ACCESS TO MEDICAL CARE:COMMON SENSE FOR DOCTORS, PATIENTS, and the PUBLIC

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One of the main reasons physicians have not come together on the issue of health care reform is that all of the well-publicized proposals have serious negative implications. There are tremendous pressures from both government and employers to reduce health care spending, and this means reduced payments to physicians and more barriers to care for patients. The unraveling of employer-based health insurance is also the major force pushing more Americans into uninsured and under-insured status.

However, US physicians have justifiable fears of a government-run single-payer system because they have experienced incompetent administration, frustrating provider services, and inadequate and irrational fees in the Medicare program. There are always pressures to reduce taxes and funding for public systems, leading to compromises in physician reimbursement and patient access to care in countries with universal plans. To varying degrees, these countries have allowed private insurance options for those who can afford them. MSA's are intended to make patients more cost conscious in purchasing health care.

This works well for the relatively healthy and wealthy who can afford to fully fund an MSA, who can use the tax break, and who have low annual medical expenses. They will stay in regular insurance plans or end up in government programs, driving up the cost of those programs. Also, a recent Rand study found that when people pay for medical expenses themselves instead of relying on insurance, they cut back on necessary care at least as much as unnecessary care. Private health insurance has much higher administrative costs than government funded plans.

Insurance companies attempt to contain costs by reducing reimbursement, using managed care, and constructing barriers to treatment or reimbursement, none of which make life easier for physicians. Individual insurance plans are also problematic as a means of assuring affordable health care for patients. The core idea of insurance is risk pooling, or spreading the cost for the sick across a large, mostly healthy population. However, in health insurance, a high proportion of the population knows their risk because they have pre-existing conditions or health risk factors.

Those with preexisting conditions are highly motivated to purchase insurance, but without a mandate to force everyone to buy insurance, the healthy will often decide to save their money and take their chances. This leaves a sicker than average pool of subscribers, driving the cost of insurance up, and undermining the benefits of risk pooling. To counter adverse selection, insurance companies use underwriting strategies to deny coverage or care, especially for those with serious or chronic illness, which runs counter to the whole purpose of health insurance.

Underwriting and competition also carry substantial administrative costs. Efforts to privatize Medicare and Medicaid by shifting funds to private Medicaid Managed Care plans, Medicare Advantage plans, and Medicare Part D plans are already turning out to be more expensive than the government programs they replace, not to mention the hassles faced by physicians and patients in dealing with a myriad of plans with complex policies and changing drug formularies.

Basic Health Economics

Surveys show that a majority of Americans believe that individuals with greater means should shoulder part of the burden of financing health care, and that individual responsibility and cost-consciousness should be harnessed to help control and manage health care costs. Neither a universal single-payer program nor insurance-based financing does this effectively, because after paying their fixed co-payment, the patient does not care about the cost. By its nature, health care requires some mechanism by which the public at large subsidizes much of the costs of care for the chronically and seriously ill.

Balanced Choice is a new two-tier proposal for universal health care that combines the administrative simplicity and efficiency of single-payer with the cost containment and flexibility of market-driven controls at the doctor-patient level. The co-payment in the SO could be waived in circumstances of financial hardship. Like single-payer, billing and administration would be vastly simplified. Doctors would be encouraged to offer both options, and patients could choose which option they would use with each doctor. Doctors could also choose how much of their practices would be devoted to each option.

Those patients with limited health care needs or limited means could choose the SO, and those who wanted and could afford expanded services would choose the IO. Doctors would also have incentives to innovate and focus on patient service to justify IO fees. Some of the resulting improvements, plus the benefits of generally improved physician satisfaction, would likely spill over to the SO patients as well.

In order to avoid inadequate SO fees, the two options would be linked with a balancing mechanism. If SO fees became too low and too many doctors were refusing SO patients, the Board would have the power to adjust SO fees or vary the IO base payment as a percentage of SO fees, so as to maintain the mandatory funding split between the options. The balancing mechanism allows market forces at the doctor-patient level to influence SO fees, limiting central control of fees for the whole system.

Balanced Choice could also be the agency to fund medical training and research, quality improvement programs, peer review, and other functions for the public benefit that need central administration. Hospitals could be paid with global budgets, saving vast amounts of money on billing and administration.

