Tag Archives: Clark County

Primary care is key piece to U.S. healthcare puzzle

Another article, this one published in the Vancouver Business Journal on June 19, 2015, found here.

 

Healthcare in the U.S. is sick, bloated and ineffective. In some circles, investment in primary care infrastructure is prescribed as one of the important components in an effort to fix the U.S. healthcare system. My personal opinion is that primary care infrastructure is the single most important piece of the puzzle.

Healthcare is a $4 trillion industry that represents more than 1/6th of GDP. It is also growing at a rate that threatens to exceed the 20 percent threshold in the next few years. The Soviet Union’s economy collapsed when non-productive spending on defense exceeded 25 percent, and it has been argued that this level in healthcare expenditures would cause enormous misery for U.S. businesses. However, it is a mistake to examine healthcare as a monolith. The system is made up of various parts, each of which has varying interests to assure their survival within the system.

Hospitals, for instance, rely on flow-through of as many procedures as possible. Orthopedic, heart and urological procedures traditionally lead the way. Physicians in these specialties are especially prized by hospitals since they tend to refer the most valuable patients. Other physicians have professional and financial interests that are diametrically opposed. If primary care was enabled to do its job, it would keep interventions in community offices, where charges are at lower rates and the care, while some would argue is technically less precise, is often more personalized and therefore more prized by individual patients.

Even the insurance industry is not monolithic in the market conditions that maximize their bottom lines. Some insurers manage care very little, limiting the review of utilization and making their money from processing transactions. In some ways, these companies are aligned with the hospitals and specialty physicians. The managed care plans assume risk for their subscribers’ healthcare costs. They stand to make money if patients use fewer services and as such, are more closely aligned to the average primary physician rather than the average specialist.

Of course, this varies tremendously from person to person. A provider at Kaiser tends to think of fewer procedures, tests and consults as better care, whereas a for-profit primary care practice may gravitate to concierge care, and developing niche service lines like Botox, varicose vein treatments and selling nutraceuticals. Some of the more abusive niche products are narcotic pill mills, medical marijuana clinics and some of the new testosterone-centered men’s clinics.

Primary care has been marginalized in an overtly specializing society. The main driver of this phenomenon is that the financial incentives for a significant portion of the industry are aligned with generating more procedures, more testing and more specialty consultations. After all, that is where the best margins are.

On the other hand, managed care and primary care tend to have aligned interests in saving money for people and the health system in general. Primary care cannot stand on its own; there is no point to having preventive services and first line care if curative care and specialized care is not available. But not every person with high blood pressure or heart failure needs a cardiologist. In fact, specialists would spend more time treating and caring for conditions more suited to their degree of specialization if front line medicine was better built up than it is today.

The trend toward healthcare purchasers utilizing narrow networks of high value providers is related to effective primary care and an appropriate specialty network. Trouble is that the infrastructure for primary care has been neglected for so long that competition for primary care services is likely to raise prices to the extent that, in the near future, it will compete with current health plan offerings. For now however, high-value primary care holds the promise of reducing employer costs and putting enough money into primary care to attract medical students and resident graduates into areas of healthcare that have been spurned for so long.

Where are the primary care providers?

This is an unpublished Op-Ed intended for The Columbian at the end of May. I got bumped by WSMA President Dale Resiner, so no hard feelings. Here is WSMA version of the Columbian editorial.

Last week, the news hit that The Vancouver Clinic was going to reduce the number of Medicaid patients they care for. This kind of patient selection is nothing new. Many county elderly already know nearly every practice is closed to Medicare. In fact, some offices that do not accept Medicare simply hand you your walking papers when you become eligible. Anyone with a background in public health will cringe at that behavior, but anyone with healthcare business experience will know that you can’t blame them.

The announcement comes at a bad time for the state as Medicaid expansion can impact health only if the new sign-ups have access to doctors, especially in primary care. There are several industry wide factors that contribute to this kind of decision: low payment rates, penalties for fraud that are so over-reaching a single billing error could potentially cost a practice over $10,000 and the extra staff time required to get approvals from Medicare Advantage plans. The same is true for Medicaid except the payments are even lower.

