The UW FP Chair references Dr. Lebow...

I'm at the Pacific Northwest Summit for Transforming Primary Care today. This is, as you know, a time of great energy and discussion about the state of medicine in the United States, and the role of primary care in the solution. And, it's a great discussion.

I was pleased to see, early in the day's discussion, a slide presented by Dr. Jim Davis, the chair of the Department of Family Practice at University of Washington which used as a reference the Healthcare Meltdown, by Dr. Jim Lebow!

It was great to see this, since I find so much encouragement from Dr. Lebow and the testimony of his life's work.

"Delayed Care: Rationing American Style"

There are those of us who have worked toward justice in our healthcare system for years; even when I was a physician-owner of a for-profit medical practice, I was resistant to actions which were inherently unjust toward those in need. So, for many of us, the healthcare reform debate has been a long time coming.

And, I'm still caught off guard that this issue has indeed become so commonplace. I was at a coffee shop the other morning for breakfast with my family. It's a vegan-friendly, dare I say "hippie" place in Tacoma. And, as I turned to put some cream and sugar in my coffee, I saw a flyer for MadAsHellDoctors.com. It's refreshing and encouraging that it's become 'top of mind' for so many people.

But, I'm discouraged that the conversation, the debate, has become so filled with anger, mistrust, and misinformation. So, after hearing some of these concerns from those in our local Town Hall Meetings, let me see if I can adress some of these issues. And, I'll use Bob LeBow's "Health Care Meltdown" as a point of reference...nearly five years after Dr. LeBow's book was first published, it has been revised and re-released.

One of the things that keeps getting in the way of constructive conversation is the claim that healthcare reform will lead to ... rationing. Well, let's talk about that.

In chapter 4 of Health Care Meltdown: Confronting the Myths and Fixing our Failing System, Dr. LeBow adresses the issue of rationing. I've heard many say that America has the best health care in the world. And, I'm afraid that patriotism is being confused with the opportunity and obligation to examine ourselves. We can be patriotic, and still be able to point out areas which need improvement in our country. And, clearly, the area of rationing of health care is one of those areas.

Just this week, another one of those self-evident articles reached publication. (I talked about that on my post "Stating the obvious.") This article has the subtitle "Going without (insurance) coverage greatly increases mortality." Really? I guess we have to state that explicitly for those who say that all Americans (and even "illegals") have ready access to health care, through any Emergency Department. But, the article does go on to help quantify the problem of delaying access to care. And makes the claim that as many "as 44,789 working Americans die each year because they lack health insurance." The study was published this week in the American Journal of Public Health, and notes that more people die each year from lack of insurance coverage (and lack or delay of care) than from kidney disease. (Of course, if you have kidney failure, our government will give you insurance to pay for your care, including dialysis, regardless of your income status - why aren't we upset at that "socialist" act? You have a legally-mandated right to public insurance coverage for this single health condition.)

So, this "news" reinforces what Dr. LeBow wrote - rationing takes place in America, and it leads to delay in care. And, delay in care leads to higher cost care, with lesser outcomes - people without insurance wait to go see the doctor until they "have" to, and then often have lost the benefit of early treatment, when the cost is lower and the chance for cure is much higher. As a physician working with the underserved, I see this every day...

So, let's not kid ourselves. Yes, America is a great place. And, it is not unpatriotic to acknowledge that our citizens are at risk because of the rationing that we currently have; we can do better.

Town Hall meetings...

Gosh, it's been a busy summer...

I've been working long hours, like my partners, in our nonprofit medical and dental practice. We're working harder to see more and more underinsured and uninsured patients.

And, I realize that I need to spend some more time updating this blog with comments about the storm which is raging across the US this summer, as seen in the Town Hall meetings.

I'm struck by the question of one of the attendees of the meeting going on this evening, in Bremerton, where this woman asks why she had to develop renal failure to warrant medical insurance coverage. Great question!

So, I'll see if I can address some of the issues that I hear coming up so often in these "discussions." ...

Summer Seminar in Clinical Ethics...