Throw in tort reform and expand the National Health Service Corps to encourage primary care in underserved areas, and we would have a system that might really start to solve most of our problems with health care access and affordability. The Balanced Choice proposal would provide universal coverage, efficient use of the health care dollar for actual health care, and administrative simplicity and transparency, all of which are sorely lacking at present. Unlike single-payer, it limits government control by giving doctors the freedom to set their IO fees higher than the SO rates.

It encourages those who can afford it to pay a higher share for health care and get something worthwhile for their money, and it effectively uses point of service market forces to keep fees reasonable and manage care. Although it has not yet been implemented anywhere, it shares all of the cost-control elements that have made single-payer health care financing so much more cost-effective in other countries, with the exception of government control of fees for the IO.

However, Balanced Choice IO base payments are less than SO fees for the same services, so the public plan would actually pay less for those choosing the IO. Like single-payer, Balanced Choice would take the responsibility for providing health care off the backs of American businesses. It is a plan that could be implemented either nationally or on a state-by-state basis. Of course, it would also make the health insurance industry obsolete, and would likely be opposed by the insurance lobby.

So where can we go with health care financing reform? Even with health care reform, the current trend is toward more centralized management by insurers and government, more complexity, and reduced fees for providers of medical care. We are already witnessing a rapid decline in physicians willing to practice primary care medicine.

MSA's can work for the healthy and wealthy, but not for the seriously or chronically ill. Single-payer can provide universal coverage for less than we now spend on health care, but involves government control of fees. Single-payer plus private insurance pits the wealthy against the rest for access to health care resources. Balanced Choice, on the other hand, allows single-payer economic efficiency and free market choices between doctor and patient to complement and enhance each other. It returns much of the control of health care costs and management to doctors and patients, where they belong.

I am indebted to friends and colleagues who reviewed and commented on drafts of this article. These include my Sunday morning coffee group: Alan Tice, and David Kemble; and also Dr. Janet Onopa and Marcia Kemble. I am also indebted to the Balanced Choice A-Team, and particularly Ivan Miller PhD who developed the Balanced Choice proposal and who also reviewed and provided helpful comments on drafts of this manuscript. It is the opinion of the physicians on the Editorial Staff that this article represents a strongly biased opinion, addresses a somewhat controversial insurance scheme, and does not reflect the collective opinion of the Editors.

This paper was written entirely by myself. I did not receive any financial compensation from anyone in relation to writing it. I have no conflicts of interest to report. National Center for Biotechnology Information , U. Journal List Hawaii Med J v. I oppose Obamacare's expansion of the nanny-state that regulates the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories , doesn't exist and never will. It achieved the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discouraged irresponsible health care "free riders" and provided support for people of modest means to purchase private health insurance in regulated open marketplaces.

It told insurers that in exchange for millions of new customers, they could no longer discriminate against the old and sick. Finally, the ACA rewarded physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may not improve health. The ACA has flaws. It didn't narrow the income disparity between different types of physicians or encourage more medical students to choose careers in primary care.

It didn't prevent pharmaceutical companies from arbitrarily jacking up prices on old but essential drugs. Its provisions to discourage overuse of unnecessary medical services were limited and inadequate to the scope of the problem. But it's worth noting that all of these problems all predated the law.

We don't have enough family physicians and other primary care clinicians, drugs in the U. That the ACA took on these issues at all was a small victory. It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the Republican Presidential nomination and then narrowly defeated Hillary Clinton, the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed reform plan that makes right-wing objections to the ACA look insignificant by comparison.

Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? But it underlines the need for thoughtful Republicans to look past their leaders' overheated rhetoric about repealing Obamacare and focus on strengthening and sustaining the ACA, starting now. Thursday, November 3, When treating addiction, the words we use matter. This isn't simply an exercise in political correctness. Stigmatizing terms that "describe [patients] solely through the lens of their addiction or their implied personal failings" have been shown to negatively influence mental health clinicians' attitudes: I've written before about the failure of our criminal approach to drug misuse and the problems that misuse of legal pain medications have created for patients who suffer from chronic pain.

