Here is a link to my latest Huff Post Blog which appears in today’s Politics section.  I look forward to your comments – gun owners and non-gun owners alike.

A Happy and Safe New Year to all!

As I discussed in an article for the Huffington Post last month, the ACA is supported by some of the largest medical organizations in the country, including not only the traditionally conservative American Medical Association, but also the national professional organizations that represent pediatricians, family practitioners, obstetricians and gynecologists, internists, psychiatrists and cardiologists. Every bit as compelling is the strong endorsement from theAmerican Nurses Association. The message from the experts to whom we trust our health is clear: The ACA must go forward.

Support for the ACA is not limited to the professionals who stand at the bedside. Doctors for America, a nonprofit advocacy group, released a letter on Friday from more than 100 of the nations’s healthcare leaders demanding the implementation of the Affordable Care Act. These included CEOs of major hospitals, heads of physician organizations, economists, and the deans of medical schools and schools of public health. These leaders were joined by over 10,000 doctors and patients who also signed the declaration.

These highly respected groups are convinced that the reforms we see in the ACA improve access to care, provide more cost effective services, and protect patients and employers from health industry profiteering. Because the law is finally tackling the root causes of inflated health costs, it represents our first serious effort at reigning in healthcare spending – something our economy desperately needs.

Who opposes the ACA? Republicans running for office. These politicians are inexplicably comfortable with knowing that their rhetoric flies in the face of all the opinions that matter. Who else opposes it? Special interest groups that make a whole lot of money from our old way of doing business, and who are dumping huge amounts of that money into Republican coffers.

And what would happen if the ACA was in fact repealed on “Day 1″ as Governor Romney has promised?

We would go back to paying the high cost of uninsured people showing up in emergency rooms, for conditions that have grown complicated from neglect — a huge, preventable drain on healthcare dollars.

Seniors will lose the prevention benefits that the ACA has provided — things like annual physical exams, mammograms and colonoscopies. The program that has saved seniors millions of dollars on prescription drugs also disappears if the ACA is repealed.

Women will lose the benefit that provides contraception services with no out-of-pocket expenses. Young people will no longer be able to remain under their parents’ coverage until age 26 — more uninsured people pushing through those ER doors.

Consumers will no longer be entitled to the one billion dollars in rebates that the ACA required insurers to return last year because the companies spent too little on healthcare and were saving too much as profit.

We would lose the essential benefits package that requires any policy an insurance company sells you to include basic coverage for things like ER visits, prescriptions, and pediatric care.

Under the current law, it is difficult for insurance companies to hike premiums more than 10 percent per year. Repeal that regulation and many businesses will find employee health benefits unsustainable.

The only people who will benefit from an actual repeal of the ACA are those who could afford insurance but opt not to. We — you and I — will go back to picking up their tab.

Governor Romney claims that he would keep all these popular benefits when he repeals the ACA. But these benefits are the ACA. They are popular because they put patients’ needs first.They are professionally endorsed because they are smart and cost effective. Romney could give no stronger support to the law itself than to say he can’t do away with the actual contents of it.

Doctors have traditionally been an apolitical lot, staying “above” partisan politics and carrying out their own solitary idealism under the radar screen — quietly seeing patients who can’t pay and serving patients’ interests above their own. The growing complexity of modern medicine and the alarming rise of corporate influence on our health care over the past decade has changed all that. Doctors realize that they can no longer protect their patients’ interest one encounter at a time. We are organizing, educating the public, and making our voices heard.

The Doctors For America Bus Tour is an example of this type of patient-centered activism. Doctors and their supporters will be rallying at the GOP Convention, meeting with politicians, and carrying thousands of signatures of support. The message : “We believe in an America where everyone has quality, affordable health care and where doctors and the public work together to build a health care system that works for all.” Over the next week they will steadily make their way north, stopping at five cities along the way to hold informational town halls and provide free health screening clinics. On September 5th the DFA bus will arrive in Charlotte, NC, where the doctors will again bring our message loud and clear to the Democratic National Convention.

Politicians whose purposes it serves to dismiss such activity will shrug this off as the voice of a noisy socialist minority. How often have you heard from the status quo crowd that doctors don’t like Obamacare? That myth vacillates between urban legend and baldface lie. Doctors support of health care reform in general and the Affordable Care Act in particular is a matter of record, and certainly not limited to progressive activists. Who officially and actively endorses the ACA? The American Medical Association for starts — the largest physician organization in the country. Then there’s my personal favorite, the American Academy of Pediatrics. The list also includes the American College of Physicians, the American Academy of Family Physicians, the American Congress of Obstetricians and Gynecologists, the American Psychiatric Association, the American Osteopathic Association, and the American Academy of Cardiology, among others. We work in private practices, community health centers, and in academics. We are seasoned clinicians and passionate students, primary care docs and health policy experts. We are pragmatic as well as idealistic, both credible and trustworthy.