I'm out of the office this week, at the Summer Seminar in Clinical Ethics at the University of Washington.

I'm sitting in a large classroom, terraced with desktops in front of a projection screen at the University of Washington School of Medicine. It reminds me of so many hours spent in similar rooms during my own med school classes at the University of Kansas. Some things have changed a bit - projector screen instead of just blackboards, and an electrical outlet next to each chair so that I can plug in my notebook computer and connect to the internet via UW WiFi. Actually, I was the first student at the University of Kansas School of Medicine to bring a full-screen laptop computer to take notes in class, back in 1985. That was a Data General ONE. So, computers have been getting me into trouble for years!

So, I find myself in this classroom, with 150 others from around the country, talking with experts about the concepts of medical ethics. And, what a time to review these concepts...

The first case yesterday brought it into focus for me:

"A homeless man with a history of drug abuse visits his primary care physician. Overall, he states he is doing 'pretty good', but is clearly malnourished. He does not have specific medical complaints, but says what he really needs is a loan of $100 to get a 'roof over my head and some food.'"

So, the question posed to the group was, "Does the doctor have a responsibility to the patient?"

And, this brought things into focus for me because we are so embroiled in rhetoric about healthcare reform that we are losing sight of the big issues...

So, does "the doctor" have a responsibility? Well, YES! As a member of society, we ALL have a responsibility to this man. (Have you heard that story about the Good Samaritan? Try reading the story again: Luke 10:25-37.) One of the scholarly pursuits of ethics is to define the underlying principles which lead to ethical decisions, to "right" choices. And, I find the basis for addressing much of today's debate in the red-letter words of the New Testament.

So, that's why I'm here. That's why I'm working where I do. I hope that those around me can see that basis in the way in which I choose to live.

How did the class respond to the question? I'm afraid they answered in a much narrower way, by saying that the doctor had only a limited responsibility to assist his neighbor. We have our text book for the week, but I'm afraid that many of the class didn't bring the other Book!

May 30 March...

We had a chance to join the May 30 March - "Health Care for All in 2009: Mothers Leading the Way."

It was a wonderful experience... I've been really struggling with the environment of our work. Ongoing demand, stories from patients about their financial stressors, and a sense of doom about the economic outlook for support of the Safety Net in our state. But, in the midst of this, I was amazed by the 6000 people, from many different backgrounds, who joined together to make the statement that we cannot wait any longer to fix the HealthCare Meltdown. It was a great "shot in the arm" for me.

I put a few shots from the day up at my Flickr site. And, I've put some links there for some of the news stories about the March. That includes a nice editorial from Carolyn Hamilton Proctor, a woman with whom it seems I might just get along, where she asks, "Am I alone in my confusion on this issue of quality, affordable healthcare for everyone in America?"

We hit the front page!

_ADF5788
Originally uploaded by Doug Felts

Edie Lau and Steve Zugschwerdt visited our new campus in Poulsbo, and prepared a front-page story on the work we are doing serving our community.

This is a shot of Steve, as Chris Adrig PAC works with a patient. She, in fact, has since moved out of the area, but returns for her medical care.

A reminder of Good News...

I just had to share a note about some good news...

It's been a tough day, week, month, quarter... As all of us experience the effects of The Great Recession, my practice has been feeling increasing pressure. We're seeing more uninsured patients, without any increased funding to do so, and we are watching our state cut $1,000,000,000 ( yeah, one billion dollars) in healthcare resources from the next biennium budget. That means many more currently insured people will become uninsured. You can read more about some of the implications here.

Needless to say, it's been a difficult time. We've had two rounds of layoffs, in a practice which has always been rather "bare bones" in our staffing, and leadership staff has all taken a pay cut. Don't worry - no corporate jets and huge executive bonuses here!

But, in the middle of this, I'm reminded this morning of what makes us different, and why I feel a calling to be here.