Those consequences were more devastating in some communities than others. For almost every imaginable medical condition, members of racial and ethnic minorities receive less care and have poorer health outcomes, and addiction is not an exception. One was diagnosed with bipolar disorder and prescribed antipsychotic medications and supervised methadone treatment. The other received an antidepressant and buprenorphine.

Why were their medical plans so different? The first man was "a Latino living in a poor section of Brooklyn," while the second was a "middle-class white man from suburban Queens. Methadone, she learned, was initially presented to the public as a tool for lowering crime in black and Latino communities. Accordingly, methadone clinics were mostly located in those areas. By the start of the new millenium, media reports warned of an epidemic of OxyContin addiction sweeping suburban and rural America.

Hansen found, was aimed expressly at this new, overwhelmingly white cohort of substance abusers.

When buprenorphine came on the market, ads portrayed the typical user as a white, middle-class dad who'd become addicted to painkillers after a back injury and wanted to return to coaching the son's baseball team. Even now, many buprenorphine providers accept only private insurance or out-of-pocket payments - unlike methadone clinics, which rely mostly on Medicaid reimbursements. Although this two-tiered approach to treatment was not intended to create inequality, Hansen emphasized, it rapidly became incorporated into the structure of medicine and perpetuated stereotypes about white versus nonwhite patients with substance use disorders: For addicted people in private care, most of whom are white, therapy is designed to minimize stigma and get the patient back to work or college; buprenorphine is used as a means toward these ends.

Addicted people in public care - which covers most poor and nonwhite patients - are administered methadone under stringent supervision, steered into perceiving themselves as permanently disabled, and prescribed psychotropic medications that may further compromise their health.

On a related note, I've given some serious thought recently to going through the certification process to prescribe buprenorphine. I can't get a psychiatrist to see my few patients with mental illness that I consider beyond my capabilities unless they can pay cash; my heart sinks when I ponder how to arrange necessary care and social services for patients with substance use disorders.

Working for a health system connected to a tertiary medical center, living in a city where the doctor to population ratio is one of the highest in the country, I rarely view myself as the health care option of last resort for anyone. But the need for accessible addiction treatment is great, and it isn't being met.

Posted by kennylin at 4: Wednesday, October 26, Underperforming big ideas in diabetes and breast cancer. Management of type 2 diabetes and screening for breast cancer make up a large portion of most family physicians' practices, including my own. Care and prevention for these patients is based on straightforward underlying theories of disease causation and behavior. Patients with type 2 diabetes have high blood glucose levels; treatment involves normalizing blood glucose through lifestyle modification and medication.

Small, nonpalpable breast cancers eventually become large, symptomatic tumors. Smaller tumors are more likely to be curable, so undergoing regular screening mammography is preferable to not doing so. But what if these underlying theories are wrong? Michael Joyner, Nigel Paneth, and John Ioannidis explored how the "big idea" or narrative that investments in genetics and information technology will lead to a revolution in health care has captured a large share of biomedical research funding and journal publications. Is tight glycemic control for patients with type 2 diabetes mellitus an underperforming clinical big idea?

In an analysis in Circulation: Cardiovascular Quality and Outcomes , Drs. Rene Rodriguez-Gutierrez and Victor Montori compared clinical policy statements and practice guidelines for patients with type 2 diabetes between and with evidence from randomized controlled trials. Despite little or no evidence that tight glycemic control hemoglobin A1c less than 6.

Posted by kennylin at 5: Thursday, October 20, The missing piece in diabetes prevention. Some of my posts, like this one on problems with proliferating systematic reviews, have very brief gestational periods. I read something that stirs my thinking on a topic, I am inspired, and I write about it in one sitting. And sometimes I have a topic in mind to write on but just can't decide where it fits best: What I had in mind was a sequel of sorts to last summer's post about the folly of screening for prediabetes , which I believed was more likely to cause harm by labeling more people as being diseased than it was to motivate them to take action to prevent diabetes.

Several times I started writing, but couldn't quite decide where the post was leading. Here is what I concluded: Changing unhealthy environments can be a far more effective and long-lasting intervention than one-on-one clinical counseling.