Doctors for America will indeed be making noise at the conventions. But they are not alone. For every one, determined white-coated doctor you get a glimpse at through a convention lens, know that there are thousands more of us across the country cheering him or her on. And we will continue to cheer, through the election season and beyond: “Patients over politics! Move health reform forward!”

In my latest Huffington Post article, I debunk the myth that doctors don’t like Obamacare, and cheer on the “Patients Over Politics” Bus Tour

my commentary on the role of medical malpractice suits in improving healthcare from Kevinmd.

Now move over and make room for one more interested party:  your employer.

Ever since the HHS ruling last month that employers cannot exclude contraception from the preventive services that their insurance plan covers, the country has worked itself up into a fever of self-righteous indignation, framing the controversy around women’s rights, religious freedom, and political posturing.   As a doctor, I see it see it through a different lens.   I see the primary symptom of our dysfunctional health care system as being the unrelenting erosion of the doctor – patient relationship – a relationship that is central to health and healing.  And I see this latest distraction from meaningful health care reform  - an employer’s wish to define what kinds of access to health care are appropriate for his employees  – as just one more assault on that very intimate and healing dynamic.  Now, in addition to trying to shut out the noise from all the parties that want to make a profit from your visit, doctors  now have to consider, “so what does your employer think of all this?”

How many more parties are we willing to invite into the therapeutic conversations we have with our health care professionals?  If a CEO of a major company is an anti-vaccine activist can she refuse to let her company’s health plan cover routine immunizations for children, as a matter of conscience?   Could an animal rights organization like PETA refuse to allow coverage of chemotherapy regimens that relied on animal research, based on that group’s deeply held convictions? This week the governor of Virginia called for legislation that would require women to have vaginal ultrasounds before undergoing an abortion.  It used to be that you had to go to medical school before ordering an invasive medical test; now apparently all you need is political ambition and a microphone. In our current divisive political climate, the conversation about our health care has become less and less about what is happening between doctor and patient, and more about what individuals or groups want for themselves – and don’t want for the rest of us.

We will know that our health care system is functioning well when the one overriding question that drowns out all the other noise in any doctor-patient encounter is this: What is best for my patient?  We can measure our health care system – and our society as a whole – by how hard we make it for health professionals to ask and answer that fundamental question, whether it be due to punitive financial pressure, marketing strategies or political agendas.  Cost effective healthcare can only result from sound health policy.  The role of political leaders is to recognize and implement sound policy, not define it.  Meaningful health care reform will require that all the self-serving noisemakers, from pandering politicians to profiteers, and yes, even people of deeply felt but not widely held convictions, get out and stay out of the exam room.   If we fail to do this, the doctor and the patient will end up having the smallest voices in the room.

That was the frustrating question that kept poking through my train of thought as I read a study from the most recent issue of Pediatrics, the official journal of the American Academy of Pediatrics (AAP).  The study, out of UCLA, examined the association between length of well-child visits and quality of the visits, including things like developmental screening and what doctor’s call anticipatory guidance (Is Suzy using a car seat?).  No big surprise that the longer the duration of the well child visit, the greater the likelihood that the visit adhered to recommended guidelines.

Unfortunately one third of visits were reported as being less than 10 minutes in duration; these occurred to a greater degree in private practice.  Longer visits of 20 minutes or more made up 20% of the encounters, and were more likely to occur in community health centers.  The big winners in the pinch for time?  Guidance on immunizations and breastfeeding were offered in 80% of even the shortest visits.  The biggest loser – developmental assessments, which don’t even achieve a mediocre occurrence of 70% until we pass the 20-minute mark for visit duration.

What’s behind all this?  A profound disconnect between our medical resources and our health care delivery. No where has modern pediatric care evolved more dramatically than in the arena of well-child care and preventive medicine. What has not evolved along with our scope of knowledge is our delivery system.  Our fee-for-service approach to health care dictates that procedures and tests pay well while addressing a child’s emotional problem gets a doctor little more than a backed up waiting room.

It is a given in our current health care culture that health insurance companies and the pharmaceutical industry shape medical practice – and our collective health – through their reimbursement policies, marketing and aggressive lobbying.  The result is a lopsided distribution of health care that overmedicalizes the well-insured while undertreating the underinsured.  Consider that a whopping 25% of US children are on chronic medications, while, according to this UCLA study, half the children in pediatric practice are not receiving basic screening and advice.

