedist or surgeon in one to three days rather than three weeks would be a godsend – getting appropriate therapy for the sprained ankle or just relieving three weeks of anxiety waiting for a biopsy. 

ZocDoc appears to be at first glance a game changing approach. If they are correct it will make a major transformation in the delivery of medical care. It will be interesting to watch ZocDoc and see how it evolves.

Notes – ZocDoc was noted in a Wall Street Journal article today on innovation. I have no financial relationship with ZocDoc; I learned about it serendipitously. There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

The Strength To Accomplish Incredible Things

Illnesses, like cancer, can be devastating but hope springs eternal and love and caring can be healing no matter what the final outcome. Fortunately in this family crisis, the outcome was incredibly positive in many ways and led to the strength to accomplish incredible things. My posts are usually my own work. But I am posting this very beautiful and positive story sent by a husband turned caregiver. 

“Lessons Learned through Caregiving

In August of 2005, my family changed forever. Our daughter, Lily, was born, and my wife Heather and I could not have been more excited to be new parents. However, three months later, our lives changed again. On that day, Heather was diagnosed with malignant pleural mesothelioma, and I got a new, unexpected job. I became a caregiver for a cancer patient. Instead of dealing with the chaos of the holiday season as planned, we began to deal with a new type of chaos – fighting cancer.

My life as a caregiver began as soon as Heather was diagnosed. Completely overwhelmed, shocked and unable to make any decisions, Heather looked at me for help. I knew I had to be there for her as best I could, and I made the first essential decision, that of where Heather would receive treatment. We were given several options, but one in particular stood out.  It was Dr David Sugarbaker, a mesothelioma specialist in Boston, known for his work with patients with my wife’s type of cancer. I told our local doctor to get us to Boston. 

I had to cut my hours in my full-time job, and Heather left her job. Instead of working my 9-5, I turned into a full time caregiver. I scheduled our trips and drove to doctors’ appointments. I was also still a full-time dad, caring for three month old Lily.

Life became a challenge. Everything was turned upside down, and I was often uncertain and worried. My to-do list turned into a whirlwind of overwhelming emotions, and I couldn’t just give up. I let myself surrender to the bad days, but I never gave up hope. Although I often felt helpless, I knew I had to stay strong for Heather. The support we received made me feel hopeful. People we didn’t even know were offering all kinds of help, giving us less to be anxious about. That outpouring of support helped keep me sane.

All of our hard work, perseverance, and refusal to give up paid off. After surgery and multiple treatments for mesothelioma, Heather beat the odds as this short video demonstrates and defeated this awful disease, a rare feat accomplished by far too few. After seven years, she is still cancer free, and has been able to see Lily grow into a beautiful young lady. 

I have since been able to balance the tasks of going back to school while raising a family. Being a caregiver and standing by my wife through cancer gave me the strength and the courage to pursue this dream of mine, two years after Heather’s diagnosis.  The stress and time management skills that I learned helped me to succeed and graduate with high honors.  I was even given the great privilege of speaking at graduation. During my graduation speech, I shared the greatest lesson that I learned as a caregiver to someone with cancer. I told the audience that within each of us is the strength to accomplish incredible things, as long as we never give up hope, and always keep fighting for the ones we love.”  

Cameron Von St James, July 17, 2013
 
 

Aging Gracefully – Part 2 Slowing The Aging Process

Can we slow the aging process?  The answer is a definite yes and it all has to do with our lifestyles and behaviors.  Here is a quiz.  What percent of Americans can answer yes to all five of the following statements?
 

Here’s a clue.  We know that about 20% of Americans smoke so the highest answer you can give to this question is that 80% could answer yes to all five.  The actual answer may surprise you.  It did me.  Only 3% of Americans can answer yes to all five! 

Let’s return to bone mineral density.  The way to slow BMD decline is to exercise and to eat a nutritious diet.  (Vitamin D supplements may also be necessary for those in temperate climates who get little sunshine on their skin.) So instead of a 1% decline per year it can be more of a ½% decline per year.  On the other hand for couch potatoe that decline won’t be 1% but it may be more like 1½ to 2% per year.  The same goes for cognition.  There are certain adverse factors such as vascular conditions and the metabolic syndrome (a precursor to diabetes) and also the chemicals released through chronic stress that speed up cognitive decline.  But there are also protective factors which we can control ourselves.  These include being physically active, intellectually challenged, and socially engaged.  It may be a surprise that physical activity is important for cognition but it has been clearly demonstrated to be critical.  Intellectual challenge is different than reading a book, even a complex book.  That’s not a challenge.  But if you belong to a book club and have to actively defend your perspective and point of view that then becomes a challenge.  Socially engaged means being involved as a human being with other human beings.  This is something that is frequently lost during older years if isolation develops due to limited mobility, inability to drive, etc. 

So the essential steps of slowing the aging process are: Avoid tobacco and remember it’s never too late to quit.  Reduce chronic stress because the chemicals released from stress have a very adverse effect on many physiologic systems such as immune function.  Eat a nutritious diet.  Do cognitive exercises which challenge your intellect.  Remain socially well connected. Physical exercise should include aerobic activity of about thirty minutes five days per week (just simple walking is adequate); resistance or weight training 2-3 times per week and balance exercises 2-3 times per week. 

 

To summarize, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this 1% decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. That said, it is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  It’s worth it.

Next post – The importance of comprehensive primary care in managing the aging process.

Further Disruptive Changes in Health Care Delivery

Technology to lower costs rather than accelerate them. Smart phones to increase physician and other providers’ productivity. Fewer primary care physicians but more involvement by nurse practioneers and others. And increasing appreciation of the value of integrative medicine. These are but a few of the disruptive changes in care delivery that are coming. 

In my last post I observed that  the health care delivery system will change in coming years – quite unrelated to reform – and gave the most important drivers of change and how these changes will often be disruptive, transformative or both. Here are a few more. 

We think of new technologies as exacerbating health care costs. But it is also quite correct to look to technology to reduce costs or at least slow the growth of expenditures. There will become a new value proposition for technology. Today and tomorrow technology wil be accepted if it to helps health care professionals to 1) compensate for shortages, 2) enhance their responsiveness to patients 3) control costs and 4) improve quality and safety. 

Smart phones with wireless connectivity and multiple apps are a good example of technology to assist, compensate, enhance responsiveness and improve quality. Increasingly, physicians are becoming very reliant on their phones as a shortcut to knowledge, to stay well informed, to argue and debate among themselves and perform many other functions. 

Robotics can likewise benefit all four parameters. A good example is how robots have made the hospital pharmacy more efficient while substantially safer. One robot selects pills via bar code; another prepares intravenous medications and solutions more accurately then a technician and a third transports medications to the nursing unit using wireless technology – sort of like R2D2. This frees up the pharmacist to do what he or she does best such as watching for drug-drug interactions, proper dosing, and critical higher order functions.  

But the coming changes are not just in technology but in the distribution and work of providers. With shortages of physicians, especially primary care physicians, appropriate integration of nurse practioneers and physician assistants can not only partially compensate but provide quality interaction with patients, augment preventive programs and enhance care coordination for those with chronic illnesses. And although there is considerable controversy as to appropriate scope of practice, it is certainly clear that the interaction of PCPs with NPs and PAs can enhance the totality of patient care.  Similarly, expect to see more mental health delivered by psychologists and social workers; visual care by optometrists; and hearing care by audiologists. 

Consumers (patients) will press for and expect a more integrative approach from their PCP and other providers. Patients today increasingly search out and use practioneers of acupuncture, massage, chiropractic, yoga, mind body techniques, energy channeling (Healing Touch, Therapeutic Touch, and Reiki) and other complementary medical modalities. More and more medical students are graduating with at least some understanding and training in the use of these approaches. And the acceptance by already practicing physicians is growing, albeit slowly in many cases.  

Integrative medicine means more attention to the whole person – family history, social situation, work environment, and how all of these plus stress, eating, smoking and drug preferences interact with the patient’s illnesses. A “prescription” for high cholesterol may still include a statin but it might well also include a trip to a nutritionist, a personal trainer, a program for stress reduction, etc. The end result is better medicine yet completely coordinated by the primary care physician.  

Health care delivery is transforming. It will come in fits and starts but it is and will continue to change. Hopefully most of the changes will be for the betterment of patients and providers alike.
 
 

Replacing the Aortic Valve Without Open Surgery!

Aortic stenosis (a narrowing and hardening of the heart’s aortic valve) is not uncommon among older individuals. It begins without symptoms and progresses for years but, about 50% will die within 2 years once the fitst symptoms develop. The standard approach is to surgically replace the aortic valve which will improve both heart function and survival. Unfortunately, about 30% of symptomatic individuals cannot undergo surgery because of older age, other heart problems or other medical conditions that render surgery too risky.

A new approach is called transcatheter aortic value implantation (TAVI.) In this procedure, a catheter is inserted into the large femoral artery in the groin and run up to the heart. From the catheter, the patient’s valve is opened wide with an inflatable balloon. Then a bioprosthetic value made from bovine pericardium affixed to a stainless steel support frame is deployed into place via another balloon catheter and secured to patient’s own aortic valve base.

A randomized study of 358 patients with aortic stenosis not considered surgical candidates was completed comparing TAVI to standard therapy at 21 medical centers and reported in the New England Journal of Medicine on October 21, 2010. The results were clearly favorable. Standard therapy was noted to not alter the natural history of aortic stenosis with 51% dead in one year. TAVI was superior with improved cardiac symptoms and good hemodynamic performance of the new valve which persisted for at least the first year of follow-up and with 31% dying during that year, a substantial decline in mortality.

But there is never a “free lunch” and TAVI was associated with a 5% risk of serious stroke (compared to 1% in the control group) and multiple vascular complications, the latter apparently related to the requirement for a large catheter placed into the femoral artery. Further MRI studies of patients suggest that many have new perfusion defects of the brain after TAVI suggesting that emboli from the new valve may be rather common.

But all things considered the improvement in symptoms and the reduced death rate (it took only 5 patients treated with TAVI to avoid one death by 1 year) argue that TAVI is now the appropriate therapeutic approach for those with aortic stenosis who cannot otherwise undergo surgery. Hopefully, coming improvements in the device will lead to fewer complications.

The big question – will this become the approach of choice for those who otherwise are candidates for standard surgery for aortic valve replacement?

Employer-Sponsored Comprehensive Primary Care

Patients need doctors that take time to listen which means a limited number of patients under care. Employers need programs that reduce costs and ideally improve the health of their staff. These apparently disparate needs can come together in a new model for effective company-sponsored primary care programs.

Those of you who have followed this series know that I am an advocate for PCPs finding ways to have a smaller patient panel so that each patient can receive more time for comprehensive primary care. When properly designed, company-sponsored primary care clinics can do just that.

Some employers are turning to outside firms such as QuadMedto initiate care models that can serve both smaller patient panels yet reduce their total costs toward healthcare. Although there are many such firms (or local practices) that will take on the role, real success hinges on a program that is well organized and allocates adequate time for the PCP to give truly comprehensive primary care. It also means that the employer has accepted the concept that it is no longer just trying to hold the line on healthcare costs but is actually looking at employee health as a strategic business imperative.

Successful programs tend to include not only PCPs, NPs, nurses and other providers but, if the employee base is large enough, a pharmacy, laboratory, and radiology suite. Other key resources are health coaches and nutritionists to maintain wellness and reduce risk factors. The typical employer in these arrangements is generally self-insured, has a large enough employee base to justify the clinic resources and is committed to employee health and wellness while wanting to reduce its total costs of health care.

A full service primary care clinic is funded by the company at or very near to the employer’s site of business. Services include routine episodic care but also extensive preventive care, intense management of those with chronic illnesses and care coordination when a patient does need to visit a specialist and sufficient time with the provider that trust can develop; in other words, this is comprehensive primary care not just limited function urgent care centers.

Employees are informed that they are welcome but not required to utilize the clinic and do so at no cost or perhaps a modest fee per visit. Some but not all employers make the clinics available to family members. Each participating individual is assigned a primary care physician (PCP) or in some cases a nurse practitioner or physician assistant. The PCP/NP/PA is paid by salary by the vendor company, not fee-for-service. In the programs that truly develop comprehensive primary care, the PCP/NP/PA has a limited number of patients in his or her panel, does a full initial evaluation usually lasting 60 minutes or more and then sees the individual thereafter as often as necessary for as long as necessary.

The expectation is that the patient and PCP/NP/PA will develop a long term trusting relationship just as they would in a private office setting. Individuals can schedule appointments often on the same or next day and there may be extensive use of mobile technologies, an electronic medical record, telemedicine and other advanced techniques. For those individuals with a chronic illness, the clinic nurses often work with the PCP to coordinate care and (often and hopefully always) the PCP communicates directly with any specialist before referring and after the visit.