Why do People Avoid Medical Care? A Qualitative Study Using National Data

In the late s, the US Department of Housing and Urban Development randomly assigned women with children in high-poverty urban areas to no housing vouchers, unrestricted traditional vouchers, or vouchers that could only be redeemed for housing in low-poverty areas. Ten to 15 years later , the group receiving traditional vouchers was no healthier than the control group, but the group receiving low-poverty vouchers had significantly lower body mass index and glycated hemoglobin levels. Although the Medicare DPP as proposed should improve the health of many of our patients, in order to prevent diabetes without worsening health disparities, family physicians also require resources to address social determinants of health.

To this end, the American Academy of Family Physicians recently published a position paper describing strategies for collaborating effectively with public health partners to lead the prevention of chronic diseases in our communities. Monday, October 17, How family physicians can reduce diagnostic errors. Due to our broad scope of practice, family physicians are likely the most vulnerable of all physicians with the possible exception of emergency medicine physicians to diagnostic errors.

Patients of all ages and different co-morbidities come in with undifferentiated complaints that could be attributed to multiple organ systems. John Ely and Mark Graber reviewed underlying reasons for incorrect diagnoses: Most diagnostic errors are caused by the physician's cognitive biases and failed heuristics mental shortcuts , such as anchoring bias overly relying on the initial information received or initial diagnosis considered , context errors, or premature closure of the diagnostic process. Caroline Wellbery explored some of these cognitive biases in greater detail.

For example, availability bias "refers to the ease with which a particular answer comes to mind," and can lead physicians toward making diagnoses based on other recent patients with similar presenting symptoms. Similarly, confirmation bias may lead physicians to overemphasize test findings that support their preliminary diagnoses. When faced with a difficult and ongoing diagnostic dilemma, refocus on the key assumptions that have driven the strategy to search for the "snakes. Design an experiment to see if those inferences are indeed true, like holding the snakes under the water to see what they will look like on the bottom of the lake.

In their AFP editorial , Drs. Ely and Graber suggested three approaches to reduce diagnostic errors in primary care: Wednesday, October 12, What can Rwanda teach the U. The relative underinvestment of resources in primary care in the U. Even though I feel that the U. I had a difficult time imagining how any semblance of a functioning health system could have emerged even two decades later, much less a system that would have something to teach the U. Here's the thing, though: In fact, there were only practicing physicians in the entire country in According to a report published in the same year , Washington, DC alone has about 3, They do it primarily by relying on community health workers , trusted local residents who receive a minimum of basic medical training and are then integrated into more comprehensive primary care teams.

Each district is served by a network of community health workers CHWs — three per village — offering health education, basic preventive and curative services, and family planning. CHWs are supported by local health centers, which serve approximately 20, people and are staffed by nurses, most of whom have a secondary school education level.

Health centers provide vaccinations, reproductive and child health services, acute care, and diagnosis and treatment of HIV, tuberculosis, and malaria. District hospitals, staffed in part by generalist physicians, provide more advanced care, including basic surgical services, such as cesarean sections. The lesson to take home isn't that the U. Indeed, Rwanda has every intention of training more doctors with assistance from other countries, including the U.

What's important is the pyramidal structure of their health system, with primary care at the base and more specialized care at the apex. If you took the U. Posted by kennylin at 2: Thursday, October 6, Does a rising tide of health outcomes lift all boats? Politicians who favor reducing taxes and other financial policies that predominantly benefit "the rich" have argued that wealthy people have an outsized influence on the general health of the economy, and that their prosperity will benefit lower earners by directly or indirectly creating new or higher-paying jobs.

A more pithy expression for this sentiment that President Kennedy first made famous is: David Kindig and colleagues asked an analogous question: Overall, in states where sufficient mortality data was available for analysis, combined-race mortality fell by a mean of 1.

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However, there was no relationship between combined mortality and racial disparity reductions across states. A few states Georgia, Maryland, Massachusetts experienced above average improvements on both measures, but others Oklahoma were below average on both, and most states experienced relatively greater improvement on one measure than on the other.

A Better Idea for United States Health Care - The Balanced Choice Proposal

Figure courtesy of CDC. The implications of these findings are that strategies to improve health across all populations the "rising tide" may be different from those aimed at eliminating racial health disparities "all boats". They also provide a baseline for what state health departments may reasonably expect when setting health improvement and disparity reduction goals in future years. Monday, October 3, Guest Post: Hotspotting meets patients where they are.