I saw a patient several weeks ago, a young woman, not unlike one of my daughters. She appeared well. She was dressed in clean and fashionable clothing. She has a strong supportive family, in the middle class. But, she was struggling with an addiction problem. We talked about some options for treatment, which are few, and I planned to see her back in the office in follow up. She didn't come back. But, she hasn't been far from my mind these weeks. I've called a couple of times, just trying to check in with her. No response. And, then today, I felt compelled to call her back. I left another voicemail.... and then, I got her call back! She's been doing well. She's in a treatment program.

I felt so relieved to hear that she's well. It's Good News! And, a reminder that my partners are doing good work each day, for all kinds of people who need our help. People in harm's way. It's a privilege to be able to work for them, to serve them, to see them come to safety and health.

Amen.

Wellbee Says

Wellbee Says
Originally uploaded by Infrogmation

Thanks for Infrogmation (http://www.flickr.com/photos/infrogmation/) for posting this hand washing poster, from the CDC, circa 1964...

Back then, "CDC" stood for "Communicable Disease Center": http://www.cdc.gov/mmwr/preview/mmwrhtml/00042732.htm. It wasn't until 1970 that it changed to "Center for Disease Control" and then in 1981 became "Centers for Disease Control and Prevention" (note the plural).

Despite the name changes, things sure haven't changed much, huh!

Did you hear the president talk about us?

As I was driving home last evening, I was listening to the President's press conference.  And, in response to a question about the disproportionate suffering in the Great Recession associated with race, I heard the President mention us:  

"When we put in place additional dollars for community health centers to ensure that people are still getting the help that they need..."

So, the President notes that we are "ensuring" people get the help they need.  That sounds like a value system I can identify with! 

But, I'm afraid I might be seeing the President showing that even he is a bit out of touch with our reality.

Here's the scoop - the Economic Stimulus Package did contain provisions to provide additional support for Community Health Centers, who are facing increased demand for services across the country.  And, we've been able to get a promise for our piece of that... let's see, the whole stimulus package was how much, $700,000,000,000?  I must admit, I can't keep track of the total.  And, we will get our piece - $130,000 a year for two years! 

But, we know that we're seeing increasing demand.  And, this webpage explains that in our state, the Community Health Centers will be the primary recipients of a $1,000,000,000 state funding cut.  

• Washington's uninsured will increased by 150,000 people, to nearly 900,000 by 2010.  
• 35,000 people will be kicked out of the Basic Health Plan, and will become uninsured.  
• A program called "General Assistance to the Unemployable" (GAU) will be cut by $43,000,000.  These disabled and chronically-ill patients will see their monthly income cut to $136.  (Yes, one hundred thirty six dollars!)  

And, who's going to see all these uninsured?  Why, the Community Health Centers, of course.  After all, that's what the President said!  

Clearly, we can't make up our share of a $1,000,000,000 loss by the "influx" of $260,000 over two years!  

I'm sorry Mr. President.  That's not the change I had in mind!

"Federal Government Declares Public Health Emergency"

Did you see the headlines this weekend? We are in a declared public health emergency! In fact, this emergency is capturing the attention of our federal government, right up to the White House.

When I heard the news, as part of the "safety net" of providers who receive emergency notification from the public health system, I was struck by the importance of this notice... 20 people in the US have been affected, and ~85 Mexican citizens.

And, then, I got a bit angry. The other event, the real emergency, was the latest Washington State budget, which puts 10's of thousands of our neighbors at health risk. And, no one seems to even notice.

I have the privilege of working with a team of dedicated people, who have turned from other, usually more lucrative, career paths in order to serve the least in our community. That privilege is supported by our work seeing patients who are covered by the state Medicaid program and the federal Medicare program; these are patients who are nearly always turned away from traditional (read: "for profit") medical practices in our community. And, as part of the response to the budget crisis, not only are we (the state of Washington) planning to

1. reduce the number of people covered by the state Medicaid program (and therefore, making them uninsured), we are also
2. reducing the support for the "safety net" providers, including non-profit Community Health Centers, like mine.

(And, to be clear, where do you think those uninsured patients are going to go for care? To the local for-profit group practice, which expects a deposit of nearly $200 before an office visit? They will defer care until it becomes an emergency, or they will come to my practice, which remains "the last open door" for them for routine, chronic and preventive care.)

