Tag Archives: Specialty

Reflections on Health Care Past, and Future

The Portland Business Journal recently sponsored a forum entitled Health Care of the Future, providing a glimpse into what Portland companies are doing to disrupt the healthcare system. Panelists discussed new models for healthcare, new technologies that extend the reach of physicians and financing methods. It was a hugely attended event, with a great buzz, fantastic networking opportunities and a lot of great information. But close to the end of the conference, a couple of comments were made by panelists that I found incredibly frustrating reflections of an old, broken, sick health care system that were oddly out of place.


First, Jared Short, the head of Cambia’s Insurance group (Regence BCBS) who recounted diagnostic failure in the primary care setting as one reason for high cost to the system. He brought up a personal experience with his son’s diagnosis of a chronic rheumatic condition that took over two years to diagnose, despite elaborate investigations. Of course we don’t know the clinical details, but that’s why it’s an unfair characterization of primary care.


As an intern, I was responsible for the diagnosis of a case of lupus in a man who had been searching for a cause over ten years. I was not smarter than my colleagues or professors, but rather, the unique evolution of his disease made it impossible to diagnose earlier. Doctors knew that waiting and watching was the best possible strategy and in this patient’s specific case, there was sufficient trust that the patient was content to wait rather than pursue useless investigations. This is always necessary in a market where distortions are introduced by the fact that advanced investigations are essentially subsidized by payers. If patients understood what little value they added at time, they would decline. It is frightening that the head of one of the largest and most powerful payers in the Northwest has such a distorted view of the diagnostic process and value within the system.


If primary care is inadequate, then we should invest in supporting primary care and attracting the smartest minds. You do not get to underinvest in a key health system function for decades and then complain that it doesn’t do its job.


The other inexplicable comment is one I used to hear frequently in healthcare business circles in the past. Martie Ross, a principal in a consulting firm out east, made the point that insurers needed to find mechanisms of transferring risk to health providers with new value-based payment methodologies.


My point is that healthcare providers are not risk bearing entities and should generally be discouraged from doing so. It is not clear which features of ACOs predict their success, but some of the most successful ones have been where the risk was transferred to the ACO, but not necessarily to the providers. Providers should be in the business of taking care of people and doing the right thing, irrespective of the cost. As far as insurers go, their business is the management of risk, not the transfer of risk. To a lifelong family physician, insurance companies transferring risk seems like cheating.


Moreover, the only entities large enough to absorb this kind of risk are large integrated health systems which is the birthplace of perverse incentives for high volume, excessive and sometimes unnecessary care. Small practices arguably do better at quality where large systems are better at collecting data and generating revenue.


The disdain for primary care and the industry’s tone-deaf dehumanization of health to “risk transfer” are part of the reason our old system is broken and we are experiencing this generational opportunity for disruption. This is the health care of the past, not the Health Care of the Future.



Are You At The Table?

In case you’re wondering, this is my piece for the Clark County Medical Society newsletter, summer 2013.

There are just under 900,000 licensed physicians in the U.S. Current AMA membership numbers about 224,500, rising up to levels not seen since 2009 when the AMA’s endorsement of Obamacare apparently precipitated a 5% drop in membership. Local Medical Societies are often loosely affiliated with the state and national medical association and can compare themselves to the national benchmark. Clark County has a better percentage than the national average, but barely. Nearly a quarter of the county’s physicians belonging to the medical society.  
In my few months as President of the CCMS I have watched with interest as some counties struggle without any physician cohesion as others have active and dynamic medical societies that contribute much to their communities’ well being.  It would be enlightening to understand what accounts for low membership in the AMA and local county societies.
The most significant drivers of membership seems to be related to the employment status of a growing number of physicians.  In the much storied  past of American Medicine it was necessary to belong to a local medical society as a source of referrals and recognition within that local medical community. As more and more physicians find themselves employed by large multispecialty groups, the relevance of a medical society diminishes. In addition most specialists seem to believe that their interests are better represented by their societies.
Perhaps at some point in the past couple of decades, the House of Medicine lost its ability to extract growing concessions from the rest of society and thus external conflicts became intra-professional conflicts. Despite the larger world relying on progressively greater degrees of specialization, it seems unwise to perpetuate internal conflicts. We each have a role to play in the larger system, including the generalist role in primary care and care coordination.
What seems self-evident is that a fragmented medical profession is easier to control and manipulate than a united one.  There was a time when a nationwide group of educated, professional healers were felt to be the best hope for advising on the population’s health. Some social theorists have suggested that the medical profession squandered its social capital on protecting its economic welfare. I would argue that a small minority of narrow-minded and short-sighted physicians temporarily hijacked an organization whose role has always been nobler than its own economic welfare.
We all have colleagues who will not join the AMA because of positions it had taken in the past. Well, the trouble with that is that no one has a voice who is not at the table. There should be no illusions about how political organizations work and how advocacy comes about; we may lose the occasional internal battles but still fight for common goals. A medical society works for the interests of its members but it would be a mistake to take a shortsighted view of what that means. Medicine based on scientific proof still safeguards the public’s health. Thus, there is no way of continuing to safeguard the public’s health, either by prevention or treatment  without a highly trained, professional force working to create a health system that is both effective and efficient improving the health of the entire population.
Health care has a knack of exposing the weaknesses of a free market system but I have also worked in a socialized health system that shared different weaknesses, but of equal magnitude.  It seems the US medical system is evolving into some sort of hybrid system midway between different ideologies. Anxiety comes with any change and we are being presented with a major change in the environment of medical practice.
Whatever your politics and personal philosophical structure, much of this change has happened with nominal input from organized physicians groups. It is important for the House of Medicine to speak with one voice whenever it can come to a consensus. My thoughts and opinions have been well-received at the state level where they have differed from the official position of the WSMA. Clark County has been particularly active at the state level, especially when it comes to advocating for the health of the Medicaid population. We have been involved in discussions regarding CUP, physician wellness programs, Prescription Monitoring Program funding (in the future, it will no longer be from your license fees), exempting physicians from the state B&O tax, the role of physicians in the state disciplinary body MQAC, and disseminating information about the upcoming state health insurance exchange.
We need to focus on what is best for the health of our population and not just what is best for ourselves. However, we must also stand up for ourselves because without a professional workforce, the population will suffer. We must face the fact that the industry of which we are an integral part extracts $2.7 Trillion from the general economy and we are being held accountable for the value we return in exchange for our share.  

One thing is sure. This is no longer your father’s AMA! It is YOUR AMA! And its actions depend on your participation at the local level in your County Medical Society.

Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn’t keep eye contact with the audience and improvised on the fly… not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.
So here it is in blog format.

You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.
The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980’s and early 90’s, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO’s were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.
Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP’s did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.
So maybe I’m wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.
On the other hand, consider the following… no matter how much the content and context of medical care changes around you and your patients, some things do not change… a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like… At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.
A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.
A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.
Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I’d rather have an internist.
So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:
Family Medicine will be fine as long as you focus on certain things:
  1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
  2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
  3. Focus on the fact that you need to work well with everyone in the allied health fields: PA’s, NP’s, pharmacists, home health aides, radiology technicians, lab porters… Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
  4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA’s, NP’s, specialists and the like… it is with them you must work to improve the health of populations.
  5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
  6. Stay involved.
    Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It’s not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.
I would like to leave you with this one final thought on how important your contribution is
“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”