Wednesday, September 28, Public speaking: Since I began blogging in July , my posts have been featured in widely read blogs such as KevinMD. I also previously wrote the consumer health blog Healthcare Headaches for U. News and World Report. Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest.

In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media in medicine and education, developing and implementing clinical guidelines, and the evidence supporting prevention recommendations. Here's a clip from a talk I gave at the National Press Foundation on cancer screening.

If you or your organization would like to invite me to speak, please send me an e-mail at linkenny hotmail. November 8, Testosterone: What Does the Evidence Say? Wednesday, September 21, In praise of individual health mandates. Five years ago, my family was involved in a scary traffic accident en route to the Family Medicine Education Consortium 's North East Region meeting. I was in the left-hand eastbound lane of the Massachusetts Turnpike when a westbound tractor trailer collided with a truck, causing the truck to cross over the grass median a few cars ahead of us.

I hit the brakes and swerved to avoid the truck, but its momentum carried it forward into the left side of our car. Strapped into child safety seats in the back, both of my children were struck by shards of window glass. My five year-old son, who had been sitting behind me, eventually required twelve stitches to close a scalp laceration. Miraculously, none of the occupants of the other six damaged vehicles, including the truck driver, sustained any injuries. Family physicians like me, and physicians in general, like to believe that the interventions we provide patients make a big difference in their eventual health outcomes.

In a few cases, they do. But for most people, events largely outside of the scope of medical practice determine one's quality and length of life, and public health legislation is more likely to save lives than the advice of well-meaning health professionals. My colleagues can counsel parents about car seat safety until they're blue in the face, but state laws requiring that young children be belted into car safety seats are what made the difference for my son between a scalp laceration and a life-threatening injury.

The often-derided individual health insurance mandate that is a prominent feature the Affordable Care Act is often compared by supporters to car insurance. If governments can require drivers to be financially responsible for their cars, the argument goes, why can't they require people to be financially responsible for their health-related expenses? The hole in this argument, of course, is that people aren't required to own cars the way that they "own" their bodies. But even the millions of children too young to drive and adults who choose not to are required to use seat belts or safety seats whenever they are passengers.

That, to me, seems to be the more apt comparison.

As insurance against unexpected accidents and injuries, laws requiring seat belts and child safety seats are, essentially, individual health mandates. And it's well past time that all Americans buckled up. Wednesday, September 14, Drowning in a sea of redundant or flawed systematic reviews. As a medical officer for the U. Preventive Services Task Force from through , I authored or co-authored several systematic reviews of the effectiveness of screening tests. Lately I have been wanting to assemble a team of colleagues to perform a systematic review of a research question that, to my knowledge, has not been satisfactorily answered for at least a decade when there was insufficient evidence to answer it , but have been putting it off because I don't have the time.

829,71 RUB

Clearly many others do find the time, though. He argues that this massive increase is not explained by the need to "catch up" with older published literature; rather, only a small percentage of studies are being included in these reviews, and so many systematic reviews are cataloging the same bodies of evidence that "it is possible that nowadays there are more systematic reviews of randomized trials being published than new randomized trials. The second of these reported a sizeable and statistically significant benefit, and the next 9 had similar findings.

Apparently not, since 10 more meta-analyses of the same topic were published between and ! In some cases, excessive production of systematic reviews seems to have a marketing, rather than knowledge-advancing, purpose. Finally, Ioannidis points out that reviews may be original and methodologically well-done but still clinically useless because they are purposely not published; they pool studies of outdated genetic approaches candidate gene studies with small sample sizes and fragmented reporting, a favorite of Chinese reviewers ; or they don't find enough consistent evidence to draw conclusions.

There are many possible solutions to this problem, including stricter standards for publication of reviews; altering current incentives for biomedical researchers to "publish or perish"; and establishing single, authoritative, publicly accessible systematic reviews that can serve as living documents to be updated periodically by teams of researchers think Wikipedia for systematic reviews.

Newer Posts Older Posts Home. Yes, health policy agendas can be bipartisan How can medical educators support students' well-b Imitation may be a form of flattery, but plagiaris The missing piece in diabetes prevention How family physicians can reduce diagnostic errors What can Rwanda teach the U. Does a rising tide of health outcomes lift all boa Hotspotting meets patients where they Watch my latest Medscape commentary.

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