Clark County has severe access problems for patients insured by government plans. Physician incomes in the Pacific Northwest are considerably lower than much of the nation and particularly in Vancouver that was once a rural county and historically did not justify the higher costs associated with being a suburb of Portland. In fact Clark sports one of the lowest primary care physician to population ratio that can be found in any urban county on the West Coast. According to the Graham Center, a primary care think tank in Washington DC, “a relative shortage in the physician workforce with geographic and specialty maldistribution contributes to difficulties in accessing needed services.” Clark County is a case in point.

When an area doesn’t have enough primary care but plenty of specialists, a few things will happen: 1) costs rise because seeing a specialist results in higher costs than seeing a primary care doctor, 2) primary care office fees rise because of a simple supply and demand equation, 3) where fees cannot rise because they are regulated, doctors opt out.

Opting out can take various forms: 1) a physician can decide do concierge medicine and cater to the wealthy, 2) they can become selective and refuse to take patients covered by low-paying insurers, 3) they can stop dealing with the hassle of sick patients’ ongoing needs and simply do urgent care for the easy no-headache payments or 4) they can close their doors.

All these options have been exercised by Clark County physicians in the past few years. Either way, patients lose out because they are the ones in need of lower cost access, coordination of care and the insights that can only be gained by a longitudinal long-term relationship between a patient and provider.

It’s just that this kind of work is thankless. It is high risk because of the awesome regulatory burden and exhausting because of the breathtaking scope of knowledge required. Every specialist knows more about their chosen field than the primary care physician, but every primary care doc is more competent than that one specialist at every other of the 130 specialties recognized in the US. A very few specialists become insensitive, unsupportive, preachy and intrusive. Intrusiveness is increasingly the hallmark of legislatures around the country with mandates for extra medical education on their pet subjects, like pain management, suicide prevention and AIDS, just to name a few. Some state imposed medical education requirements may be relevant and other times merely a distraction from the real work of medicine. It is ironic that this is the year of the suicide prevention mandate from Olympia, imposed on physicians, the profession with the highest suicide risk of all.

The question no longer is why you can’t find a primary care doctor, but how can any still exist. The problem with healthcare is not Obamacare, and definitely not the absence of Obamacare. What got us into this mess is under-investment in the primary care workforce. With or without Obamacare, the current path is not sustainable and will adversely affect the greater economy soon, that without draconian government efforts, it could be too late to fix. If we had an effective source of primary care, the whole system would be efficient enough to take care of everyone without some practices dropping whole groups of patients.

Health Risk and Pleasure

I thought I would post this one from The Physician Executive because Val was once my favorite internet buddy. My Canadian ex-compatriate is now remarried and has moved to South Carolina. But one thing has not changed: the timeless notion that people somehow view healthcare as a way to dodge the consequences of overindulging their little pleasures. In this case we are talking about something relatively innocent: unpasteurized dairy consumption. Our health officer in Clark County gets upset every time he hears about another place selling raw milk in Clark County. The latest I found was Camas Produce selling raw goat’s milk.

It’s easy to condemn the practice of consuming raw dairy on its scientific basis. Trouble is I love artisanal French cheeses. Many are raw and were outlawed int he US at the time this post was written in 2007. I am a happy camper now that I can get unpasteurized cheese. I hope Dr. Melnick will forgive me this one indulgence.

 

Dr. Val at the Voice of Reason posted an article on the hazards of raw milk. She grew up on a dairy farm, so her observations are particularly cogent. The article raised two questions in my mind.

First, our clinic’s practice is heavily Latino, dominated by Salvadoreans who have a tradition of consuming raw milk products. In fact, Salvadoreans consider yogurt made from raw milk one of the healthiest foods for young infants. My patients tell me it is usually introduced at around two or three months of age.

Of course, this goes against the usual recommendations for baby feeding in the US, which appears to me to be based on bowel maturity and propensity for allergies, as much as on healthy nutrition. There have been sporadic cases of bovine mycobacteria amongst Hispanic infants in our area, which is a stone’s throw and a ferry ride across the Potomac from Dr. Val’s stomping grounds (so much for anonymous blogs, eh?)

My classic and rigorous medical training causes me to carefully counsel my patients against the consumption of anything other than breast milk and formula for the first four months and to avoid raw milk products until they are old enough to choose for themselves. My cultural sensitivity makes me wonder if this is truly appropriate.