The obsolete business models that the health care industries rely on are like the tyrannosaurus rex in the room, emphasizing expensive, short term productivity (think prostate screening) rather than cost-effective long term quality, while cognitive care – a high level of skill and expertise delivered face to face in a personal manner – is in danger of becoming extinct. The scope and challenges of our health grow ever more complex, and chronic conditions like obesity and diabetes overtake acute threats. Yet we keep trying to squeeze our health care delivery into the model we used back when you only went to a doctor to treat your pneumonia, or to have a farm implement removed from your foot.

It is not surprising that community health centers are associated with longer, higher quality well-child visits. The doctors are salaried, which means they are somewhat insulated from the array of financial disincentives that currently infuse primary care, like the need for rapid patient turnover.  The centers are also likely to utilize a more rational division of labor, so that every issue doesn’t immediately make its way to the most expensive professional in the room (and the one with the prescription pad) simply because that is the only person we know how to par for the visit.  Nurses at all levels of skill are used for a wider scope of encounters, and there are often ancillary resources – nutritional and mental health services for example – that expand the kinds of care the patient receives, approaching the ideal of a comprehensive medical home for all patients.   It is also not surprising that the practice settings that are successfully evolving into medical homes are largely publicly funded.  By their very nature, they put patients’ best interest above profit, and have a vested interest in long term outcomes as opposed to short term productivity.

So back to the study from UCLA.  We know what every child should receive in the way of well-child care, and we know that quality primary care saves money in the long run.  We have professionals at all levels of training and pay scales capable of delivering high quality care.  We have incredibly skilled and dedicated pediatricians who can coordinate this kind of teamwork. So why are we wasting our time arguing about how to pay for obsolete delivery models and payment systems?  Why not design a system that offers what we are capable of, and saves us money in the long run.

We all know what is standing in our way: Profit.  Special interest.   Self-serving politics.

That is why we need to keep asking the fundamental question: Why can’t we have a smarter health care system?

Physicians have always had a complex relationship with the health care industries. It requires careful collaboration and communication to bring the latest innovations to our patients. And who doesn’t enjoy a free steak dinner in the process? But in business, collaboration often involves payment, and communication is marketing. Physicians as a group have been a slow to acknowledge that we are as susceptible to corporate marketing as everyone else on this planet, and this hubris/naïveté has allowed us to be manipulated in ways that can influence our clinical decisions.

As doctors are learning, being the recipient of a gift — even one as seemingly benign as doughnuts for the office staff — can confer a sense of obligation on the recipient. Over the past decade, significant data has accumulated to show that all manners of gifts shape the prescribing practices and clinical decisions of conscientious physicians in ways they may be completely unaware of. Doctors who receive gifts tend to choose the marketed product more frequently and rapidly, and acquire them for the hospital formularies at a greater rate, while their prescribing of generic drugs declines.

Free drug samples are probably the most widespread form of “gifts” to doctors. Those over-packaged samples sitting in a doctor’s cabinet represent the latest and priciest versions of pharmaceutical products. The doctor may be well intentioned in passing them out — the patient may not have insurance, or the pharmacy may be closed — but they often cost the patient much more in the long run when the actual prescription is filled. And the fact that in the short term they were free does not mean they were the best choice of medication in that instance; they may have simply been the most convenient to reach for, or the first to come to mind thanks to that five minute chat with the very likeable drug rep earlier that day over a free bagel and cup of coffee.

Non-medically-related gifts to physicians — tickets to an NFL game for example — have largely become a thing of the past, as pharmaceutical companies have taken voluntary steps to restrict such overt attempts to gain favor. On the other hand, medical device industries are still famous for wining and dining specialists in exotic locations. There’s nothing like an all expenses-paid vacation to a five-star resort to make an artificial hip look interesting — especially when you are honestly convinced that palm trees and Mojitas would never cloud your objectivity about hip replacements. Clinical influence aside, there is no such thing as a free lunch. Consumers, aka patients, ultimately pick up the tab.

One of the thorniest issues around physician gifts concerns medical conferences. Doctors want to, and in most states are required to, participate in many hours of expensive continuing education. Grants from the health care industry help defray that cost. The industry has voluntarily taken measures to remove overt marketing influences from these settings, but more nuanced strategy remains. For instance, speakers (or “thought-leaders” as they are known in the industry) may offer presentations that, while factually accurate and useful, weigh much more heavily towards treatment than diagnosis and prevention. To justify industry insertion into the medical education process because educating doctors ultimately benefits the patient is like allowing soft drink vendors into schools because that will help fund after-school sports. The means shouldn’t run counter to the end.

Over the past decade many of our professional organizations, like the American Academy of Pediatrics, have been working hard at raising physician awareness on these matters and providing explicit guidelines.Ethical discussions on these issues are prevalent in our professional journals. The Institute of Medicine has published recommendations on limiting the role of industry in medical education. The AMA has had a shakier role here, enraging doctors a few years ago by selling physician databases to pharmaceutical manufacturers for the express purpose of providing them marketing tools. On the other hand, landmark articles have appeared in JAMA, the AMA’s journal, urging stringent restrictions on physician/industry relationships.