We are also reducing access to affordable health insurance for individuals, reducing support for the services of the elderly and disabled.

You can't turn on the radio or the TV without seeing information about the growing concern regarding the swine flu. (My favorite report is that Israel has renamed the illness, since swine are not kosher! Talk about political correctness! Oy Vey!) But, where's the concern, where's the outrage about the tens of thousands, in Washington State alone, of single moms, young families, the elderly, the disabled, who will go without needed health and social services in this "economic pandemic"? There's barely a mention of it on the local news, and little on the national perspective. (You can read the summary on the Washington State legislature website: http://leap.leg.wa.gov/leap/budget/detail/2009/so09113waycompare_0424.pdf )

Well, back to work... not only do we need to figure out how to see more patients with less resources, now we have to prepare to assist the community's response in preparation for the swine flu, err, I mean "Mexican flu" outbreak, should it come to our state...

How Health Savings Accounts Lead to Wiser Health Care Choices

How Health Savings Accounts Lead to Wiser Health Care Choices
Originally uploaded by M1khaela

I thought I'd share this cartoon from Michaela Reed, seen on Flickr.

Take a look at the cartoon, and at the comments - it's still so concerning that people are so misinformed about the realities of health care in America.

One comment says "just go the Emergency Room." And, gosh, who do you think will absorb the cost, if the patient can't pay? (Answer - those who CAN pay, by increased insurance premiums and higher bills!)

"You think YOU'VE got a headache!"...

You know, as the conversation about America's heatlhcare "system" goes on, I'm struck by some of the standards of practice that we've all engaged in. When I put "system" in quotes, I mean to imply that we don't have a system - certainly one of the criticisms of health care in America is that there is little coordination of care among different providers, different settings ... let me tell you a typical story about that.

This week, I saw a young man in our Community Health Center. He's unemployed, and living with his father. He is uninsured, and we are able to see him on a sliding scale basis, charging him "according to his ability to pay." He tells me that he is here because he had a prescription from an emergency room visit a few months ago, which he'd like to have filled in our pharmacy.

I spent some time getting to know a bit about him, and reviewed the history about his headache. He notes that this seems to be worse when he's around dust. Some further conversation and examination confirms my impression that he has an allergic condition. No big deal; I know how to treat that.

Oh, but what about that prescription? He was seen in an Emergency Department at a well-respected hospital in Seattle. And, he tells me that he had a sinus infection. I just got the notes to review...

So, with a story similar to what he related to me, the ED physician did the following tests:

• CBC with differential
• Complete metabolic panel
• Urinalysis
• Blood culture
• Sedimentation rate
• C-reactive protein
• amylase and lipase
• CT-scan of his head
• Total cost: ???

Gosh, am I just a bad doctor? I didn't even consider any of those tests! In fact, I'm not even smart enough to figure out how ordering amylase and lipase levels, often used to evaluate abdominal pain due to pancreatitis, would relate to the assessment of a patient with a headache! I guess I need to watch "House" more often!

And, the prescription? Well, it was for:

• Augmentin - an antibiotic [approx retail price from Drugstore.com = $145.99]
• Nexium - a proton pump inhibitor, to reduce stomach acid [ARP = $176.01]
• Beconase AQ - a steroid nasal spray [ARP = $149.32]
• Fiorinal - a migraine headache medicine [ARP = ~$45]
• Total cost: $516.32

So, this uninsured young man saw me for a few minutes. I charged him $20 for the visit, and our pharmacy charged him $15 for the nasal spray.

What do you think that Emergency Department visit cost? All those tests, the highly-trained ED physician? Am I just an incompetent quack, because I have the confidence in my own skills to make a diagnosis and begin treatment without any of that stuff? After all, I just listened, mostly...

As our Administration wrestles with healthcare reform, this case illustrates too much about what's wrong with our "system"... overtesting, overtreating, overutilization. Money spent in the ED which could have been used to address the healthcare needs of many more in the primary care setting, including immunizing kids, providing dental care, managing chronic disease. Misaligned incentives and muddled motivations.