The clinic manages wellness and preventive programs with health coaching and lifestyle behavior management. This might include but is not limited to nutrition counseling, fitness counseling, stress management and smoking cessation. It depends on the provider company selected to develop and manage the clinic, but if the employer already has an effective wellness program ongoing with another provider, the primary care company may agree to partner with that wellness provider to create seamless programs. It can thus be an employer wellness program and a comprehensive primary care program rolled into one. It may even be population health to the extent that the PCP and the team proactively interact with each participant to address risk factor and incipient chronic illnesses rather than waiting for an employee/patient to call or visit with a problem. To repeat, a very key ingredient is assigning no more than a reasonable number of employees and family members to each PCP/NP/PA. What is “reasonable”? – it depends – on average age, whether many individuals have chronic illnesses, etc.

Some provider companies such as WeCare TLCcall their model “medical risk management,” a term generally thought of in medicine as programs and policies to reduce the potential for malpractice claims. Here however it has a completely different meaning. It is called medical risk management because the driving principle is identification and management of ongoing medical problems while at the same time addressing potential health risks for the future. It is really an employer-sponsored (although not directly involved) companywide approach to population health management. It is taken from the concept of enterprise risk management which seeks to identify and mitigate corporate risk as a strategic advantage. It is management of risk not just from a downside perspective but from an upside or positive perspective as well. The employer therefore needs to be thinking about health risk management as a strategic perspective, not just as a tactical effort. In other words, a healthy workforce is available to be productive and a healthy workforce creates a very substantial savings in medical costs for both the company and the employee.

Note that it is not just “episodic” visits but rather comprehensive primary care in a medical hometype model with proactive population health concepts.

The provider company and the employer usually agree up front to a set of performance measures such as utilization/penetration of the clinic (are employees actually using it), patient satisfaction (do they like what they get), quality outcomes (standard measures used nationally such as blood pressure control, diabetic control, immunizations up to date, etc.) and of course functioning within budget and a return on the employer’s investment at a pre-agreed level. Companies that engage in these clinics, provided that the services are actually comprehensive in nature as described, tend to find that their return on investment very good.

Since in these models of comprehensive primary care where the employer fully pays for the primary care services, there can be a significant savings for the employee (patient) and family members.  Importantly, the employer pays the bills, perhaps offers incentives for participating but is otherwise kept at a distance. The PCP and other staff members work for the provider company, not for the employer, and cannot be expected to share patient information. The employee gets quality healthcare with a strong emphasis on maintaining wellness, active prevention and on chronic illness early detection, management and care coordination. The result is a healthier workforce leading to greater productivity, greater workforce satisfaction, reduced or no employee costs for primary care and reduced or at least limited health insurance cost increases for both employers and employees.  Definitely a triple win.

But there are potential downsides to consider. Some KevinMD readers will certainly comment that it is best to keep the employer completely out of healthcare. Another downside would be if the employer wanted to be intrusive and learn medical information about individuals. A third would be the loss of a trusted PCP when a person leaves the company for other employment. So in the end, each person offered the option needs to make an informed decision.

Note: I have interviewed principals at both QuadMed and WeCare but have no financial or arrangements with either. They are used as examples only; their use does not represent an endorsement.

Your Genes Need Not Be Your Fate: Nutrigenomics To The Rescue

Genomics Part 4 — Medical Megatrends 

Are you concerned about a family history of heart disease? Or cancer? Worried that you genes will be your fate? We know that good dietary habits are generally good for us but can foods affect our genes? The new science of nutrigenomics suggests that they can. 

Nutrigenomics is about using what you eat to change your gene expression (meaning how your genes function) to optimize your health.  

Nutrigenomics is the science of how bioactive chemicals in foods and supplements alter the molecular expression and/or structure of an individual’s genetic makeup. It is apparent that one size does not fit all when it comes to nutrition. We have become aware of the limitations of population-wide advice such as the food guide pyramid. Second generation approaches have proliferated with pyramids tailored for children, the elderly, ethnic groups, vegetarians, etc. Although these attempts are steps in the right direction, they do not take full advantage of the breakthroughs in biomedical science. Fortuitously, this realization has come at a time of great expansion of knowledge with the genomics/informatics revolution. 

Nutrigenomics is a young science and built around the revolution in genomics. As such, the science is still evolving. The excitement about nutrigenomics comes from a growing awareness of the potential for modifications of food or diet to support health and reduce the risk of obesity and many deadly chronic diseases.  

Nutrigenomics will become a critical part of the entire “personalized medicine” concept that is revolutionizing medical practice as discussed in detail in The Future of Medicine – Megatrends in Healthcare. Personalized (or “custom tailored”) nutrigenomics medicine is an approach that means it is possible to have a direct impact on long term health and longevity by very specific dietary manipulations. Nutrition will no longer be “one size fits all.” 

Nutrigenomics offers hope to those who know they have a strong family history of heart disease, cancer, diabetes, obesity, and most likely many other diseases as well. At the same time it takes away the excuse of “everyone in my family is overweight so I am too.” One no longer needs to be fatalistic in this regard and hope may lie at the end of a fork.  

Nutrigenomics is not a phenomenon, a fad, or a technique to use in a vacuum. It is best as part of a total approach to lifestyle management. 

It is increasingly apparent that various foods directly affect critical genes – turning them off or on as the case may be – and thereby directly impacting the development of atherosclerosis, diabetes, many cancers and obesity, among others. The foods that we consume play a role in how genes that affect our health are expressed, or “turned on” and “turned off”.  

For example, we know that broccoli is good for us because it is one of the most nutrient dense foods that we can consume. One of the reasons that consuming broccoli may enhance our health is that many of the nutrients in broccoli have been shown to turn on genes that protect from disease and turn off genes that increase the risk of disease. For example, a nutrient in broccoli called sulforaphane has been shown to turn off genes that cause many forms of cancer. The omega-3 fatty acids found in salmon, grass-fed beef, walnuts, flax seeds, and fish oils appear to turn on genes that protect against heart disease and its risk factors. These are just a few examples of how eating a nutrient dense diet can improve health by turning on genes that protect from disease and turning off genes that cause disease.  

It is important to realize that processing foods removes or destroys phytonutrients. Hence, processed foods contain less or no phytonutrients, and this lack of phytonutrients along with chemicals that directly affect our cells’ genes explains, in part, why overconsumption of processed and ultraprocessed foods contributes to chronic disease. 

See the Future of Medicine – Megatrends in Healthcare for a fuller discussion of the implications of genomics. And watch for new developments in this fast moving new science. 

Remember, nutrigenomics has made it clear that your genes need not be your fate! Just because you have a family history of a certain disease does not mean that you are also destined to become a victim.

“Why Are Medicare Costs Rising So Fast? – It’s Actually Not Complicated”

My last post was the beginning of a primer on Medicare. Medicare covers about 50 million older Americans for general health care and covers about 75% of covered services or 50% of total health care costs of these seniors. Medicare, as the largest single insurer, sets the standard for reimbursement rates across all insurers. It tends to pay slightly less than costs, leading hospitals and doctors to cost shift or charge others a higher rate. Medicare costs are increasing at about 4% per year and will reach $1 trillion by 2022, an unsustainable cost to the government (tax payer). 

There are multiple “parts” to Medicare. Part A is principally for hospital care; Part B is for largely for physician costs and Part D is the prescription drug benefit. Part C or Medicare Advantage is a private insurer managed care alternative to Part A which incorporates Part B and often Part D into one plan. 

Each of us and our employer pays 1.45% (total of 2.9% combined or for a self-employed worker) of earned income into the Medicare Trust Fund each year for Part A. Beginning in 2013, the tax is 3.8% on earned and unearned (i.e., salary or wages plus interest, dividends and capital gains excluding interest on municipal bonds) income above $200,000 for a single person and $250,000 for a married couple. The money paid in is not invested and set aside for use when the individual reaches 65. Mostly it goes to pay for the hospitalization costs of today’sbeneficiaries – it is a generation transfer tax. As the population continues to age and continues to live longer, there will a relatively smaller working population to pay the annual bills. It is estimated that the current 50 million enrollees will expand to 80 million by 2030 and the ratio of workers to enrollees will drop from 3.7/1 to 2.4 /1. So the combination of rising healthcare costs, more beneficiaries living for longer times and a relative shrinking of the taxable base means that the Trust Fund will ultimately become insolvent.  

Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more. Aging brings on chronic impairments (“old parts wear out”) such as impaired vision, hearing, mobility, dentition, bone strength and cognition. Additionally, enrollees also suffer from the chronic illnesses largely but not entirely the result of life styles. These include obesity, hypertension, heart disease, diabetes, chronic lung disease, cancer and many others.  Chronic diseases are inherently difficult to manage, will last a lifetime (some cancers excepted) and are expensive to treat. Chronic illness results in over 70-85% of claims paid. 

But these chronic illnesses consume more than they need to for a few very clear reasons.  First has been a lack of quality preventive care and attention to wellness. Second has been the lack of careful care coordination. These patients need a full multi-disciplinary team of providers to assure complete care (e.g., the diabetic patient will need an endocrinologist, nutritionist, exercise physiologist, podiatrist, ophthalmologist and others over time). But any good team needs a quarterback and the logical choice, the primary care physician, has been marginalized by Medicare for years. The result is that PCPs only allot about 15 to 20 minutes per patient visit (which translates into about 10-12 minutes of actual face time) – not nearly enough time to deal with multiple chronic issues, multiple prescriptions let alone take the time to call a specialist to explain the rationale for a referral and seek a prompt appointment for the patient. 

These are the basics of Medicare and the major reasons for continuing cost escalations. The increasing costs mean that it makes little sense to promise “Medicare as we know it” to persist in its current state into the future. Change is mandatory. The question is not whether there will be change but how to make changes in a manner that protects the medical and the financial health of the beneficiaries both today and into the future while keeping the benefits affordable. The Democrats and the Republicans both agree that change is mandatory but they offer widely divergent approaches to cost containment.  

The next post will evaluate the actual costs of Medicare for the average retired couple.
 
 

Reasonable Goals for Health Insurance Coverage and Defining Medical Necessity

Health care should be a right but it needs to be paired with some responsibility – some share of the cost, especially for routine care, and some attention to maintaining a reasonably healthy life style. To do so will not only lead to better health but reduced expenses overall – positive outcomes for all.
One of the major goals of the Affordable Care Act is to reduce the number of uninsured from the current about 50 million people (or 16+% of the US population) by both offering Medicaid to many more individuals and creating state-based insurance exchanges for individuals who cannot obtain insurance at their worksite. Medicaid will be available for those at <133% of the federal poverty rate (currently $22,050). The insurance exchanges will be available to everyone but those with income below 400% of the poverty level ($88,200 for a family of four) will be eligible for tax credits based on actual income. Unlike Medicaid which has essentially no cost sharing by the individual, insurance from the exchanges will be purchased at one of four levels – 60, 70, 80 or 90% of the approved covered expenses will be paid by the insurance; the remainder will be the individuals’ responsibility. Higher deductibles will likely correspond to lower premiums.

The Institute of Medicine (IOM), at the request of the Department of Health and Human Services, formed a committee to consider the process for defining “essential health benefits” which ultimately will translate into what is covered or not by the insurance from the exchanges. The IOM, wisely in my opinion, emphasized he need for affordability rather than just comprehensiveness. They argued that coverage should be “evidence-based, specific and value promoting over time.” They proposed that medical necessity should be based upon clinical appropriateness, best scientific evidence and a likelihood of providing an “increased health benefit…that justifies an added cost.” [For a fuller discussion of the IOM recommendations, see John Iglehart’s article in the New England Journal of Medicine, Oct 20, 2011]

These seem like wise and sensible proposals. Too often there has been a “push” to insist on very comprehensive coverage, little attention to evidence-based criteria and little or not cost sharing by the patient.

My own hope is to see insurance that carries high deductibles to encourage each of us to personally monitor our health expenditures. When we have our own money at stake, we are more likely to ask our physician if that MRI, procedure or specialist visit is really needed of if it is “just to be complete.” That high deductible may also encourage us to maintain a better life style and maintain our health. That is good for us and reduces the overall costs further.

My new book discusses these topics in detail – “The Future of Health Care Delivery, Why It Must Change and How It Will Affect You” will be published in Feb, 2012 by Potomac Books

Your Lifestyle Can Prevent Sudden Cardiac Death

Adhering to a moderate yet healthy lifestyle can reduce the risk of sudden cardiac death by about 90% according to a new study. It is well known that high blood pressure, high cholesterol, and diabetes correlate with coronary artery disease. Life style factors do as well – a combination of a Mediterranean style diet, moderate regular exercise, appropriate weight and non smoking all correlate with less coronary artery disease, less stroke, less high blood pressure, less diabetes, less cancer and multiple other chronic conditions and lower (or later) mortality overall.

