Health Policy

The number of the day is 222—the international dialing code for Mauritania.  More interestingly, 222 is the number of nationwide ER visits per minute in 2011, according to the 2007 Emergency Department Summary from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Across the year that amounts to “116.8 million ER visits or 39.4 visits per 100 persons.”

Last Monday the Alliance for Health Reform held a Briefing addressing this topic: "The Right Care at the Right Time:  Are Retail Clinics Meeting a Need?" The briefing was sponsored by the Alliance and WellPoint, Inc. to examine the question of whether urgent care clinics and retail care clinics (together called convenient care clinics) are meeting a need in the health care system. The panelists at the event included physicians from WellPoint, RAND Health, and the American Academy of Family Physicians (AAFP). The president of the trade association for retail clinics, the Convenient Care Association, was also on the panel. The conclusion of everyone present was that convenient care clinics are meeting a need. In a broader sense, their findings also presented a strong case for a reinvestment in and retooling of the primary care system, as a whole.

The use of emergency departments has been on the rise for many years. Contrary to popular belief, a Senate hearing reported that the main increase in traffic is not due to increased utilization by uninsured patients. Instead, the largest increase has been seen in those with private insurance.  The report also listed that "physician office visits have increased at an even higher rate than emergency department visits." They suggest that the concurrent increase in ER visits reflects a growing increase in demands for ambulatory care services, and that some of that demand is spilling over into the ER.

Urgent care clinics, like NextCare Urgent Care, and retail care clinics, like CVS’s “Minute Clinic,” are perfectly poised to benefit from this spillover (and the numbers show that they have).  They are open more hours than primary care offices, and cost less than the emergency rooms.  Granted, if you suddenly lose feeling on the left side of your body and start to slur your speech you are not going to stop to consider this dilemma, but ERs across the country already see a steady stream of people who are not in such life or death situations (ask any ER doc).  In fact, one of the panelists pointed out that nearly 25% of ER visits could be safely seen at other sites.  For the working single mom, whose daughter developed a fever of 101 on Saturday night, a quick Sunday morning visit to the nearest urgent care clinic will no doubt be preferred over an expensive 4 hour long ordeal at the ER.  And their transparent prices make it a feasible option for the cost conscious patient.

Rick Kellerman, former president of the American Academy of Family Physicians (AAFP), was the panelist representing traditional family physicians. As one might expect, family physicians initially felt threatened by the convenient care movement—especially by retail clinics, which are usually staffed with physician assistants or nurse practitioners. While many of their concerns (fragmentation of medical care, decreased care coordination, “medicalization of symptoms”) persist to this day, Kellerman said that the AAFP eventually told their members that they needed to wake up to the demands of their patients: “If you don’t like retail clinics, change the way you practice.” Subsequently, many physicians responded by offering changes such as extended hours, open appointments for call-ins, “quick clinics” for walk-ins with minor problems, and group appointments for chronic disease management. Many of these doctors have embraced the movement by partnering with clinics in order to get referrals or becoming supervisors of clinics. In forming such partnerships, these physicians are offering their patients a way to get setting of care that hopefully will combine the cost-consciousness and convenience of an urgent care clinic with the benefits of a long-term doctor-patient relationship and better-coordinated care.

While disagreements remain, the facts show that convenient care clinics are increasingly common, while the number of medical students going into family medicine is decreasing.  The convenient care movement has flourished in part because the status quo in health care is failing.  Regardless of what happens to the Affordable Care Act in the upcoming days, policy makers need to work toward a solution to the primary care problem—a solution that includes both convenient care clinics and traditional primary care. Everyone--primary care docs, retail and urgent care clinics, ER docs, and patients can benefit from making sure people are treated in the right place at the right time

If you want to find out more, here’s a link to the materials from the briefing.

The Supreme Court will soon pass down their decision on the most hotly-contested and highly influential policy decisions in recent years:  the Affordable Care Act (ACA).  As CNN has put it, this is "an issue that affects every American."  If fully implemented, the ACA is projected to extend coverage to millions of Americans—a huge victory for universal coverage advocates.  It has also received opposition from those who claim that it represents an unprecedented intrusion of government into the free market.  But free market lovers also have reasons to cross their fingers that the ACA will be upheld in its entirety.  Here's why:

1.  The ACA is market friendly: The ACA is among the most market driven universal health care proposals that has, to date, been tried in other universal health care systems around the world—beat only, perhaps, by the Swiss model.   Ezra Klein shares this view:  “I think conservatives would be smart to embrace the Affordable Care Act structure…giving private insurance a central role in those markets and leaving us with a health system that looks more like Switzerland than like Canada.”  