Yogurt, perhaps reserved for later infancy, is probably a great source of nutrition to have become an important staple in El Salvador. Culture is important to everyone who has one, and food and child-rearing are important aspects of culture. The documented number of infections in our County was 4 in 2005. Is that enough to intrude on culture and tradition, or can we just remain sensitive to the fact that these children are at risk an intervene early? I’ve never had to treat an infant with cow tuberculosis in their gut, but I wonder… I just wonder…

The second thought that came to my mind is about the French! No I’m not getting political… I just like French cheese. One of my favorites is Camembert from Normandy made from raw milk. Perhaps there is something in the process of making cheese that I am missing, but raw milk cheeses taste better and have been really hard to find because of the Department of Agriculture’s import restrictions. I just found a really smelly cheese store nearby and I’m in heaven. The first thing I asked is if they had raw cow’s milk cheese and the guy behind the counter smiled and nodded knowingly. He probably figures me for a connoisseur for asking!

Raw milk products have inherent hazards, but this isn’t like eating a puffer fish prepared by a novice sushi chef.

Just wondering…

A Splintered House

This is the text of a speech I gave to the Clark County Medical Society’s New Physician Reception in 2013.

Thank you to our sponsors and guests, to the Board of the CCMS and especially to each of you for coming. To all the new physicians; welcome to Clark County and to the medical society. I want to take a few minutes tonight and talk to you about our medical society and its history, my personal spin on what has happened to medicine in the 72 years since CCMS got started and how the House of Medicine became splintered. I would also like to talk a little about what our future might look like under the current and coming reality. Life is changing quickly for physicians these days.

“Clark County Medical Service Corporation” was established in 1941. The articles of incorporation, written under the name “Clark County Medical Society, Inc.”, were signed by Clyde B. Hutt, MD, as President and L.E. Hockett, MD as Secretary/Treasurer and were approved and filed on December 3, 1942. The constitution and by-laws of 1942 were amended on May 6, 1947 and adopted by membership on May 4, 1948. The bylaws have stood unamended since the last review and overhaul accomplished in 1991. They have withstood the test of time.

Medicine was simpler back in 1941. The bulk of CCMS membership knew each other. The largest group in town was the Vancouver Clinic and it had four doctors: a GP, a surgeon, a pediatrician and an OBGYN. If you wanted to hang a shingle, you may have wanted to meet the local docs so they could tell patients about you and maybe put in a good word for you at local merchants and businesses or maybe the bank. The county medical society was a way to let people know what your special interests and skills were and this was the way you got most of your referrals.

No I am not going to wax sentimental about the golden age of medicine. County medical societies had a dark side: they were exclusive and closed old-boys clubs that enforced standards of behavior in a manner that would be frowned upon today. They focused too much on their own interests and not enough on the health of the people they served. Keeping an eye on the money worked well for the US medical societies, and their parent organizations all the way up to the AMA, until the first turf wars erupted. I don’t need to belabor strife within the House of Medicine.

At the turn of the last century, there was a tug of war in the House of Medicine regarding the need for specialization: Some thought that generalism was necessary to understand the whole person, others thought that specialism was the way of increasing the relevance of physicians and to provide the best possible care for individuals. This was all derived from scientific medicine and the notion prevalent in an industrial society that there was more value in specializing.  Sir William Osler, perhaps the largest historical proponent of scientific medicine was ambivalent about the notion: “[Specialization]’” he said and I am quoting here, “must then be associated with large views on the relation of the problem, and a knowledge of its status elsewhere; otherwise it may land him in the slough of a specialism so narrow that it has depth and no breadth, or he may be led to make what he believes to be important discoveries, but which have long been current coin in other lands. It is sad to think that the day of the great polymathic student is at an end; that we may, perhaps, never again see a Scaliger, a Haller, or a Humboldt—men who took the whole field of [human] knowledge for their domain and viewed it as from a pinnacle. “

One of the earliest specialty societies was the American Academy of Pediatrics, hatched about 15 miles from here at an AMA meeting in 1930. In 1933, dermatology, OB-GYN, ophthalmology and ENT were the founding members of the ABMS. 1941 marked the year that the CCMS was founded and that Anesthesia became America’s 15th recognized specialty. Today we have splintered into between 130 and 157 specialties and sub specialties depending on how you count them and nearly as many specialty societies.

I think that is the word that best represents the House of Medicine today: splintered.