These same factors have now been demonstrated to also reduce risk for sudden cardiac death, i.e., a sudden arrhythmia that leads to death in less than an hour from symptom onset.
S. E. Chiuve, etal of Harvard and the Brigham and Women’s Hospital in Boston (JAMA, July 6, 2011, p62) evaluated sudden cardiac death (SCD) among 82,000 participants in the Nurses Health Study between 1984 and 2010. 321 individuals had SCD during those 26 years at an average age of 72.

The authors set out four criteria for low risk lifestyles: not smoking, BMI <25, exercise >30 minutes per day and being in the top 40th percentile of the alternate Mediterranean diet score. In essence, the latter is a diet rich in fresh vegetables and fruits, nuts, whole grains, legumes and fish with moderate intake of alcohol.

The results were clear. The more risk factors, the greater the rate of SCD. Stated differently, “a low risk life style (not smoking, exercising regularly, having a prudent diet and maintaining a healthy weight) was linearly and inversely associated with risk of SCD among women.” Those women who had all four low risk lifestyle attributes experienced a 92% lower risk of SCD compared to those who had no low risk attributes. This suggests that the vast majority of SCD could be prevented by life style modifications.

The study authors point out that although 80% of women do not smoke today, adherence to the other three factors is low. Less than 40% of middle aged women have a BMI <25, 25% drink light to moderate alcohol and only 22% exercise regularly. And although the data on diet habits is limited, a simple observation of what is purchased in the supermarket is telling.

It is evident from this study – and many others – that managing lifestyle factors can prevent serious chronic illnesses including coronary artery disease, cancer, stroke, high blood pressure and diabetes along with sudden cardiac death. This is true even for those with a genetic predisposition – “your genes need not direct your fate.”

Smokers Die Ten Years Sooner Than Nonsmokers

We all know that smoking is bad for our health. But how bad is bad? The answer is very bad. It takes a decade off of life.
Death rates are about 3 times higher for smokers than nonsmokers. The chance that a young person will live to age 80 is about 70% for nonsmokers but about 35% for smokers. Stated differently, a smoker loses about 11(women) to 12 (men) years of life compared to nonsmokers.
 
Now that women have been smoking for long periods of time, their risks match those of men who smoke. “Women who smoke like men die like men who smoke.” Women’s relative risk of developing and dying from lung cancer (compared to nonsmoking women) is about 25, same as for men. For chronic lung disease, the relative risks are 23 and 25 for women and men, respectively. For ischemic heart disease the relative risks are 2.9 and 2.5 and for stroke they are 2.1 and 1.9.
These are the results presented from two studies of very large populations of Americans published January 24, 2013 by the New England Journal of Medicine, one by Prabhat Jha and colleaguesand another by Michael Thun and colleagues. Each analyzed different populations but arrived at essentially the same conclusions. 
Alarming as these numbers appear, there is hope. Those who quit smoking will gain back substantial years of life, with more years gained the sooner one ceases smoking. For example, in Jha’s analysis, those who quit in the age range 25-34 reverted almost to the nonsmoker status – they gained back 10 years of life. Stopping between 35-44 years of age gained 9 years and between 45-54 years of age the gain was 6 years.
 
It is never too late to quit and the benefits are clearly substantial.

 
 
 
 

A Vision For Health Care In America

In researching  The Future of Health Care Delivery – Why It Must Change and How It Will Affect You, I had in depth interviews with over 150 leaders from across the country including hospital CEOs and COOs, practicing community and academic physicians in both primary care and specialty areas, pharmacists, nurses, insurance executives, health care consultants and many others. But I found what I think is a very good vision and resulting model right at home in Howard County, Maryland.

County Executive Ken Ulman and former health officer Peter Beilenson, MD, MPH created “Healthy Howard” to assist those without insurance.  Their concept was to provide primary care access for all, an extensive network of specialists, community and tertiary care hospitals and a basic electronic medical record. Methods were built in to maintain costs as low as possible. But part of the basic premise was that with these “rights” for the patients came certain “responsibilities” – some limited payment participation and some requirements toward practicing healthy living as well as compliance with treatment recommendations. It structured a good balance between patient rights and responsibilities, between care delivery and a working payment system, between access and effective care.

Howard County, between Baltimore and Washington, is a fairly affluent county with excellent providers and a highly regarded community hospital. Despite affluence, there are uninsured individuals and families. Some could afford insurance but choose to spend their dollars elsewhere. Some are the young invincibles who don’t feel they need it. Others work in the service industry where their employer does not provide insurance and they cannot afford to carry the entire burden. And some are simply indigent.  The question was how to provide for this disparate group in an effective yet equitable manner that would render good quality care at a moderate cost.

Healthy Howard is a county-assisted, community based not for profit organization which collects a modest fee, on a sliding income scale, from its members. In return, each individual gets unlimited access to a primary care physician (PCP). The office employs a care coordinator who works with the PCPs to assist those patients who have complex chronic illnesses such as chronic lung disease, cancer, or diabetes with complications. There is also a pharmacy benefits manager located in the PCP office to assist patients find drugs at the most reasonable price in the community. They work with the physicians to find generics, discuss other effective agents with the doctor or even contact the manufacturer if appropriate to get a reduced price for an indigent patient.

Of course some patients will need to see a specialist physician. Healthy Howard has developed an agreement with the county’s specialists to accept, gratis, these patients with the understanding that the program will allocate the patients across all the specialists in a given field (e.g., cardiology or orthopedics) so that no one physician has an excessive burden.  Howard County General Hospital, being part of a unique system in the state of Maryland, has always accepted indigent patients but under the agreement with Healthy Howard, the hospital forgoes any attempt to collect from these patients.  Further, since the hospital is part of the Johns Hopkins Health System, an agreement was reached with Hopkins to accept any patient that needs tertiary care at no charge.

These might be termed the “rights” of the patients. But there is also some participation required in order to be part of Healthy Howard; these are the corresponding “responsibilities. In addition to the modest sliding scale fee, each patient is assigned a health coach with whom he or she must meet on a regular basis. The coach works with the patient to develop a plan for healthy living. This might include attending a smoking cessation program, attending a gym for exercise or working on a diet plan. Together patient and coach develop a plan of action with benchmarks at various intervals. The patient meets with the coach periodically to compare actual results to the benchmarks.

The coach is there not just to measure results but to assist and to help break down barriers. Sometimes just some encouragement is all that is needed; sometimes referral to a specialist such as a nutritionist is helpful; and sometimes a more involved approach is required. As Mr. Ulman described to me, imagine an overweight lady who wants to participate in a fitness program at the local health club – to which Healthy Howard has worked out a special free arrangement. But she says cannot attend because her daughter is a single working Mom and so she, the grandmother, must babysit the child. No problem, the coach finds a fitness center that also has built in day care, breaking down the barrier that had to date prevented success.  The idea is that the plan will help overcome barriers yet still expect responsibility to meet objectives.

Healthy Howard, as its name implies, will mean healthier participants a few years down the road. The primary care physicians, with help from the coaches, will give attention to prevention thus lessening the burden of chronic illness in the future. And they will give careful care coordination for those with chronic illnesses now- thus lessening the current cost burden by reducing the need for specialist visits, excess tests and imaging and unnecessary drugs

And it worked. Now a few years in, there has been a 35% reduction in ER visits and a 50% decline in hospital admissions. Enrollees are healthier and more behaviorally motivated to maintain good health. Sufficient success to substantiate the awarding of a federal contract to utilize these principles  to create a state-wide consumer operated health insurance plan (a CO-OP) for the ACA Maryland insurance exchange based on the principles of 1) having the vast majority of care provided by primary care, 2) using bundled or capitated provider compensation and 3) using evidence-based medicine.

Healthy Howard, as its name implies, means healthier participants. Its great value is as a vision of health care delivery that incorporates improved quality, reduced costs and excellent access in return for a modest fee and a commitment to living a reasonably healthy lifestyle. Rights and responsibilities working together. It is a good vision to use as a starting point.

Integrative Medicine Part V – Busting Stress

 

Stress is with us all the time. Issues at work or at home, getting a traffic ticket, the grocery store out of your favorite yogurt. Life has stresses. We can go to the doctor and ask for a pill or we can learn to deal with our stresses effectively without much medication.

 

Acute stress is normal and can even be lifesaving – seeing a truck barreling down the road at us. But when stress is chronic it becomes a major cause of ill health.

 

Chronic stress builds up when the demands upon us become greater than our resources to respond in an effective manner. Stress tends to become cumulative. You can handle the first stressor and even the second, but when the third one occurs, even if it was rather minor, it tips over your balance point. Since we cannot completely escape stress, our agenda must be to boost our resources – to “fill up our cup” as Delia Chiaramonte, MD of the University of Maryland Center for Integrative Medicine liked to term it during her “Busting Stress” workshop at the Center’s recent Health and Wellness Conference held in Baltimore, MD.

 

Integrative medicine does not avoid traditional “western” medical approaches such as medications. But it does look at the whole person to determine if there are other parts to the “prescription” that might be equally or even more valuable. The agenda is to maintain health and further develop wellness.

 

There are external and internal sources of stress. Our boss ignored our hard work or disparaged our report – these are obvious external stresses. If they become too much it may be best to just look elsewhere for a new job and escape the situation.

 

But other stresses are internally mediated. We might convert an event into a thought that in turn leads to a negative feeling that in turn causes stress. Imagine that a loved one is late to get home and has not called. That is the event. The thoughts can be quite different. One thought might be that he was in an accident resulting in a stressful feeling of anxiety. Or perhaps this event leads to the thought that he is having an affair – leading to a feeling of hurt. Or perhaps the thought is that he just didn’t care that he was late and didn’t bother to call – leading to a feeling of anger. Perhaps more likely he is just stuck in bad traffic and doesn’t have his cell phone with him – in that case you might have a feeling compassion. The three stressful feelings came from your thought interpretation of the event. The question you need to ask yourself is what is the likelihood of any of these thoughts being correct?

 

You need to restore rationale thinking. Do this by labeling the irrational thought and then refute it with a new thought like “I have no evidence of an accident; he is probably just stuck in traffic.” Then detach yourself from the thought with the recognition that “this is an anxious thought, not a rational thought.” Finally, do something to distract yourself like playing with the kids.

 

To “fill up your cup” Dr Chiaramonte suggests considering these approaches. Begin a “gratitude ritual.” This means to take a time each day for gratitude perhaps while falling asleep or perhaps at dinner time. Think about what is good in life – today – maybe a spring flower, a smile from your loved one, the bright eyes of your child. It can’t be a rote thought however. Make it different every day. Amazingly enough, it works. It will increase your happiness and correlates well with general health and well being.

 

Here is a line from the song “Counting My Blessings” sung by Bing Crosby and Rosemary Clooney in the movie “White Christmas.” “When my bank roll is gettin’ small, I think of when I had none at all, and I fall asleep counting my blessings…” This is the concept of gratitude.

 

A second approach is to aggressively try to be a “benefit finder” rather than a “fault finder.” It’s an approach in which you rethink and with doing so decrease your emotional reactions. Instead of the thought, “I have a vision problem that limits me” you might instead think of, “I still have one good eye and the world looks good to me.”

 

Sleep is important. You feel more stressed if you are sleep deprived. Most of us get too little sleep. Fill your resource cup with added sleep. And the gratitude ritual at bed time will help you sleep more soundly.

 

Food is equally as important. Things to avoid are processed foods with high levels of carbohydrates and fats (of course, these are the ones that taste so good to us!) like doughnuts, macaroni and cheese or pizza. Instead get more high quality proteins and skip the refined sugars as in sodas.

 

And add in some exercise. Just moderately paced walking each day will not only decrease your stress but will improve your cardiovascular health, bone health and overall add to your sense of wellness.

 

This may sound like a lot of effort. Actually it’s really not. It doesn’t take much time; it improves your physical health; and it will allow you to cope much better with stress. Better to “fill your cup” than rely on an anti-anxiety medication.

Ultraprocessed Foods Lead to Chronic Illnesses

Much of today’s foods are “ultraprocessed,” lead to obesity and its ultimate diseases such as diabetes, coronary artery disease, hypertension, many cancers and worsening of diseases such as osteoarthritis.

Ultraprocessed foods originate from just a few grains, namely corn, wheat and soy but these then undergo extensive chemical and mechanical manipulation resulting in compounds that humans have never eaten before. Just look at the ingredients list on many store products and notice first how many ingredients are listed and second how few of them you recognize. Further they are concentrated as to sugars, salt and calories while deficient or totally lacking in the fiber, micronutrients and phytochemicals found in fresh or frozen grains, vegetables fruits and unadulterated meats and fish.