Many free market advocates point to the fact that our current insurance structure is the problem—patients are shielded from the costs of their medical care, so market forces don't play into their choices.  The ACA will, to some extent, level the playing field in that area.  The creation of state insurance exchanges, with minimum coverage requirements, demystify the health care shopping process, allowing patients to compare apples to apples and buy a plan based on the best value.  Unlike systems in other countries, where government officials negotiate prices, this will force insurance companies to compete for your business, pushing them to provide the best service at the cheapest price.  As Austin Frakt puts it, "That's, essentially, competitive bidding."   The ACA allows the private markets to stay in the game, increases competition, and buys us more time to tinker with free market solutions to escalating costs.

2.  Inaction will kill us:  Inaction—the very thing that the anti-ACA legal case claimed the government is trying to regulate—is the thing that will bring us down.  The rising cost of health care is unsustainable and represents, according to the bipartisan Social Security Advisory Board, "perhaps the most significant threat to the long-term economic security of workers and retirees."  If something isn't done, we will be spending one of every five dollars on health care by 2020.  Imagine the jobs that could be created if we weren't paying so much to the health care system!  (And no: more health care jobs are not always a good thing!)

Some sort of major health system reform is coming in the next decade or two, regardless of how the Supreme Court rules.  As a nation we will soon come to the point when we have to decide if we want to keep spending a fifth (or a fourth? a third?!) of our paychecks on health care. We can either willingly enter the realm of 21st century health insurance (like the rest of our industrialized buddies), or we can have our tattered economic carcass dragged there when our ever-burgeoning health care costs squash other economic activity.  Fast forward fifty years to when more than a third of our GDP--one third of all economic activity--goes to pay for health care.  At that point, public and market pressure will force the government to move to contain costs, and it's hard to imagine they'll do anything 'market friendly.'  Then will free market advocates look back, longingly, to a time when we could have had a health care system with maximum free market involvement?  

We are waiting with bated breath to see how the court will rule.  Regardless of what happens, one group will bemoan the end of the world and another will throw a party.  Free market advocates should think twice about where they would be most comfortable.

The number of the day:  11%

That's right, kiddos.  The number of the day is 11%--the probability of randomly picking Grumpy if Snow White, the Seven Dwarves, and Prince Charming all sit down for tea... or, in this case, the 11% of people in the US, according to the CDC, who are taking five or more prescribed medicines. 

You read that right.  One in nine Americans is taking five or more prescription drugs.  In the medical world we call that "polypharmacy," and it makes the doctor's job a lot harder. Each new medicine that is introduced into your body increases the chance of drug-drug interactions with undesirable side effects. While practitioners receive extensive training on how these drugs interact and which ones not to combine, there still remains a risk associated with polypharmacy. The more possible interactions, the more likely it is that a doctor might miss one. That becomes even more likely when the evidence on drug interactions can be flawed, incomplete, or falsified. Having so many people on so many drugs is practically begging for errors to happen.

Such a suggestion is made by Jeanne Lenzer in a recent article published in the BMJ.  Lenzer cited a report from the Institute for Safe Medication Practices (ISMP) which "calculated that in 2011 prescription drugs were associated with two to four million people in the US experiencing serious, disabling, or fatal injuries, and 128,000 deaths."

Leading this pack of oft-misused drugs are anticoagulants like warfarin, which the authors report "prevents ischemic strokes in approximately 1% of high risk patients a year, but causes major bleeding in an estimated 3%."  Other harm-causing drugs include an antibiotic (levofloxacin); a cancer drug (carboplatin) and a hypertension drug (lisinopril).

Numbers like 11% suggest that we need to re-evaluate the safety and effectiveness of many "standard" practices.  Numbers like 11% contribute to the staggering 128,000 deaths associated with prescription drugs--that's 10 times the number of people killed in drunk driving accidents each year.  It's not surprising, then, that ISMP calls prescribed medicines "one of the most significant perils to human health resulting from human activity."  We have Mothers Against Drunk Driving, but maybe it's time for Mothers Against Profligate Prescription.

Last week, New York city mayor Michael Bloomberg announced a plan to ban sales of sugary beverages larger than 16 ounces. The ban would apply to both bottled soda and fountain drinks containing more than 25 calories per eight ounces, but would exempt alcohol, fruit juice, or any beverage that’s at least half milk. That means that the city’s 20,000 restaurants, coffee shops, food carts, movie theaters, and stadiums will no longer be able to sell empty calories in supersize portions.

New York Mayor Mike Bloomberg's most recent public health proposal, to limit sugary beverages to 16 ounces in restaurants, theaters, food carts, and stadiums, has provoked a bit of controversy.