But somehow I think that people with an MD or a DO degree after their name may share certain characteristics more than a similar day-to-day existence within their own narrow silos of specialty and employment.

Somehow I think that people whose primary role is to help patients navigate our current morass of regulation, government, insurance, corporations, pharmaceuticals, manufacturers of various gadgets and medical technologies from titanium hips to scribe-friendly keyboard operated EHRs… somehow these people who bear the primary responsibility for trying at least to improve the health of well-being of their patients (and by consequence our community) have more in common than their differences would suggest.

When I first got to Clark County 4 years ago, I set about charting a course to understand how I could personally influence the course of events impacting my life. I have a MPH,  so I was interested in my role as an advocate for patients and how I could impact the epidemiological measures of health. I looked at what my specialty society was doing in the local community. I found the impact was driven by individuals, many of whom were involved with the local residency. The point is that my specialty association’s largest impact was being felt at the national level and had recently hired a lobbyist at the state. At the local level it was not any association, it was the individuals. I think this is probably true for each of our specialty associations. We can do at least as well locally.

So I believe that medicine has a role in improving the health of our communities. It may follow that when we band together and work towards that purpose, we may have better chances of success. It’s a subject for another day, but medicine has a role. It must have a role if the industry is to remain relevant as a social good, otherwise, we might as well all quit and become bankers, because that’s where the real money is.

Don’t get me wrong, I proudly carry the flag of my specialty society, but the fact is that all our specialty societies are somehow vaguely inadequate to the grass roots tasks. Its not just primary care, but all aspects of medicine that are at work in this town, from the anesthesiologist and the gynecological oncologist and the cytogenetic geneticist. We have more impact as a House of Medicine united in this one common mission that we agree on than worrying about turf wars.

And the impact is felt community by community. A truism in epidemiology is that you need large numbers to detect small changes, but it tells you nothing about what happens to individuals. And communities are made up of individuals, states are made up of communities and nations are built on states. It all starts where you live and work and being concerned for the health of your neighbors and the people around you. The health of Clark County depends in a small way on each one of you. The health of Clark County needs you to speak for it and for its concerns.

One aspect that has helped the health of Clark County has been the role of CUP. CCMS has advocated and will continue to advocate on behalf of this local non-profit community-based health plan both because it works for the community’s health and because it is a significant employer. We were concerned with toxic byproducts of a recycling plant and successfully shot it down. At the state, with other medical societies, we helped overturn the rule that emergency rooms wouldn’t be paid if their services were retrospectively judged not to be emergencies. Physicians got involved to work with the DOH and saved them more money than they envisioned by their prior plan. We also fought the B&O tax which no longer applies to physicians in WA. We are now looking at the impact of a coal terminal on our coast as well as the trains have along the route, so we are supporting studies to clarify the impact and publicize our concerns. At the state we have also supported public health nurses working on STD’s, reproductive equity in the state and pushed for medical staff reviews that are not quite so abusive of physicians.

Only here in Clark County can you speak out about our lack of availability of fresh food in a wasteland of fast food. Only in Clark County can you do something about obesity in your community. Only in Clark County can you set up community forums to counter the vaccine objectors’ propaganda that makes us so vulnerable to epidemics IN THIS COUNTY!

I hope you each continue to support the county medical society, I hope you get involved, speak up, be a light for others to follow, be obnoxious if you want, just speak!!! And tell you colleagues about the society. You need to take responsibility for your own “belonging” to a group you believe in. And if the AMA or WSMA or even CCMS does something you disagree with, remember that your voice counts. Without that voice, it’s not surprising the organizations do things that don’t meet with your approval. You won’t win every battle in a democracy, but you will win some/ You will make a difference.

Vaccinate, Support Local & Subscribe

Our clinic, Lacamas Medical Group, runs a couple of free immunization clinic for kids in Camas and Washougal who could not ordinarily pay for their pre-school physicals and vaccines. The Camas-Washougal Post Record, supports us in this endeavor, once running a free ad and this year sending a reporter. This is a link to her story on the web, but they held back a significant chunk for the print edition i wish it had all been online, but I understand why they do that.

I think this may convince me to subscribe. It is a very good publication by the standards of a local weekly newspaper. Moreover it is local, with local news and full of information about local businesses. We can complain about the lack of ethics in corporate America all we want, but without supporting local business, like the Post Record and the businesses that advertise in it, all is for nought.