David Ludwig MD, PhD of Boston Children’s Hospital wrote a cogent article on ultraprocessed foods in the April 6, 2011 edition of the Journal of the American Medical Association and upon which the proceeding was based. He explains that there have been three major breakthroughs in food technology. The first came perhaps 2 million years ago with the development of stone tools and the use of fire for cooking. This allowed the human who did not have the running speed of large carnivores nor the digestive tract attributes of herbivores like cattle and sheep to expand his diet. The second big technology breakthrough was domestication of grains – agriculture. This led to civilization in the sense of larger more stable communities because domesticated grains such as wheat and corn greatly increased calories available and no longer required migration to hunt or gather. He makes the interesting observation that human stature dropped a few inches with this change because grains carry fewer micronutrients and protein per gram than do animal meats and nuts.

The industrial Revolution was the third breakthrough technology which led to refined flours and concentrated sugars along with grain-fed rather than grass fed cattle, sheep and hogs. Such animals are heavy with saturated fats although their protein content and ready availability has resulted in a return of greater stature in recent generations. More recently have come ultraprocessed foods.

These ultraprocessed foods are high in calories from sugars and fats – often hydrogenated and trans fats – yet low in micronutrients. They are found in supermarkets’ “middle aisles” as processed foods such as cereal with added sugar, cheese “spreads”, “macaroni and cheese,” soups high in salts and calories, “sticky buns,” and of course sugared sodas. And ultraprocessed foods are readily available in many fast food outlets where a muffin may have 400 calories with high contents of sugars and saturated fats. A bacon cheeseburger, large fries and large soda can contain well more than one half of a day’s caloric needs yet be deficient in nutrients.

Ludwig concludes with “the problem is the creation of a dietary pattern based on factory-made, durable, hyper-palatable, aggressively marketed, ready-to-eat or heat foodstuffs composed of inexpensive, highly processed ingredients and additives. Reducing the burden of obesity-related chronic disease requires a more appropriate use of technology that is guided by public health rather than short-term economic benefit.”

What can we do? We need to cut back on the ingestion of these ultraprocessed foods. But this will not be easy. For this to work I believe we need incentives. After all, that bacon cheese burger tastes good – sugar and fat are pleasing in our mouths. So we need more than just knowledge that we are eating well and thereby preventing future disease while improving our health. Knowledge is important because most people just do not realize the extent of the harm that comes from over consumption of ultraprocessed foods. With knowledge we can follow the advice of Pollan in his “In Defense of Food” to never buy a product that has more than five ingredients or has ingredients that we have never heard of or cannot pronounce. But knowledge alone is just not incentive enough to overcome the temptations.

Some thoughts: Government can help with how it subsidizes agriculture, incenting the growth of a broader array of crops and not marking the fattest meat as “prime.” And it can continue to insist that restaurants, especially fast food outlets, display calorie counts. Business can help with wellness programs that reduce the employee share of health insurance premiums in return for weight reduction or exercise programs. Insurance can offer incentives as well. Schools can offer only quality foods – good in itself but also a lesson in good dietary habits for our children in their formative years. And we each need to create our own incentives – as I typed this I also ate a chocolate chip cookie. I enjoyed it but have set myself a limit of one per day. My treat for finishing this blog post.

Using Genomics to Improve Treatment of Lung Cancer

Drug companies can use genomics to create targeted drugs like imatinib (Gleevec) and trastuzumab (Herceptin.) Physicians can then use the results of genomic studies to guide prescribing. As discussed in prior posts, a person with Philadelphia chromosome-positive (i.e., having the BCR-ABL translocation with its aberrant tyrosine kinase) chronic myelocytic leukemia will likely respond to Gleevec. And a woman whose breast cancer shows high levels of the Her2neu receptor will likely respond to Herceptin. There would be no reason to treat a Philadelphia chromosome-negative CML patient with Gleevec nor a breast cancer patient without Her2neu receptors with Herceptin.

Recently the treatment of lung cancer has advanced considerably as a result of genomic analysis of the tumor and the development of targeted drugs. Lung cancer is divided into a number of different categories based on the microscopic appearance under the microscope. One type is called small cell and the others are usually “lumped” together as “non small cell” lung cancer because the former is treated much differently than the latter group. The non small cell lung cancers can be genomically evaluated to determine if there are certain common genetic mutations such as KRAS, EGRF, MEK and other mutations or the EML4-ALK translocation.

Patients with the EML4-ALK translocation respond reasonably well to the tyrosine kinase inhibitor crizotinib (somewhat similar to the one used for CML). As with the translocation seen in CML, this is a fusion gene that occurs during a translocation of two parts of two chromosomes that lead to a portion of the normal EML4 gene being fused next to the normal ALK tyrosine kinase gene. When this happens the new gene transcribes a variant tyrosine kinase protein which leads in part to the development or progression of lung cancer. Studies to date indicate it to occur mostly in the subtype called adenocarcinoma, in those with prior treatment, in younger patients and those who have no or a minimal smoking history. Although this represents just a small subset of all lung cancer patients, treatment of them in a Phase 1 trial with crizotinib resulted in a confirmed response in 57% (47 of 82) of patients with another 33% (27 of 82) having stabilized disease. [Kwak et al, New England Journal of Medicine, Oct 28, 2010] Although not a randomized trial, it is well known that most second line treatment regimens have no better than a 10% response rate so this would appear to be a breakthrough of sorts. Certainly it is not a panacea, nor a cure. But with minimal side effects these patients received some useful benefit and probably will have a lengthened survival Further studies will need to be done but if it is correct that about 5% of lung cancer patients have this fusion gene, then about 9000 patients per year would potentially benefit form crizotinib or similar ALK kinase inhibitors. Concurrently, one would not choose to use this drug in patients without this fusion gene and its abnormal protein. It also appeared that some patients had a further mutation such that crizotinib was not effective in them. [Note: Crizotinib is not yet approved by the FDA so access to the drug is via clinical trials.]

Patients who have the EGRF mutation appear to be distinct from those who do not as to response to the drugs erlotinib (Tarceva) and gefitinib (Iressa). EGRF is a tyrosine kinase that when mutated appears to play a role in lung cancer development and progression. Those who do have this mutated gene and its transcribed protein will respond to these two drugs in about 70% of cases with progression free survival of about a year and total survival of about two years. This would appear to be superior to standard drug therapy used today. Without this mutation, the patient will do much better treated with chemotherapy. So the treatment of a new patient with lung cancer today should include genomic analysis of the tumor so that the patient can receive the most appropriate first line treatment and then reanalysis later to determine if there are further mutations or translocation that would direct second line treatment options.

This is just one more example of how genomics is making medical care more custom-tailored, one of the five key medical megatrends.

The Doctor’s Customer Is The Insurer – Shouldn’t It Be The Patient?

You the patient are really not the customer of your primary care physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.  

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000. 

As for the insurers, you are not their customer either. Their customers are the ones who pay them – your employer or your government.  And it shows – by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit. 

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or ask to use of email or telephone. Because you are not paying for the time and your insurance will not do so either. It is just not your choice. 

To be clear. Yes, you are paying the physician directly in the co-pays and the deductibles but it is still the insurer that determines whether and how much the physician gets paid. You just get to contribute whatever portion you are told.  

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.  

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. More effective preventive care. More attention to the complex chronic illness with fewer referrals to specialists.  Better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop. Spending  the time to listen and become trusted as the healers that they could and should be — all leading to better care at much lower total cost.  

A new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians – they are and should be the backbone of the healthcare system – who are able to offer outstanding preventive care, care for the vast majority of complex chronic illnesses, offer coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike – with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured and assuring that PCPs have fewer patients for more time each.  

It is possible but it will require both doctor and patient alike to demand it. There are many ways to skin the cat but the most promising is direct primary care (membership/retainer/concierge) practices. More on this later.
 

My next post in this series on the crisis in primary care will be about today’s impediments to good primary care.

Bringing Down the Costs of Medical Care

It is currently popular for government officials to single out the insurance companies for the rising cost of healthcare. Not that the insurers are without fault but the real reasons for cost increases are rarely addressed and therefore not appreciated. We are a country with an aging population (“old parts wear out”) and of many adverse behaviors (e.g., overweight, sedentary lifestyle, stress and 20% still smoke.) Combined, these are driving a rapid increase in chronic diseases such as diabetes type 2, cardiovascular disease including heart attacks, heart failure and strokes, high blood pressure, and cancer.
These are illnesses that, once developed, are usually with the individual for life, have a major impact on quality of life and are inherently expensive to treat. The Milken Institute did a comprehensive study of chronic diseases. Among their findings: 109 million Americans have a chronic illness now [that’s about one third of us!] and many have more than one for a total of 162 million. The costs of care today are about $275 million and the total economic costs are well over a trillion dollars per year in lost productivity, etc. They estimate that we are on a track for a 42% increase in these chronic diseases by 2023 (as a result of aging and behaviors,) not that long from now. And if we do nothing to change the way we care for these patients, the costs of medical care will be $790 billion and the total economic costs will be over 4 trillion dollars.
There are two things to do to reverse this trend. These are illnesses that by and large are caused by our behaviors or are the result of aging. We can’t stop aging. So, the first step is to have an active program in behavior modification. Easier said than done, of course but here are some principles. We need to individually accept responsibility for our own health. But we need to understand what we are doing and how it impacts us over the long term. Government can help here with educational programs, rules about school lunches, requiring restaurants to post calorie and fat contents, labeling food packages with a more realistic total calorie assumption (today packages imply that the average person needs a 2000 calorie diet) and other steps. Incentives, primarily monetary ones, can have a big impact. Incentives need to be large enough to be useful yet focused enough to drive toward the desired end. Our employer can help with wellness programs to assist us to stop smoking, loose weight, improve our nutrition or deal with stress more effectively. The incentive here can be asking the employee who is successful to pay a lower portion of their health insurance premium. Insurers can create incentives directly for following a healthier lifestyle by lowering premiums for those who don’t smoke or are at a reasonable weight.
The second major step is to ensure that those who do have a chronic illness get very good care coordination. Unfortunately, this is just not the case for most patients today. They end up with multiple doctors, each doing their own thing, excess specialist consultations, too many medications, unnecessary tests and procedures and sometimes even unneeded hospitalizations. This drives up the cost of care dramatically. When one has a primary care physician that takes the time to fully coordinate all the elements of care, the use of specialists declines as do tests, procedures and hospitalizations and drug therapy is well managed.
Unfortunately, most primary care physicians have too many patients under their care to allow adequate time for prevention sessions or the time needed for care coordination. They need to care for fewer patients meaning they will need to receive a higher fee for each visit and this must include a reasonable payment for preventive activities and coordination efforts. Added to this they need to be paid to take the time to respond to emails and to use other technologies that can keep the patient out of the office unless really necessary. Some docs are doing just this by limiting their practice to about 500 patients (rather than the usual 1200-1400) and charging a flat fee for all care for a year. Others are refusing to accept insurance, both commercial and Medicare, and instead are billing the patient just as a lawyer or accountant or other professional would. The billing includes time spend in prevention and coordination. These may well be the future of primary care reimbursement and a means to assist the patient to first prevent chronic illnesses from occurring and second to assist in good coordination of the care when one does develop.
But all of this raises critical questions. What should and what will government do to help us modify our behaviors? Will insurers be allowed and will they accept the responsibility of a two tiered premium pricing system? Will employers accept the added chore of developing wellness programs? Will physicians, even if they are offered adequate payments, actually spend the time needed for good prevention and good care coordination? And, most importantly, will we as citizens accept our responsibility to lead a reasonably healthy lifestyle?

You Are Not Your Doctor’s Customer – But You Can Do Something About It

Our care is generally good in the United States but not as good as it could be nor as good as it should be. There are multiple problems to consider.  

First, ours is a medical care system not a health care system. We focus on disease once it has occurred but give relatively little attention to maintaining health and developing wellness.  

Clearly there is a need for greater attention to disease prevention and health promotion.  Second, our sytem developed over many decades to care for acute illness but today we are faced with more and more chronic diseases. Sure there are still patients with an ear infection or a broken leg. But more and more individuals are developing diabetes, heart failure (both of these now becoming epidemics), cancer, chronic lung disease and others. These are illnesses that generally last a lifetime (some cancers can be cured, of course), are complex to manage and inherently expensive to treat. They are best handled by a multi-disciplinary team coordinated by a primary care physician. But such is seldom the case today.  

Third, of course, many do not have health insurance with some 47 million uninsured and many more underinsured. And as they obtain insurance or join the Medicaid ranks as the result of healthcare reform, there will be way too few primary care physicians to care for them. They will therefore continue to use the emergency room as their principle place for care.

Fourth, our system of care is not customer-focused. We wait long weeks and months for an appointment, spend long times in the waiting room and are frustrated that we get just 12-15 minutes with our doctor. Our doctor suggests that we go to a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. 