OK, that might be an understatement. The reaction has included furious opposition people claiming this is the nanny state run amok, applause from anti-obesity groups, and a fair amount of confusion over what, exactly, the policy will accomplish. Ta-Nehisi Coates, blogging at The Atlantic, asked for more information on how it might work, so here's the rationale: There is extensive evidence from psychology and behavioral economics that people respond to larger portions by eating more. The classic experiment in the field was run by Cornell researcher Brian Wansink: his team gave random sets of subjects either large or small buckets of popcorn, and tested how much they ate during a movie. People with larger buckets ate over 30% more than people with smaller buckets. The effect persisted even when they ran the experiment with  popcorn that was two weeks old: while subjects agreed that the popcorn didn’t taste good, they still ate it, and larger buckets still made people eat more.

The main thing that the ban could accomplish is to help people who just want a soda with lunch drink less of it. There are hundreds of thousands of people in New York every day who get a soda at lunch, and don't really care about how big it is. They want enough to wash down their pastrami on rye.  Those people will be perfectly content with 16 ounces instead of 24, and they'll probably end up drinking less because of the change. By drinking just a few ounces less a day, they can cut a few hundred calories out of each week. That adds up.

The size limit isn't the only option that might work to reduce soda consumption--Bloomberg pushed for a soda tax at the state level in 2010, but it died in the legislature--but nor is it as random as it initially appears. If it's enacted (which it probably will be: the Mayor has solid control over the Board of Health), it has a real chance to do some good.

And now, a collection of the reporting and opinions expressed so far:

Our own Shannon Brownlee has a piece up at TIME Ideas laying out the fast-food economics that created half-gallon sodas in the first place. http://ideas.time.com/2012/06/04/why-americans-need-bloombergs-big-gulp-ban/

Former New York Times restaurant critic Frank Bruni has an excellent take: with nearly a third of our adult population obese and facing serious health consequences, we're beyond the point of gentle nudges. There is a crisis, and Bloomberg is on the right track. This piece also provided the title of this post. http://www.nytimes.com/2012/06/03/opinion/sunday/bruni-trimming-a-fat-city.html

Sarah Kliff, on the Washington Post's Wonkblog, places this policy in the context of Mayor Bloomberg's other innovative public health efforts, many of which have spawned imitators across the country. http://www.washingtonpost.com/blogs/ezra-klein/post/mayor-mike-bloomberg-public-health-autocrat-a-brief-history/2012/06/04/gJQArSJbDV_blog.html

Molly Ball at The Atlantic points out that Bloomberg is perhaps uniquely able to push policies like these: he's a lame duck with no concern about re-election or his popularity, but he remains powerful and doesn't have to get cooperation on this from the city council. http://www.theatlantic.com/politics/archive/2012/06/mike-bloomberg-doesnt-care-what-you-think/258001/

And finally, Jon Stewart finds himself in the painful position of agreeing with a Fox News commentator. http://www.thedailyshow.com/watch/thu-may-31-2012/drink-different

New York Mayor Michael Bloomberg was in the headlines last week for his proposal to ban soft drink servings over 16 ounces. It’s the latest front of his war against obesity, which kills 5,000 residents in the city each year. (The mayor is the founder of Bloomberg LP, which owns Bloomberg Businessweek.)

The U.S. is a heavyweight champion in fat. It has the most obese population of any industrialized nation. About two-thirds of all adults in the country are overweight and one-third are fully obese, according to the World Health Organization.

It’s the end of an era in modern medicine. House is no more.

The Fox show House ended last week. It was entertaining, but as far as health policy is concerned, we’re not sorry to see it go. The main character (Dr. Gregory House, played by Hugh Laurie) exemplifies the kind of “cowboy doctor” too many patients have come to expect. The cowboy doctor rides in on a lab result and offers a brilliant diagnosis, saves the patient’s life, and rides off into the sunset, never to be heard from again. It’s the dominant image of heroic doctors in television. Even Hawkeye Pierce, the caring Army surgeon in M*A*S*H whose demeanor is the polar opposite of House, saw his patients in one-off interactions before sending them home or back to the front.

For most of us, though, that’s an entirely unrealistic portrait of medicine. Our interaction with doctors is usually about trying to stay healthy and avoid problems, or managing long-term, chronic diseases like diabetes, heart disease, obesity, cancer. We need doctors who will listen to us, who can explain things clearly, and who we’re comfortable telling our concerns. Chronic disease management makes for lousy TV, but in recent years it has become the dominant kind of problem doctors and patients face day to day.