Meanwhile, individual doctors and practices are becoming more aware, active and vocal in the way they manage these encounters. Growing numbers of private practices limit access to sales representatives, and refuse gifts or samples from them. Some teaching hospitals now restrict the financial relationships their faculty can have with industry. The Sunshine Provision only provides a reporting system. It does not, in itself, change the way we do business in health care. But it is one more indication that doctors and society at large are coming to terms with the complex role that the health care industry plays in shaping medical practice. We will never achieve meaningful, cost-effective health care reform that puts the patient’s interests first until we understand just what it is that needs reforming. For that we need transparency, and this provision of the Affordable Care Act appears to be a step in the right direction.

I spent my formative years as a pediatrician in the US Navy, and so it happened that I was a seasoned pediatrician of nearly ten years before I had my first experience with Medicaid. I left the Navy for civilian practice in 1990.  Moving from the military system of universal coverage to our civilian two-tiered health care system of haves and have-nots was a harsh culture shock.

When I first began working at Narragansett Bay Pediatrics in Rhode Island, we were one of the few practices that accepted Medicaid. The program’s low reimbursement rates drove most practitioners away.  So many children in Rhode Island with Medicaid coverage, or who were otherwise uninsured or underinsured, simply did not have a medical home.  They were not receiving preventive screening and care, and were using the emergency room as their entry to our health care system.  I witnessed this situation change seemingly overnight in 1997 with the introduction of SCHIP (now CHIP).  This expanded Medicaid program covered more children and offered improved, if still low, physician payments.   I watched the doors to quality pediatric care open across the state.

My personal experience was confirmed by national data.  A study published in the journal Pediatrics in 2002 showed that children enrolled in CHIP where more likely to be receiving well child care, dental care and immunizations than were uninsured children, and – attention taxpayers – they were less likely to receive care in an emergency room.  Another study in 2006 demonstrated that health care gains for publicly insured children as opposed to the uninsured increased with the number of health risk factors the child had; the more vulnerable children were experiencing the greatest benefits².

Back here in Little Rhody, we have good data to support our commitment to public insurance programs.  In our state, only one in four hospital admissions for Medicaid/CHIP enrollees are emergent, as opposed to eight of ten admissions for the uninsured.  And only 10% of hospital admissions were deemed preventable for enrollees, compared to 22% for uninsured children.  Our system for getting poor children appropriate care in a timely fashion is working.  We need to focus our attention now on optimizing these kinds of cost-effective improvements.

It is painful to imagine a scenario in which we would take a step backward from these gains. This is why the current movement in Congress to reduce Medicaid funding is as misguided as it is alarming.  Recent data from the American Academy of Pediatrics reveals that if proposed Medicaid reductions are carried out, approximately 300,000 children nationally will lose their insurance⁴. Compounding this loss is that with reduced federal funding, many states, including Rhode Island, will have to further cut physician fees, resulting  once again in limited access to providers even for those children who continue to have coverage. According to a recent AAP survey, a pediatrician in RI can expect payment in the range of $27 to $37 for a preventive (well-child) visit – an amount that may not even meet overhead expenses much less generate income⁵. Reducing these payments further will bring us back to the days when physicians in private practice found it financially unsustainable to see large numbers of Medicaid patients. It will mean a return to the days when poor children’s only options were to delay care as long as possible, and then beat a path to the local ER. Ethical questions aside, delayed, uncoordinated health care only ends up costing the taxpayer more in the long run.

We should be refining and bolstering our Medicaid system, not chopping it.  We can – and need to – provide smarter, more cost-effective, quality-driven healthcare for everyone.  Our nation desperately needs that kind of rational healthcare reform.  We cannot afford to be distracted from those serious efforts by simplistic, politically driven measures – like cutting Medicaid – that only cause only harm and suffering without saving us anything.

References

1. Eisert, S., Gabow, P.  Effect of Child Health Insurance Plan Enrollment on the Utilization of Health Care Services    by Children Using a Public Safety Net System. Pediatrics 2002; 110:5 940-945

2.  Gregory D. Stevens, Michael Seid, Neal Halfon. Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association With Health Status and Primary Care Access. Pediatrics April 2006; 117:4 e751-e759

3.  RIteCare Results – Nov2010.pdf

4. AAP Department of Federal Affairs: Keep Medicaid Strong

http://federaladvocacy.aap.org/

5.  AAP Medicaid Reimbursement Survey 2007/08.pdf

http://www.aap.org/research/medreim0708.htm