And then there are the insurers. We are not their customer – our employer is their customer or our government is their customer but not us. And it shows – by our long waits on the phone, by the complex often hard to understand paperwork and by the frustration when the insurance we thought we had does not cover our latest tests, x-rays or specialist visit.

Indeed we are not the insurer’s customer nor are we the doctor’s customer. The physician is the customer – sort of – of the insurance company. We are mere bystanders. This is hardly the type of contractual relationship we have with our lawyer, architect or accountant. 

So a new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses (who consume 70-85% of all healthcare claims paid) to both improve quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be – of both the physician and the insurer. It’s doable but it means a rethinking of how our delivery system is structured. 

One thing individuals can do now is to obtain a high deductible insurance policy. This means your premiums will come down and you will be paying for primary care out of pocket. But primary care is generally not expensive and now you will be in a position to expect more from your doctor – after all, it is you who is paying the bill and doing so directly. Alternatively, look for a PCP that has a retainer based practice or simply does not accept insurance. In each of these scenarios, you now have a direct professional contractual relationship with your doctor. You will be treated as such and now you are more likely to challenge suggestions and ask questions. You will also get better preventive care because the doctor has more time to spend with you. The result will be far fewer referrals to specialists, fewer tests and procedures and an ultimate savings in health care costs.
 
 

Most Medical Decisions Are Not Risk Free

Interpreting Your Benefits and Risks of Medical Decisions

Patients and doctors need to be a team in making important health care decisions. Good decision making requires solid, appropriate information but all too often it is either not available or presented in a format that is not of great value. Well grounded decision making is critical because every action has not only the hoped for outcome but also the risk of an adverse outcome. No medicine is devoid of side effects. A diagnostic test may produce a false positive or a false negative. A procedure may or may not cure. For example, choosing statins may lower cholesterol but may also cause muscle damage. A decision to have a mammogram may lead to a suspicion of cancer leading to a biopsy which turns out to be negative – a false positive. Choosing to have a stress test that turns out negative may lead to a sigh of relief and yet the patient dies of a heart attack the next week. A false negative.

These and others like them are high stakes decisions so doctor and patient need good data in order to reach a well informed decision. The information needs to be presented in a manner that is easy to grasp and to visualize in one’s mind’s eye.

Eric Rifkin, PhD and Andy Lazris, MD address these in Interpreting Health Benefits and Risks– A Practical Guide to Facilitate Doctor-Patient Communication. For each of twenty commonly encountered decision points they offered well informed information. Should I get a mammogram at my age? How likely is a stress test to clarify if I have coronary artery disease? What are the risks/benefits of taking a statin? Do I need an annual examination with my primary care physician, and if so what should it include? If I have atrial fibrillation should I take a blood thinner?

To each of these and sixteen others they give a concise overview of the data available, pointing out where it is strong or weak. They also include a patient vignette from Dr. Lazris’ internal medicine practice, thus giving each decision issue a compelling connection to real life situations. They then add a third and critical layer, a visual representation that adds clarity to the complex issues.

The visual is called Benefit Risk Characterization Theater (BRCT). It uses the floor plan for a thousand seat theater. Each seat represents a person. So for example, if a person smokes regularly, the question might be what is the risk of death at 25 years of doing so? The theater shows a thousand seats with 198 of them blackened out. This of course means that compared to 1,000 non-smokers, this group of smokers will experience 198 extra deaths compared to the other group. Seeing the blackened seats is a strong statement of risk – more compelling than just indicating  a percentage. As the authors state, “the graphic should do the math for the patient.”

 

Implicit throughout the book is the understanding that great controversy exists within the medical community about the risks and benefits of many screening tests, diagnostic procedures and therapeutic approaches. The BRCT allows the patient to become a co-equal with the doctor regarding the data and thus a real contributor to the decision making process.

For the purpose of shared decision making, the combination of factual data, a patient’s story and especially the visual BRCT allows patient and doctor to approach the question at hand with substantial assurance that whatever decision is made, it was done so in the context of real knowledge.

I have only one criticism of the book and it is leveled squarely at the publisher (Springer), not the authors. It is a paperback priced at $89.99, apparently assuming it will be of interest to a limited number of academics. In fact, it should be in the consultation room of every primary care physician and available to all patients who want to participate in their health care decision making. My recommendation: It is too expense for the average person to buy so ask your library to get some copies and then avail yourself. You may be surprised at what you learn. You will certainly be better equipped to talk with your doctor.

Inadequate Communication Between Hospitalist and PCP is Detrimental To Patient Care

The American health care delivery system is reaching a point of crisis.  Its costs are escalating as outcomes and quality of care are diminishing.  It focuses on crisis management and treating problems aggressively with medicines and interventions of uncertain benefit, while neglecting true health and wellness.  It is estimated that 1 trillion dollars annually is being spent on unnecessary care, much of which occurs in the hospital, and some of which leads to harm. Medicare, although concerned about rising health care costs, does little to address the real issues and actually but subtly encourages aggressive management when less could indeed be more.  Hospital acquired infections and death from medical errors are far too numerous, often occurring in patients who did not have to be hospitalized in the first place.  Patients and physicians are frustrated, while private insurers and both Medicare and Medicaid are becoming unable to fund this excessively costly care without raising premiums or exhausting trust funds.  Something certainly must be done.
We wish to focus on one glaring problem occurring in hospitals that is relatively easy to fix and whose resolution could improve outcomes.  Currently, as many hospitals close their doors to primary care physicians (PCPs) and instead rely on hospitalists, there often is a lack of communication between these doctors that can lead directly to costly mistreatment.  A true and common story will set the stage.
Mrs. P suffers from dementia and lives in a nursing home.   One day she became unresponsive.  The nurse on duty could find no obvious reason and so immediately called 911 and sent her to the hospital.  While she quickly woke up, the emergency medicine physician admitted her for further evaluation.  Her assigned hospitalist found bacteria in the urine and treated her for a urinary tract infection, calling in an infectious disease consultation and starting her on a potent intravenous antibiotic.  He also requested consultations from a cardiologist and a neurologist to determine the cause of her unresponsiveness, and they ordered further tests including an MRI and an echocardiogram.  Mrs. P became more confused, was exposed to aggressive evaluation and treatment, and was losing her strength as a result of bed confinement.  She was ultimately sent back to her facility after tens of thousands of dollars of medical care, worse off than when she arrived.  She was fortunate to have not suffered further harm from her hospital-induced delirium and the potent medicines she received.
Let’s dissect what happened, and why.
The emergency medicine physician was faced with a lethargic person who could not give a coherent history, hence she was subjected to an extensive work-up and then admitted to the hospital. The hospitalist, likewise, was faced with a patient he had never met before, with only the emergency room records as guidance. He detected neurologic, infectious, and cardiac problems and so called for specialist consultations and extensive testing. 
It is unfortunate that the nursing home nurse did not call the patient’s primary care physician (PCP) upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her.  Had they called Mrs. P’s PCP they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost.  A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event so avoiding unnecessary antibiotics must be a top priority.
The growth of the hospitalist movement over the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggested that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community based PCP to achieve.
The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge.  Communication with the patient’s PCP however could alleviate many of these issues.
PCPs have been – generally – content to allow the hospitalist to manage their patients, indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time, time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barredfrom doing so by hospital rules. 
In this situation, both PCPs and hospitalists could have improved Mrs. P’s care substantially, and reduced the cost of unnecessary care, simply by communicating.  A call or text by the hospitalist to the PCP upon admission and at various decision points might have enabled Mrs. P to leave the hospital before any consults were called, before extraneous tests were ordered, before antibiotics were initiated, and before she became more confused and weaker.  More than half of elderly patients leave the hospital worse offthan when they came in, and involvement of a PCP in a patient’s care could potentially facilitate more rapid discharge and less aggressive treatment. 
A recent surveyindicated that 95% of hospital leaders are concerned that discharge communication is “inefficient” and 80% have concerns about communication among care team members.  PCPs complain that they are never called. Hospitalists often state that they just don’t have time to call the PCP but when they do, the PCP is not available. Each is culpable. Each must remember that the issue at hand is the patient’s care and welfare, not their convenience or preferences. It is a matter of professional responsibility. What could help? The electronic medical record was supposed to solve these sorts of problems but it has not and probably will not in the foreseeable future. There are some HIPPA compliant texting systems which could be utilized and there are HIPPA compliant smart phone apps that can coordinate among all involved physicians, nurses, hospitals, other facilities and even the patient him or herself. One of these types of systems could potentially negate the issue of non-availability although it will not top the value of nuanced conversation among physicians. 
In the end, there is nothing that trumps good physician to physician communication. It must be incumbent on hospitalists to involve PCPs during in-patient stays and it must be incumbent on PCPs to respond to hospitalists and provide crucial insight and information when asked to do so.   Not only can outcomes be improved, but costs can drop and patients and their families can feel more comfortable knowing that their own doctor is involved in their care.  If necessary, hospitals should set policy that makes hospitalist to PCP communication mandatory; everyone will benefit.  Very basic solutions can frequently lead to profound improvement. 

 

This post was co-authored by 
Andy Lazris, MD, CMD  a primary care physician whose private practice focuses on geriatric patients especially those residing in long term care and assisted living facilities. He is the author of Curing Medicare and co-author of Interpreting Health Risks and Benefitsand was first published on Medical Economics on July 29, 2017


The Paradox In American Healthcare

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, The pharmaceutical, biotechnology and diagnostic equipment industries continuously bring forth lifesaving and disease altering medications, devices and diagnostics. So we can be appropriately awed and proud and pleased at what is available when needed for our care. 

But, on the other hand, we have a very dysfunctional health care delivery system. A fascinating paradox. One wonders just why it is that Americans tolerate this paradox of incredible medical advances and outstanding providers yet a dysfunctional delivery system. 

Our medical care system works poorly for most chronic medical illnesses and it costs far too much. Chronic illnesses are ones like diabetes with complications, cancer, heart failure and neurologic illnesses like stroke. 

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose which combined with the long term effects of behaviors  lead to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer.  

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to treat and expensive to treat – an expense that continues for the rest of the person’s life.  

Primary care physicians can deal with most of the issues of these patients – if they have the time to do so. But referrals to specialists is often necessary. Primary care physicians generally do not have the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost. Over time, most chronic illnesses will need a team of caregivers. Consider a patient with diabetes who may need an endocrinologist,  nurse practitioner, podiatrist, nutritionist, personal trainer, ophthalmologist and perhaps vascular surgeon and cardiologist and many others as well. But any team needs a quarterback and in general the person is the primary care physician. He or she needs to be the orchestrator as much if not more than the intervener. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute illness where one physician can usually suffice. It is this shift to a population that has an increasing frequency of chronic illnesses that mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need.  

In healthcare the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. So we need to focus there. 

Since most chronic illnesses are preventable, what are needed are aggressive preventive approaches along with attention to maintaining and augmenting wellness. This would reduce the burden of disease over time and greatly reduce the rising cost of care. Unfortunately, America places far too little attention and far too few resources into wellness and preventive.  Most primary care physicians do not give really high level preventive care. Yes, they do screening for high blood pressure and cholesterol and for various cancers and they attend to immunizations. But this is not enough. Patients need counseling on, at least, tobacco cessation, stress management, good eating habits and a push toward more exercise. They need an admonition to not drink and drive, not text and drive and to buckle up. They need to be reminded that dental hygiene today pays big dividends in the later years of life. And they need someone to really listen closely to uncover the root cause of many symptom complexes as in the story given in the first of this multipart series on primary care. 

When a patient is sent for extra tests, imaging or specialists’ visits the expenditures go up exponentially yet the quality does not rise commensurately. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do not have enough time for care coordination or for more than the basics of preventive care.  And they just do not have time to listen and think. 

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery is not what it should or could be. The result is a sicker population, episodic care and expenses that are far greater than necessary. The fix is change the reimbursement system to get PCPs the time needed to listen, to prevent, to coordinate and to just think. This will lead to better care and less expensive care.

The next post in this series will be about customer focus.
 

As A Physician Do You Have Adequate Financial Expertise?