I wonder how his headache is? I'm getting one just thinking about it all...

The "S" word... Socialism...

In conversations about healthcare policy and politics, I find that someone, sooner or later, says the "S" word - socialism. And, everyone involved cringes, as though we've spoken of some dark sin, or Harry Potter's "He Who Must Not Be Named." Like Darwinism, the word takes on an emotional content that is much more than it might deserve. (The Darwin talk is for another day...) Let's take a look at what the word might mean, as it applies to healthcare policy.

That great resource wikipedia defines socialism , in part, as:

a broad set of economic theories of social organization advocating public or state ownership and administration of the means of production and distribution of goods, and a society characterized by equal opportunities for all individuals, with a fair or egalitarian method of compensation."

So, that's might be much more broad that what most of us would really mean when we talk about healthcare policy and socialism. What most of us are talking about is changing from access to healthcare being for only those who can afford it, to a setting where access to basic healthcare services is available to all citizens, as a benefit of citizenship.

The concern that most people have when they speak of socialism and medicine is that the State will be in the business of purchasing health care. (Well, I gotta break it to you - the State already is! Over half the obstetrical care in our state of Washington is paid for by the taxpayers, as only one example.)

But, what's so wrong with the idea of the State ensuring that we all have access to health care?

We think of basic education as a right of every citizen. Therefore, it's provided by the State. So, it's "socialized."

We think of security as a right of every citizen. Therefore, it's provided by the State as federal, state and local law enforcement. And, on a bigger scale, as an Armed Forces to protect the integrity of the country. So, it's "socialized."

We expect protection from fire. Therefore, it's provided by the State. So, it's "socialized."

And, I don't hear anyone getting upset that "the market" isn't allowed to determine what level of police protection I have access to, what grade I can complete in school, whether the firefighters will come to my house in an emergency.

In fact, the issue of socialism is addressed in this article on the Physicians for a National Health Plan website, describing a "consumer-driven fire department." Take a look at the commentary, and the video demonstrating the concept.

So, let's take it step by step:
1) Is access to health care a right, or only available to those who can afford it? (I've often chuckled at the sign which hangs outside a medical practice I know which asserts "Excellence in Patient Care." It seems they just left off the next line: "If you can afford it.")
2) If you think it's a right, then society has a responsibility to ensure that all members of society can access this right.
3) If our current system has not delivered on this right, then we have a responsibility to step in, as a "government of the people."

This panel discussion on NPR would seem to agree...

But, let's get past the emotional baggage of the "S" word, and "the market", and get to work on a solution!

The President's Address, 2/24/09...

I was particularly interested in listening for Mr. Obama's address to congress. The transcript and video of his address are available on the White House blog, at http://www.whitehouse.gov/blog/09/02/24/The-Presidents-address-Excerpt/. So, what did he really have to say about healthcare reform?

"I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."

I'm particularly interested in the approach... he mentions the healthcare meltdown as weighing down "the conscience of our nation" - that's a hint that he and I would agree that we have a moral failing in the system of healthcare rationing we have in America. (Oh, you don't think we have rationing? Just ask our uninsured if they have access to the most basic of preventive services - they don't do pap smears in the Emergency Department, Mr. Bush. Or, ask our nation's retired military if they can find a local specialist, or even primary care doctor, to take care of them. I've talked about this 'economic rationing' before...)

But, the language that is stressed most is that America demands healthcare reform as an economic issue. Finally! Someone is saying it out loud! If you can't agree on the morality issue, then I think we can all find that we should work to reduce the high cost of healthcare, as it is a significant contributor to our economic burden.

I've often told of the per capita cost of health care as it relates to my own age... In the year I was born, 1962, the per capita cost for the US in the provision of health care was ~$200. And, the money we spent on health care was something like 5% of our GDP. The latest numbers show that per capita healthcare costs are now ~$8000+, and has risen to represent 16.3% of GDP in 2007. And, the trend of an aging population and costs rising faster than inflation would anticipate that healthcare costs will rise to 20% of GDP in 2017.