That's not our only quibble with Dr. House. In addition to being a cowboy, he's not much of a diagnostician. Through the magic of scripted TV he somehow manages to stumble on the treatment that saves the patient, almost by accident. He practices what I call “spaghetti on the wall”  medicine—as in, “throw the spaghetti on the wall and see if it sticks.”  He diagnoses his patients' rare illnesses by throwing treatments at patients and seeing what happens—often causing significant harm in the process. That's just bad medicine, and it isn’t something that doctors should do lightly. To us, House isn't a hero, he's a hazard, a catastrophe waiting to happen. Blinded by his own pain, he's indifferent to the suffering he causes through his reckless, unscientific, non-evidence based treatment decisions.

But there’s one point in House’s favor: he works with a team—and that team actually talks to each other. Unfortunately, that’s as unrealistic as the rest of the show. There are only a few hospitals and medical practices (Virginia Mason, in Seattle, comes to mind, and the Mayo Clinic in Rochester, Minnesota) where communication among providers is very good. In most places, the ball gets dropped between the hospital and primary care doctor and home, or even between different specialists in the same hospital.

Maybe one day TV will produce a more realistic version of medicine, but beware: it won't be the clean-cut single interactions we saw in House, or any of the other medical dramas out there. It'll be messy, and it'll be ambiguous: something a lot more like The Wire than Marcus Welby, M.D.

Those are the final questions in this article on Yahoo! News, under the title "How Much Medicine Do You Need?" The final quote comes from Rita Redberg, editor of the medical journal Archives of Internal Medicine, and pretty much sums up the questions that people ought to ask themselves when considering treatment. There's a lot more in the article that we're not going to summarize--check it out!

When most of us think about Facebook, the first phrase that comes to mind probably isn’t “good Samaritan.”  Facebook is an easy way to keep in touch with friends, and it can be a gigantic time-suck, for sure, but last week the site did something that could truly benefit a lot of people. On May 1, Facebook launched an initiative to encourage users to become organ donors, and within 24 hours there had been a spike in the number of people volunteering their body parts for the good of others. California’s registry saw almost two months’ worth of people sign up within the first day after the Facebook put up the feature.

Organ transplantation is one of the miracles of modern medicine, but there simply aren’t enough organs to go around for all the patients who need them. According to the United Network for Organ Sharing (UNOS), there are 72,900 people on active lists waiting for an organ. Compare that number to the 2,263 transplants that took place between January 2011 - 2012. Last year, more than 6,000 people died waiting for an organ.Obviously, increasing the number of organ donors could have a huge impact on the number of transplants – and on the lives of thousands of people.

Why don’t more people become donors? Some object on religious grounds, but the biggest obstacle is inertia. Most of us who sign up to be organ donors (I’m one of them) do so when we renew our driver’s license, by checking a box on a form saying we want to donate our organs. If you don’t mark the form, it’s assumed you don’t want to donate. Most people only encounter this choice every few years, when their driver’s license is up for renewal, and it’s hard to think about such a decision while standing at a Department of Motor Vehicles counter.

Some countries, such as Spain, Australia and Germany, have opt-out systems. It’s assumed that you are willing to donate unless you’ve said you prefer not to. Rates of donation in those countries are sometimes higher than in the US, although some presumed-consent countries have much lower rates. (Factors other than the number of donors, like the availability of surgical facilities and transplant surgeons, can affect the number of actual transplants in different countries.)

Another way to get more people to donate would be a “mandated choice.” This idea was proposed by behavioral economist Richard Thaler, in his book Nudge: Improving Decisions About Health, Wealth, and Happiness (with Cass Sunstein). Instead of a form that you can simply leave empty if you don’t know whether you want to donate, you have to choose between “yes” and “no.” There’s psychological evidence that even having to make that choice could get more people to think about their preferences and choose to donate. Israel has yet another incentive to get people to donate: those who are registered as donors get priority if they later need an organ themselves. Facebook’s effort depends on another psychological effect, the power of social persuasion. If your friends are all donors, maybe you should sign up, too.

Whether or not Facebook’s initiative will have a sustained effect on the number of available organs remains to be seen, but there’s a side to this issue that deserves at least a mention. Organ transplants are expensive. The surgery itself can cost as much as a million dollars, and that’s not including the drugs and other care transplant patients require for the rest of their lives. Granted, that’s money well spent in terms of lives saved. But imagine if there were enough organs for every person who needed one. We’d have to find more than $100 billion a year in addition to what we’re already paying for health care.

I’m not suggesting more organ donation is a bad idea, or that we shouldn’t do more transplants. Just the opposite. It would be money well spent. It’s also yet another reason to weed out the trillions of dollars we are on track to waste over the next decade on health care that doesn’t help patients or improve lives.