Book Review – Physicians (and dentists, nurses, nurse practitioners, and other health care providers) need to understand money but most have limited financial expertise. No wonder and it’s not your fault. Four years of college, four more of medical school and three or more of residency left little time for personal financial education. But you still need that education and now is the best time to start.
The financial playing field is definitely not level and so you need to do what you can to level it. You are probably encouraged regularly to invest in various money making schemes that sound too good to be true. Making good financial decisions over time means the benefits can compound over long time periods – to your definite advantage.
Unfortunately, medical school and residency programs have essentially no time devoted for personal financial education and little if any time for learning the financial implications of starting a medical practice. You are on your own. Your natural mentors – professors, senior residents or senior colleagues in your practice – are probably no better equipped than you. Some medical students are obtaining combined MD/MBA degrees but this is overkill for just your own personal financial educational needs.
I was encouraged by consultants at Sage Growth Partners to meet Dr. Yuval Bar-Or. Dr. Bar-Or comes from a medical family (father and brother are physicians) but he entered the finance field, obtaining a PhD in finance from the University of Pennsylvania’s Wharton School. He is now a faculty member at the Johns Hopkins Carey Business School. His own family’s circumstances led him to realize that medical families need access to clear, objective, expert financial knowledge. He has written a set of two books, called Pillars of Wealth I and II, to address this need.
The books are straight forward, easy to read, thorough, yet not mired in financial jargon. In short, you can learn and do so easily. He begins with what he calls three axioms (reminds me of high school math!) 1) Your most valuable asset is earning capacity (not lucrative sounding investments); 2) Your most precious resource is time (saving now will pay off handsomely in retirement); 3) Your greatest enemy is procrastination. From there he reviews the basics of stocks, bonds, real estate, business ownership, insurance, annuities, 529 college savings plans, etc. He puts an emphasis on getting out of, and not entering into, debt (except a mortgage for a reasonably priced home.) This is followed by a discussion of risk and risk anticipation as a front line of financial defense. This leads to insurance – what you need and what you can avoid in terms of life, disability, liability and of course malpractice insurance.
It is an important principle that sound financial decisions early in your career have a big impact down the road – and so too do suboptimal decisions. You are probably bombarded by sales people that assume you have money to spend; some will have good ideas and products and many will not. Should you have a personal financial advisor? Or can you learn enough to make sound decisions yourself – for your own financial well-being, for your family and for your career?
A personal financial advisor would be worthwhile but you need to find the most appropriate person whom you can trust to offer sound meaningful advice and who charges appropriately. Pillars of Wealth gives suggestions on making this choice.
Bar-Or is articulate and passionate to meet. He thinks of himself as a financial risk management “physician”, i.e. to keep your finances healthy and functional while you help your patients stay healthy.
Your practice priorities are always uppermost but for some limited time and on a regular basis you deserve to consider your own financial health. Pillars of Wealth might be a good place to start. A chapter every few days will put you in a much better position over time to benefit financially from your education and training. These books are very well written and thoughtful. I will go so far as to say they should be must reading for all medical students and residents.
Note – Dr. Bar-Or and I met for lunch; we each paid our share. I bought his books before we met. I have no financial relation with him or his book sales.
 
 

The Coming Disruptive and Transformational Changes in Health Care Delivery

There will be some very disruptive and some transformational changes in the way health care is delivered, not as a result of reform, but as a result of the drivers of change described previously. They included an aging population, an obese society, shortages of doctors, and emerging consumerism, among others.                       

I interviewed in depth about 150 medical leaders from across the United States to collect information and then distilled it down to a few key observations for my book “The Future of Health Care Delivery – Why It Must change And How It Will Affect You.”. 

As a result of those previously discussed drivers of change, here is some what we can expect to occur in the coming years. 

First, there will be many more patients needing substantial levels of medical care. These won’t be just any patients but two specific groups that are growing rapidly. Americans are aging. “Old parts wear out” and there are impairments in vision, hearing, mobility, bone strength, dentition and cognition that become more prevalent with age. And of course our society has many adverse lifestyles such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and 20% still smoke. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will many more individuals with chronic illnesses. The especially sad thing is that many of these individuals will be moderately young as a result of obesity since one third are overweight and another one third are frankly obese. (And now that the AMA has specifically listed obesity as a disease rather than just a predisposer to disease, then the number of Americans with chronic illnesses jumps dramatically.) This increase in chronic diseases and the impairments of aging will have huge impacts on care delivery.           

Of course, more and more care is and can be done out of hospital. But with many more patients in need of care for serious chronic illnesses, there will be a need for more high tech hospital beds, ICUs, ORs, and interventional radiology. This is different than the mantra of recent decades which proclaimed that there are too many hospitals and too many beds. Now it is the just the reverse. This too is a big change. 

But building new hospitals or new wings or renovations costs a lot of money. So does technology such as the electronic medical record, new CT or MRI scanners, and the needed technology for the operating rooms or radiation therapy equipment. To garner the required money, hospitals will need to access the capital markets. What will smaller hospitals do that have less ability to enter the credit markets? Merge with larger systems to get access to capital. So there will be more and more smaller hospitals merging into larger systems. Indeed there will be few stand alone community hospitals in the coming years. This is quite a disruptive change. 

There is already a shortage of primary care physicians and this will undoubted accelerate since few are entering primary care today after medical school and training.  In part to compensate, there will be greater use of NPs and PAs, especially in primary care. Notwithstanding the debate as to whether NPs can serve as well as MDs in primary care, they can be very effective and allow the MD to do what he or she is best at doing. Together they can create an excellent team.  

Primary care doctors are caught in a catch 22. They are in a non sustainable business model. Reimbursements from insurers have stayed level for years but office and other expenses have gone up each year. So in order to keep their personal income at least flat, they need to “make it up in volume” by seeing more patients. This means no longer visiting their patients in the hospital and in the ER. Instead they wait for the hospitalist or the ER doctor to call with reports. And they shorten the time with each patient so they can see 24 to 25 patients or even more each day.  

But seeing this many patients means they cannot give comprehensive preventive care  and cannot adequately coordinate the care of their patients with chronic illnesses – two of the key things a PCP should be doing for optimum quality care. It is the absence of time – time to listen, time to prevent, time to coordinate and time to just think – that is the critical issue. 

There are at least two approaches PCPs are taking to counter this dilemma. One is to no longer accept insurance and rather expect patients to pay a reasonable fee at each visit. Pay at the door. It cuts out a lot of haggling with the insurer and means they can spend more time with the patient. Importantly, it recreates a normal, typical professional-client relationship since the patient, not the insurer, is paying the doctor directly.  But this is certainly a disruptive change to not accept your insurance! It is like going back a few decades.   

Another approach gaining rapid popularity is to switch to retainer based practices, sometimes called concierge or boutique practices. The basic concept is to limit one’s practice to 500 patients rather than the typical 2000 or more. This means more time per patient. So in return for a fixed fee of about $1500-2000 per year the PCP agrees to be available by cell phone 24/7 and by email. He or she will see you in the office within 24 hours of a call. You get as much time as needed for the problem at hand. And the PCP will visit you in the hospital, the ER or the nursing home – maybe even do a house call.

The result is better quality. But there is more. Since the doctor now has the time – the patient now gets much more preventive care attention. And if a patient has a chronic illness, the PCP will take the very real time needed to coordinate that care. This will mean much better care from the specialists and will avoid unnecessary tests, scans and procedures. Better care at less expense.  – One more very disruptive and I would say transformational change occurring in medical care delivery.
 
 

 

Reframing the Question of Doctor Frustration

There has been a lot of interest in the Daily Beast articlewritten by Dr Daniela Drake, about very frustrated primary care physicians (PCP.) She quoted both Dr Kevin Pho and myself. Dr Drake noted that nine of 10 doctors would not recommend medicine to their children as a career and that 300 physicians commit suicide each year. “Simply put, being a doctor has become a miserable and humiliating undertaking.”  Dr Pho offered his own commentary herepointing out that “it is important to have the discussion on physician dissatisfaction….demoralized doctors are in no position to care for patients…To be sure many people with good intentions are working toward solving the healthcare crisis. But the answers they’ve come up with are driving up costs and driving out doctors.”  
Yes, it is definitely true that PCPs are very frustrated. In a series of in depth interviews, almost all tell me that their major frustration is not enough time with each patient. No time to listen, no time to think, no time to do critical activities. Why? Because they have to see too many patients per day in order to cover overheads. A few of those that I interviewed have left clinical practice because of these frustrations; others felt that they needed to do “something, soon,” to improve their situation.
But patients are frustrated as well. They find they have to wait a long time for an appointment, sit in the apt named waiting room and then get just a few minutes with the PCP. They observe that the doctor interrupts them within just a few moments, never lets them tell their full story, isn’t really listening and shuttles them off to a specialist or gives them a prescription while never really explaining in their terms what is going on. And they know that they pay a lot for their insurance with premiums rising every year along with lots of co-pays and deductibles. So they are in no mood to feel sorry for the PCP who earns, according a Medscape survey, about $170-180,000 per year.
The usual response of the medical community is to point out the years of education and training, the high debt loads, the hours of work and the calls at night. That other doctors earn much more. That there is an ever growing burden of paperwork, of wasted calls to the insurers and nonfunctioning EHRs. That the responsibilities are high and what could be more important than your health. All true — but it falls on deaf ears for the family with an income of <$51,000 (median US household income in 2011, per census).
One major problem is that the average person just does not know what really good primary care could do for them and their health over time. Nor do they appreciate that primary care is or at least can be relatively inexpensive. We (the collective medical community) have not done a good job explaining the value of outstanding primary care.
So let’s reframe the frustration question.
How can patients get superior care from excellent energized and satisfied practitioners at a reasonable cost all leading to not only care of disease but prevention of illness and preservation of well-being? And if this can be achieved, will it lead to more students choosing primary care as a rewarding career?
Government is not likely to solve the problem nor will most insurers. It will be up to PCPs and their patients to create a new primary care delivery paradigm. And doctors need to take the initiative to educate the public and lobby for useful change.
There are many options. One is direct primary care (DPC) in its many formats such as pay per visit, a monthly membership fee or retainer-based (concierge) models. The latter two with their limited patient panels are often thought of as only for the elite or the rich but membership or retainer based practices need not be expensive. Several have been written upas “blue collar” plans  with low feesyet limited numbers of patients, same day and lengthy appointments, 24/7 cell phone availability and even free or reduced cost medications and lab testing.
I live in Maryland where I looked up the 2014 Blue Cross (not for profit) premiums in the local exchange. A Bronze plan for a 55 year old costs $3660 per year with a $6000 deductible, essentially a “catastrophic” plan. A Platinum plan costs $7728 per year with no deductible but up to $2000 in hospital co-pays. If the individual requires major medical care, the total out of pocket costs for premium and deductibles/copays in either plan is therefore about $9700. Buy the Bronze plan, create a health savings account and then pay the membership/retainer with tax advantaged dollars. The individual gets high quality health care in a setting where it is to the physician’s advantage to keep the patient well. Alternatively, stay with the Platinum plan and get a 12 minute visit.
As to the PCP shortage and patient education issues, Primary Care Progress is one of a number of new organizations sprouting up to bring current and potential PCPs together. To educate patients, they have produced a useful 2 minute animation.
Looking ahead, insurers might one day decide it is logical to buy the membership or retainer for their insured’s. The cost would be rapidly repaid may times over. Likewise employers could do the same leading to a healthier, more satisfied workforce with higher productivity and reduced total health care premium costs. Sounds radical but it is actually logical. Patients would get great care and maintain good health. Providers get to be the true healers they always aspired to be. The total costs of care would come way down. Maybe even more students would choose primary care as a career. Win-win-win-win.
 
 

Lifestyles Cause Most Serious Disease and Deaths

We all recognize that as a society we have some adverse lifestyle behaviors such as overeating a non-nutritious diet, being fairly sedentary, having chronic stress and having 20% of us still smoking. These behaviors cause the majority of the serious chronic illnesses that are rampant today– yet they are largely preventable. And it is these diseases – heart disease, cancer, chronic lung disease, diabetes, etc. – which are the major causes of death. It’s quite clear that the best chance we have for increasing our life spans and overall improving our health is to adjust our personal behaviors and to do so at an early age. 

We often think of heart disease, cancer and stroke as the major causes of death and, as diseases that cause death, which is correct. But what if we go back further and look at what caused those diseases. The rank order of causes of death according to a study from the Centers for Disease Control in the Journal of the American Medical Association lists tobacco, poor nutrition, lack of exercise, alcohol to excess, infections, toxic agents, motor vehicle accidents, sexual behaviors and illicit drug use as the primary predisposing factors to the diseases that cause death. A look at that list shows that the ones at the top of the list and a number of others all relate to our behaviors.   

The diseases that cause death have changed substantially over the decades (see “The Burden of Disease and The Changing Task of Medicine”.) At the beginning of the 1900’s it was infectious diseases that caused most deaths. Over time they came under reasonably good control with preventive techniques such as immunizations, sanitary sewer systems and clean water systems and then, of course, antibiotics. Meanwhile chronic illnesses such as coronary artery disease became much more prevalent. [See this graphic] Even though fewer people smoke than a few decades ago our obesity and our lack of exercise have led to rapid increases in diabetes, heart disease, stroke, high blood pressure and many other chronic illnesses that last a lifetime.   