How does that compare with other countries? The data reported in this article is now several years old, and lists US per capita costs as $4000 in 2001. But, the article does have a nice comparison of costs across countries.

And, the journal Health Affairs has a nice editorial piece which calls for reform now. My favorite comment in the article is the revelation of the two major barriers to reform: "Democrats and Republicans".

So, the president is positioning healthcare reform as an economic issue, and now our task is to be diligent to watch that the reform process still includes the moral issue in the proposals.

"Yes, we can."

Healthcare as a right...

I've talked about this issue before - access to adequate health care as a basic human right. As my son scanned the news last night, for his journalism class, he paused on a story about this very issue. The commentator opened by making the statement that prisoners are the only Americans who have a right to health care granted by the Constitution. "Really?", he said. Yeah, really...

The eighth amendment guarantees the right of prisoners to be free from cruel and unusual punishment. And, the Supreme Court has affirmed that lack of timely access to medical care would be cruel and unusual punishment.

This comes to light as we are all reeling from the Great Recession. And, because the State of California has so many more prisoners than space to keep them, we are reminded of this right to health care. You see, a recent decision by a panel of federal judges tells California that they will need to release 55,000 prisoners, since the overcrowding conditions impedes this access to health care.

So, to extend this analogy, if the US Supreme Court were to affirm that access to health care is a fundamental human right, as does the World Health Organization and the United Nations, would that mean we would then have a responsibility to send 46 million of our citizens to another country, one with universal healthcare access? (46 million is the often-quoted number for the number of uninsured Americans; with the Great Recession, we have certainly seen the number of newly-uninsured patients in our Centers increasing.)

It's about time...

It's been way too long since I have commented here; ...

We find ourselves in some new days.  All of us.  And, I guess, "It's about time."

At our Community Health Center, we've been feeling the changes.  In the late fall, one of our Behavioral Health Professionals sent out an email asking for help.  You see, she had been finding more and more patients who were seeking help because they were losing their homes.  Her plea:  does anyone know of any resources to help these people?  The answer:  No, other than to refer them to the limited shelter beds available in our communities.  The Great Recession is real, and it's touching us now.

I had a wonderful chance to hear a leader in the National Association of Community Health Centers (www.NACHC.com) speak at a regional conference in October.  Dan Hawkins is Senior Vice President at NACHC, and in those days leading up to the election, spoke of the differences in the candidates plans for healthcare reform.  (Run this google search for "Dan Hawkins" and "NACHC" and you can see some of the work Dan has done for Community Health Centers.)  The analysis of Mr. Obama's plan offered some promise.  Maybe now we could do something together to get this fixed... As I did a photowalk around Denver, I was struck by the message of hope echoed in the sign, "All Together Now".  

But, where are we now?  The country, and the world, has turned nearly all attention to the economy, blaming greed and housing and bad business practices for the onset of the Great Recession.  And, the nation and it's leaders seem to have mostly forgotten about healthcare.  

And, I think back to many discussions I've had over the past few years.  Discussions about how inhumane our current healthcare "system" is toward our less-fortunate neighbors.  Even our previous President thought that the Emergency Department was the answer to the millions of children he had denied access to healthcare by refusing to sign the State Childrens Health Insurance Plan into law.  "After all, you just go to the Emergency Room."  [Our current president sees this issue a little differently.]

And, during these discussions, I'd often hear the sentiment that, if the poor people need something else from our healthcare "system", the should just use their political power to influence our elected leaders to make it happen.  The poor, I'm afraid, don't have that power.  If they did, perhaps they wouldn't be poor!  

But, now, all of us are poor!  The list of names of those losing billions to Mr. Madoff includes many people who are smarter than the rest of us.  And, have you taken a look at your 401K lately?  So, now, maybe the "nouveau poor" will be able to speak for the "old poor".  Maybe now, we can really turn our attention to the work of creating a healthcare system for all of us.  Even the prestigious New England Journal of Medicine sees that there may be a silver lining to the recession which is causing so much suffering now - finally, healthcare reform.  

It's about time...All Together Now...