What we need in America today is a focus on health care meaning a greater focus on disease prevention and health promotion beginning in childhood and a recognition that our adverse behaviors or lifestyles are the major drivers of today’s chronic illnesses – the ones that will lead to our deaths.
 
 

United Airlines Fiasco Should Be a Healthcare Wakeup Call


The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it’s not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is “stockholder value “as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  “The friendly skies” are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that “no money, no mission” but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 
From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

Physicians are in a bind as well. If the time per patient is short and the PCP only deals with “simple” problems, referring all of the rest to specialists, then the patient comes to feel that the PCP (e.g., internist, family medicine doctor or pediatrician) is irrelevant, often unavailable and yet expensive. The patient is increasingly likely to go to CVS, Walmart or Walgreens and get seen promptly for minimal cost. Here is an example from a friend: “For Boy Scout camp it is necessary to have a health form filled out by the pediatrician. In our son’s case, our insurance covers one physical a year, and we usually go around his birthday in June. But the form is due April 17th so I found myself in a Catch 22 situation. The insurance company won’t pay for a physical until June, the pediatrician won’t fill out the form without doing a physical. So I ended up taking him to CVS WellCare and paid them $69 to fill out the form, much less than what the pediatrician would have billed.”
There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggestedsome “fixes.”
Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare – have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.
The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.
Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.

The forcible removal of a passenger from the United Airlines flight has reminded flyers of their general dissatisfaction with the airline industry. Perhaps surprisingly, it should also be a stern warning to physicians. The brunt of dissatisfaction in healthcare delivery will fall on the providers although the real culprits are the insurers; they too should take notice.

The airlines do not appreciate the real basis for the outburst by the traveling public. The forcible eviction, despicable as it was, was really just the “straw that broke the camel’s back.” Airline travel was once a special, adventurous part of the journey. Today it is an undesirable but necessary means to an end. Why? Because the airlines treat their customers with disrespect at every part of the process. It is not just United; it is all of the airlines. The uproar is not about the rules, “the contract of carriage,” but about the manner in which airlines think about their passengers – definitely not customers who deserve respect. Respect and dignity are the key words.

The public’s general consensus – it’s not fun anymore; there has been complete loss of autonomy and dignity; flyers often feel they are herded like cattle with total loss of all control and definitely not treated as valued customers. The sense is that the corporate view is “stockholder value “as the priority, not customer satisfaction, preference and loyalty as a means to generate that value.  “The friendly skies” are no longer, if they ever were. There is no sense that the airline executives who set the employee standards and culture remember that a customer pays the employees’ salaries, their bonuses and ultimately the stockholders’ dividends. In this environment, the employee from captain to gate agent to luggage handler is captive. They may – and I suspect to a large degree do – want to treat their passengers as real people, real customers deserving of real respect but it is clearly not the corporate ethos.

In any business, for profit or not for profit, it is true that “no money, no mission” but money has become the mission.

Such is the case with much of healthcare. Patients are frustrated feeling that they are not respected, not afforded autonomy or control and not valued. As a retired physician and academic hospital CEO I have witnessed and felt the transformation within medicine over the past 50 years. As with the airlines, most physicians, nurses, pharmacists and other staff are all well-meaning and caring. But patients are at the breaking point. In short, the patient is not treated like a valued customer but more like a commodity.

 It takes about three weeks to gain an appointment, there are long waits in the “waiting room” and then just a few minutes with the doctor.  You may personally like your physician but you are not pleased with the situation and feel helpless to rectify it because you are not the customer, the doctor’s customer is the insurer.  The insurer will determine if and how much the doctor is paid; the patient is a bystander to the transaction yet saddled with copays and deductibles. The patient cannot even request more time for more pay – the insurer prevents direct payments to the doctor. 
From the doctor’s perspective, he or she is undervalued by the insurer who acts capriciously, produces extensive rules, regulations and requirements that do not add to patient care but require extra work – time not spent with the patient. And since insurance payments for primary care especially are notoriously low yet with ever rising overheads, the physician is obliged to shorten visits often to about 8-12 minutes of actual face time.

It is a situation right for an outburst – from both patient and doctor although for different reasons. An event – not malpractice but just something totally unacceptable like being dragged off the plane – could dramatically upset the status quo. Patients will cry out that they “will not take it anymore.” They will demand accommodation for privacy, courtesy, autonomy and especially respect and dignity. They will expect to be treated as valued customers. 

There is a clear difference between the airline industry and the healthcare industry, even above and beyond the obvious that one is an option much of the time and the other is frequently not an option. The issue with the airlines is not price which is generally reasonable; it is the lack of being treated as a customer. In healthcare, the prime issue is also about not being treated as a valued customer – with respect and dignity. But now, where price never mattered in the past, it has become very important. Previously, I have suggestedsome “fixes.”
Healthcare needs to open its eyes and realize that its bread-and-butter is highly vulnerable. Yes, the insurers make life difficult if not near impossible. But the object of healthcare delivery is, or at least should be, for the patient. The hospital and the physician may be vulnerable to the whims of government and insurers but – more importantly yet unrecognized– may be exceedingly vulnerable to the very patients who have entrusted their care to them. Let this be a wakeup call and let it begin a careful look in the mirror rather than looking for external demons. When the uprising occurs, the blame will be heaped on the providers – hospitals and physicians alike. If it is a hospital issue, the doctor can’t escape – the patient looks to the doctor as the face of the hospital.
Insurers should take a close look as well. In their effort to reduce costs, they – beginning with Medicare – have systematically held primary care reimbursements low yet added excessive nonclinical work requirements. The result is the morass of today with frustrated, burned out physicians, angry patients and increased costs.
The initial response of United Airlines completely missed the depth of societal outrage and later did not appreciate how deeply the traveling public feels devalued. More recently, the board chair stated that this was a “defining moment in the history of United Airlines pivoting to customer service and customer delivery.” If he means it, it will mean a momentous change in corporate ethos and business practice. Let’s hope.
Perhaps healthcare – including Medicare and commercial insurers – will come to recognize that it too must change or ultimately feel the wrath of dissatisfied patients – their customers. Meanwhile physicians need to take the offensive to direct change. Unified they can force the changes needed for the benefit of their patients, themselves and the total costs of care.
20,2017

Originally appeared in Medical Economics, May 

Improving Cancer Patient Care While Markedly Reducing Costs

It is often difficult to appreciate that improving the care of patients can actually reduce the costs of care. Last year Dr H Brody wrote in the New England Journal of Medicine (vol 362, p283-5) about “Medicine’s ethical responsibility for health care reform – the top five list.” In essence he challenged physicians to be first to find ways to rationally reduce health care costs by identifying the top five tests or treatments in any given specialty or subspecialty that could be markedly reduced or even eliminated without harm to the patient. He made some specific suggestions to get things started.

Now Drs.Thomas Smith and Bruce Hillner, two oncologists from the Massey Cancer Center in Virginia, have accepted the challenge and published in the same journal (vol 364, p21, May 26, 2011) a proposed list of five suggested changes in medical oncologist’s behaviors and five changes in attitudes and practices. Their proposal is noteworthy because it directly addresses some of the most important issues that affect cancer patient care yet inordinately increases the cost of that care.

I will not repeat each of their suggestions but will comment on a few. One change in behavior is to limit chemotherapy to patients with a good performance status (with an exception for those with highly responsive disease.) It is well known that a person’s performance status is a very strong predictor of whether a patient will respond to a treatment or have any meaningful extension of survival. The authors point out that their proposal is in line with current guidelines by national oncology organizations. They make the simple recommendation that a patient should not be given chemotherapy if he or she cannot walk into the clinic unaided. Unfortunately, many oncologists today push ahead with further treatment despite their patient’s performance status.
Another suggestion is to “replace the routine use of white blood cell stimulating factors with a reduction in chemotherapy dose in metastatic solid tumors.” The hematopoietic colony stimulating factors (CSFs) are very valuable in pushing the bone marrow to recover white blood cell numbers after aggressive treatments. The concept is that infection is common when the white blood cell count drops below 500 per ul. This is a common occurrence in the treatment of acute leukemia and some other situations where very aggressive chemotherapy is used and the CSFs can be lifesaving in those patients. But they are not needed for modest reductions in WBC counts. In truth, drops below 500/ul rarely happen in the treatment of patients with most solid tumors such as breast, prostate, lung or colon cancer. Yet these very expensive stimulants are used routinely but at high cost. Smith and Hillner suggest that at about $3500 per injection, the sales by oncologists to their patients’ amount to some $1.25 billion per year.
And there is the rub – to change these two practice patterns would be to substantially reduce the oncologist’s income. Oncologists earn a decent but not high income from basic care of their patients. But fully another one half comes from the administration of chemotherapy and support medications such as drugs for nausea and vomiting and drugs to boost the bone marrow to produce red blood cells (erythropoietin) and white blood cells ( pegfilgrastim, Neulasta). In effect they serve as a pharmacy for these drugs, buying them wholesale from distributors, preparing them and administering them while collecting a markup for their effort. This brings their incomes to among the highest among internists. To cut back on chemotherapy or Neulasta administration would have a telling financial impact.
Another suggestion, this one a change in attitude, is to address the importance of end-of-life discussions. The authors point out the truism that such discussions are a critical perquisite to good care planning by both doctor and patient and family. But they point out that far too often, oncologists wait until new symptoms appear or until they feel there is nothing else that can be done before entering this type of discussion. But when such discussions are held at an appropriate time, there is greater use of hospice and “less depression or anxiety, less aggressive end-of-life care and [patients] rarely die in an intensive care unit or on a ventilator.” Further “it allows the surviving caregiver to have a better quality of life and would save our society millions of dollars.” And yet, such discussions are all too infrequent or come too late. It is the physicians’ obligation to their patients and patients’ families to be honest and direct, albeit caring and compassionate at the same time.

With these changes (and some of the others that Smith and Hillner recommend) in behaviors and attitudes, the care of cancer patients would be greatly improved yet the costs would be very greatly reduced. That is a good exchange. Let’s hope these suggestions become the norm of care and that physicians in other specialties take up Brody’s challenge as effectively.

Lung Cancer Part 3 – Rx with Surgery and/or Radiation


Surgery has long been the only way to cure lung cancer. If the tumor was discovered early – a rare occurrence in the past – then resection could remove it totally. Recently it has been shown that radiation can be used successfully for early stage disease. And new approaches to radiation therapy result in the ability to give higher doses to the tumor, limit damage to surrounding normal lung and do so with relatively few sessions under the machine.
Thus far in this five part series has been a general discussion of lung cancer facts and figures followed by controlled enthusiasm about early diagnosis using CT scanning. The treatment of lung cancer has also progressed dramatically and with early diagnosis as a result of CT scanning high risk individuals, it is now possible to cure a larger proportion of patients.
Today an increasing number of individuals are having their cancer detected early so curative approaches will become more common. But many if not most lung cancer patients are older and have either chronic lung disease, heart disease or both, rendering them at higher risk for surgery. At a minimum the surgeon wants to do as limited a procedure as possible, using the least invasive approach. Still, not all patients are good surgical risks.
Despite finding the cancer when it is still small and with no apparent evidence of spread, many patients still relapse in a few months or years after surgery. The addition of chemotherapy to treat microscopic but undetected disease has a resulted in improved cure rates. The same approach is being used for those treated with radiation of early stage lung cancer.
Until recently, it was assumed that only surgical resection could cure small early stage lung cancer. But many patients are poor surgical candidates due to age, chronic lung disease, heart disease or other concomitant conditions. The question thus arises, could these newer approaches to radiation therapy be as effective.  Multicenter trials have now demonstrated that stereotactic body radiation treatment (SBRT) appears equivalent to surgery in terms of the local control of the tumor in small (

It is important to understand that radiation can destroy any cancer if sufficient radiation can be applied. For many cancers, however, the risk of damage to adjacent normal tissues that are essential for life (e.g., normal lung) makes it impossible to give the desired dose. That said, radiation oncology has advanced dramatically in the past decade and the rate of progress is increasing rapidly. Innovations as a result of engineering and computer advances along with conceptual advances are making a dramatic difference. Major advances in radiation therapy mean greater effectiveness, fewer side effects and less time in treatment.
Newer devices allow stereotactic treatment not only for stationary tumors but also lung cancers– overcoming the problem of motion caused by breathing or even heartbeat and blood flow. The combination of continuous imaging, motion detection and robotic guidance combine to allow much more effective treatment than in just the very recent past.
Stereotactic body radiation treatment appears to be a very useful new approach to many otherwise difficult to treat cancers such as in the lung. It begins with the use of earlier techniques where the cancer is treated from multiple angles such that the tumor receives a large dose but the adjacent normal tissues receive much less. Stereotactic means that the tumor is imaged and the radiation adjusted to directly attack the cancer and not the normal tissue. A related innovation is to link actual delivery of radiation with the patient’s breathing parameters (gating). This is done with an infrared device that observes motion and turns the radiation beam on and off during the breathing cycle. This can be of great value in lung cancer because the target is constantly moving. This greatly reduces normal tissue damage occurring as the lungs move with respiration. It also means that the cancer gets a higher dose because the physician is less encumbered by a concern for damaging adjacent normal lung. This is a real improvement as in the past it was necessary to curtail the ideal dose with the realization that that dose would cause unacceptable side effects on adjacent normal tissue.
Hypofractionation, that is giving a much higher dose of radiation per session, with the much greater accuracy of the stereotaxic approach, means many fewer sessions yet with high effectiveness. Much SBRT is now done in 3-5 fractions rather than the more typical approach of multiple, perhaps as many as 45, fractions over as many days or more. Add robotic guidance based on motion detection and the combination becomes very powerful. With robotic control of the equipment from outside the treatment room, this means less time is wasted by the staff moving back and forth to make adjustments and less time on the table for the patient. 
Most radiation today is delivered by X-rays or electrons (photons). Another approach is to use protons. Proton beam therapy has the advantage that the proton gives up its energy only when it hits its intended target – in this case the tumor. It does not continue through the tumor and damage normal cells on the far side. So it allows for the delivery of very high doses of radiation to the tumor with minimal side effects. It follows that proton beam might prove very useful because one can give a much higher dose without as much fear of adjacent normal tissue damage. But it is critical to keep in mind that there are no controlled studies showing superiority of protons over photons and certainly none in lung cancer as of yet. As a result it is important that the clinical value of proton beam therapy not be over inflated. The cost of one center runs into the hundreds of millions of dollars — which would purchase 20 or more photon linear accelerators.
What is clear is there is a steady and rapid, advance in the ability to deliver radiation therapy to those with lung cancers in a more effective and more safe manner, often in much less time than in the past. The realization that radiation can actually be used to cure early stage lung cancer is a stunning advance, allowing effective treatment for those not able to undergo surgery.
In the next of this series will be a discussion of the dramatic advances in lung cancer treatment with drug therapy.

Mitral Valve Repair Without Open Surgery – Exciting Development in Medical Devices

The mitral valve separates the heart’s left atrium from the left ventricle. When the ventricle contracts to send blood to the aorta and out to the body, the mitral valve closes to prevent blood rushing backward into the atrium and back to the lungs. The mitral valve can become stiff and tight, called stenosis or it can become unable to close tightly, called regurgitation. Once the regurgitation becomes sufficiently severe to cause heart failure, the death rate reaches about 5% per year. Most such individuals are referred for cardiac surgery to either try to repair the valve, replace the valve or do a procedure that in effect lessens the amount of regurgitation without actually replacing the valve. The latter procedure, although not curative, can be quite successful and alleviate the heart failure and the symptoms leading to a longer and better quality life.

A new procedure has now been reported in the New England Journal of Medicine, April 14, 2011 that does not use open surgery to repair the mitral valve leak. The process is to insert a catheter via the large femoral vein in the groin and pass it up to the heart. From the right atrium it crosses over to the left atrium and then is positioned at the opening of the mitral valve. This mechanical device, manufactured by Abbott Vascular, is able to grasp the two sides of the mitral valve and clip the two leaflets together. It does not create a tight seal but in most cases can markedly reduce the amount of regurgitant flow back into the atrium.

The study randomly allocated patients with grade 3+ or 4+ (i.e., serious) mitral valve dysfunction to either the customary open repair or replacement (the specific procedure at the surgeon’s discretion based on the valve status) or to have a percutaneous repair done with the new device. The study endpoints were freedom from death, freedom from surgery for mitral valve dysfunction and freedom from grade 3+ or 4+ regurgitation at the end of 12 months. The primary safety end point was freedom from major complications during the 30 days post procedure.

The study ws performed at 37 institutions in the United States and Canada. 279 patients were randomized with a 2:1 ratio of percutaneous vs. open procedures. 21 patients withdrew consent before the procedure was done, leaving 258 treated patients.

After the procedure, 41 of 178 (23%) patients who had the percutaneous procedure still had grade 3+ or 4+ regurgitation and were therefore referred for open surgery. Among those 80 patients who initially had open surgery, all had less that 3+ regurgitation after the procedure. By the 12 month end of study time, the composite of freedom from death, from surgery or from grade 3+ or 4+ valve dysfunction for all randomized patients were 55% vs. 73%. If one looks only at those who actually were treated per the protocol (i.e., did not exclude themselves, etc) then the rates were 72% vs. 88%. As to safety, the rates of major adverse events (most often the need for transfusion) as of 30 days were 15% vs. 48%. Quality of life improved in both groups of patients over the 12 months although there was a decrease at 30 days for the open surgery patients.

What these results suggest is that open surgery is more likely to greatly relieve the mitral regurgitation than will the percutaneous catheter procedure. However, the percutaneous procedure is safer, requires less time in the hospital, and is associated with improved quality of life and improved ventricular function from baseline. Many patients might therefore decide to choose the percutaneous catheter-based procedure on the grounds that it greatly relieves the problem in almost three quarters of the patients, is less invasive and is safer than surgery. Then if that individual patient was not among the success stories, he or she can choose to have the follow-up open surgery.

Further, although not mentioned in this article, there are patients who simply cannot tolerate open surgery for any number of reasons who might still be able to undergo the catheter-based procedure. This might then open up an option for repair not otherwise available today with open surgery. Not discussed in the article was cost. This might become a deciding factor as well once the procedure is on the market.

In an accompanying editorial, Otto and Verrier suggest that the decision on surgery (and which surgical procedure) or one of a number of catheter-based procedures (assuming logically that others will undoubtedly arrive soon) should rest on the advice of not one physician but the joint opinion of a multi-disciplinary team of, at least, a nonprocedural valve-disease specialist, and interventionalist cardiologist and a cardiac surgeon, each with substantial expertise in mitral valve disease. To this team I would add the patient’s primary care physician and principal cardiologist – both of whom will have known the patient and his or her overall health and family situation over the years. The other addition to the team is the patient –whose opinions should be incorporated from the beginning of the evaluation and advice process.

Primary care has lost its quarterback position in patient care


There is a crisis in primary care and that crisis is now flowing over into the hospital when a primary care physician’s (PCP) patient is admitted. No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician- patient relationship, the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged.  At a time when the patient most wants and needs the comfort of a long time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to this create state of affairs?

PCPs have seen their overhead costs rise dramatically along with insurer mandated paperwork and government mandated electronic medical record (EMR) time requirements. This means the PCP must see more and more patients for shorter and shorter periods to cover overheads and reserve time for the nonclinical requirements. The average visit time is now 15 minutes with only 8 to 10 minutes of “face time”. It also means that most – but definitely not all – PCPs no longer attend their patients in the hospital, leaving that function to the hospitalist

Hospitalists are trained in caring for patients in the hospital. Since that is all that they do, they become very experienced in dealing with the types of medical issues that require hospitalization. Working full-time in the hospital means that they know how to get things done in that setting and do so fairly efficiently. The growth of the hospitalist movementover the past twenty years has been truly phenomenal – at 50,000 physicians it is the largest medical sub specialty (cardiology is next at 22,000), surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000.
Early studies suggested that quality was improved and costs reduced with the advent of hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something difficult for the community based physician to achieve. And with the need to see multiple patients each day in the office to cover overheads, many PCPs willingly ceded hospital care to the hospitalist. 

In our experience hospitalists are a heterogeneous group, many are just out of an internal medicine residency; some are working part-time because of childcare obligations. Many are contemplating a fellowship but want to catch up on loan obligations. Some hospitalists anticipate at a future point to become PCP’s. Still others intend to make a career as a fulltime hospitalist.

Frequently employed by the hospital, they still must meet productivity standards in order to earn their salary.  Often this means caring for a large number of patients, most of them quite ill. Although they are expert in what they do, they do not have the years of interaction with the patient that the PCP has. And so they did not know the patient before the hospital event and are not likely to know him or her after.  Each patient is an individual with his or her unique family, social, economic and of course medical background. The patient today may well have multiple chronic illnesses such as diabetes, congestive heart failure or chronic lung disease and now enters the hospital with a new problem or an exacerbation of an old one. The hospitalist can deal well with the reason for admission. Nevertheless they will not be cognizant of the fine balance of personality and medication that has otherwise maintained the patient as independently living in the community.  It also unlikely that they know what studies have been done prior to the admission. 

In recent back to back articles in the New England Journal of Medicine, Wachter and Goldman along with Gunderman present rather different perspectives on the rise of the hospitalist subspecialty yet the decline of comprehensive care. 
 
Our observations of routine hospitalist care is that a given patient may have multiple hospitalists over the course of the admission rather than one doctor who knows the patients well. In a four-day stay a patient may easily be cared for by three different hospitalists. Test redundancy and unneeded consultations are all too common.
There is also a tendency to ask for consultations from subspecialists when more time with the patients might have been sufficient to establish the issue at hand. Fever-infectious disease, pneumonia-pulmonologist, chest pain – cardiologist.  Relatively easy procedures are also handed off to a specialist, e.g., joint effusion – call the orthopedist to do the arthrocentesis.  Mildly demented patients all too often get a repeat head scan because of an inadequate handoff that the patient has already had a more than adequate evaluation for reversible causes of dementia. Typically a hospitalist service is made up of many physicians that have a minimum of three years of internal medicine training. We are not sure if the statistic exists but in many community hospitals the average number of years of experience after residency is likely less than five years.  So if an unusual problem arises, call for a consult. There typically are multidisciplinary rounds but the admitting hospitalist may not be the rounding physician. 
More discouraging is the finding that hospitalists tend to place the primary care doctor’s patients often on the wrong medication, very often there is inadequate communication between the hospitalist and the primary care physician to review details at the time of admission. This of course can lead to a more extensive hospital stay. To compound the problem, the handoff back to the PCP at discharge is often problematic with inadequate communication between them. The PCP may not even know that the patient was admitted or discharged until the patient calls for a new appointment. Meanwhile, the fine balance of those chronic illnesses may be out of kilter so that, not surprisingly, about 20% of older individuals end up back in the hospital with an unplanned admission within the following month.

The PCP was always the backbone of American medicine. He or she not only cared for patients in the office but also collaborated with the emergency room physician and attended to hospitalized patients, seeking specialist consultation as needed. Today, only a few PCPs even visit their hospitalized patients, relying entirely on the hospitalist and the emergency medicine physician.

Hospitals are scary places. You never really want to be admitted but sometimes it is necessary and indeed even lifesaving. This is the time when you most want a knowledgeable professional friend of long standing, one you with whom you have deep seated trust.

Although most PCPs do not visit their patients in the hospital today, some do and they are committed to give the patient the expert care that the patient requires. But for these physicians some community hospitals for various reasons have determined that only the hospitalist may have privileges to care for the patient. That’s right; hospital managements are discouraging primary care doctors from coming to the hospital and in many cases have prohibited them from having active admitting privileges.  Somehow, they discount the possibility that the primary care doctor knows the patient best and can work effectively and collaboratively with the hospitalist for the patient’s benefit. Erroneously, hospitals in many cases believe that primary care doctors diminish quality and increase the length of stay. We have discussed this very issue with a retired board member from a large Maryland insurer and confirmed that a huge  uncontrollable expense to the hospital bill is over consulting with specialists and redundancy of procedures and testing ordered by hospitalists.

The PCP is being marginalized. This is distinctly to the patient’s disadvantage.
Interestingly insurers are having an impact on control of costs but not in the hospital. Primary care physicians are now rewarded for guiding patients to the less costly specialist and using visiting nurses to manage co-morbidities that have saved hundreds of millions of dollars. We believe now the insurers need to understand the value of comprehensive primary care that extends into the hospital; this would translate into even more savings. PCPs need to earn enough with a smaller panel of patients that they can afford to care for fewer patients but with greater time spent with each as appropriate including visiting their hospitalized patients, working collaboratively with the hospitalist and interacting with the emergency medicine physician. Insurers (including Medicare) need to dramatically reduce the unnecessary paperwork and requirements so that the PCP can actually spend time with the patient.
We are not intending to disparage hospitalists. They are well trained, committed and productive and overall have added quality to the hospital environment. We are advocating however for a collaborative process of hospitalist and PCP working together. Returning the PCP to his or her positon as the quarterback of patient care is good medicine; it means greater quality, a more satisfied patient, less frustrated physicians yet much lower total costs of care. A win-win-win.
Harry A Oken MD, who coauthored this post with Dr Schimpff, is a primary care physician in private practice who still cares for his patients when hospitalized and is a clinical professor of medicine at the University of Maryland School of Medicine.