Tuesday, December 20, 2016

Does Life Expectancy Matter?

U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014.  However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply.  Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate.  It is a well-known and reproducible statistical relationship that holds true throughout the world.  In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.


Headlines last week highlighted how much these unexpected results left the researchers baffled.   Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.”   Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015.  Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide.  Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous. 

For fear of sounding like a broken record, I reference a post published on this site about investing more in primary care if the healthcare system wants more people alive and healthy.  Funding a system with a primary care focus is not an innovative concept; it is a well- accepted winning strategy on which to build the health of a nation.  In 2007, the Director-General of the World Health Organization, Margaret Chan, said “A primary health care approach is the most efficient and cost-effective way to organize a health system.  International evidence overwhelmingly demonstrates that health systems oriented towards primary care produce better outcomes, at lower costs, and with higher user satisfaction.”  A thorough meta-analysis by Macinko, Starfield, and Shi (2007) addressed the question of whether increasing the number of primary care physicians could improve health outcomes in the U.S.   In every health outcome analyzed, the PCP/10,000 rate was associated with improved results.  You cannot find a more definitive conclusion than that. 

Health policy experts, IT executives, and politicians jumped on the ACA, HITECH, and MACRA bandwagon while clinging tightly to their misguided belief that more electronic records, ACO’s, care coordinators, administrators, pay for performance schemes, and other fads or gimmicks would improve health outcomes; it turns out one of the most fundamental measures of healthcare quality, our life expectancy, is no better than before.  

Unfortunately, thanks to predatory insurers, lobbyists, and self-serving CMS directors plundering the private health care practitioner, now there is another obstacle looming on the horizon which will prove to be a larger hurdle than originally anticipated.  The primary care physicians we so desperately need are running from clinical medicine like their hair is on fire resulting in a supply that cannot meet demand.   

Based on statistics in 2000, increasing by one PCP/10,000 required 28,726 more primary care physicians.  The situation has worsened as the plight of the primary care physician has become more unpredictable and calamitous.  Considerable gains in population health could be realized if CMS focused their efforts on more adequately reimbursing physicians rather than penalizing them.  Coaxing more physicians to enter primary care or strategizing ways to entice those “retiring” physicians to rejoin the workforce would be worthwhile endeavors indeed.   It would be far better than waiting to crank out a new generation from medical school.  After all, only 7% of graduates choose primary care as a career for reasons that should be clear by now. 

Fifty years ago, just over half of the physicians in the U.S. practiced primary care; today that ratio sits at 30/70.  The U.S. has a lower life expectancy and higher infant mortality rate than many other highly developed countries where the primary care to specialist ratio far exceeds ours.  Evidence from studies of those countries indicates a primary care centric system results in better health outcomes, fewer medical mistakes, cost-containment, and higher patient satisfaction.  If I have said it 1000 times, I will say it again:  expanding insurance coverage makes no difference if there are not enough primary care physicians in the workforce to care for patients in need.  Paying primary care doctors adequately enough to retain them is the only way out of this mess.    

Neither researcher, health policy expert, politician, nor economist, I am just a primary care physician on the front lines seeing sick patients who are getting sicker.  A decline in life expectancy was not unforeseen by many of us.  What if life expectancy continues to decline in 2016?  What if my hypothesis is correct as to the reason life expectancy is heading in the wrong direction?  Will the political machine and predatory insurance industry wake up and pay attention?   My hope is researchers, economists, and politicians holding the fate of our healthcare system in their hands take my words to heart.  Decreasing life expectancy may be just the tip of the iceberg.    The dwindling primary care physician supply will matter more as the predicted physician shortage materializes.  Before primary care physicians go the way of the dinosaurs, make sure to establish a relationship with one of us.  In the future, there is no doubt your life expectancy will depend on it.   

Friday, December 9, 2016

The Price is Basically Right

Recently, President-Elect Trump selected Rep. Tom Price, MD to lead the Department of Health and Human Services.  Suffice it to say, this signals Mr. Trumps’ resolve and commitment to definitively repealing and replacing.  Dr. Price has already sunk his teeth into health care reform, having proposed alternative healthcare solutions in every Congressional session since 2009.  As a physician myself, I am delighted at the prospect of having another doctor at the helm of HHS. The last physician to lead HHS was Louis Sullivan, MD as part of the administration of George H.W. Bush.  Having a physician, who can understand the needs of physicians and patients, representing both in health policy decision making at the federal level gives everyone the best chance for meaningful and successful health care reform. 

Dr. Price is a third generation physician and a retired orthopedic surgeon with experience in clinical practice and academia before being elected to the U.S. House of Representatives.  At his core, he has been a fierce critic of Obamacare.  Dr. Prices’ most frequent objection to the ACA is the fact it hinders the ability of patients and physicians to be in control of medical decision making and puts the government squarely between doctors and patients.  Amen! He understands the subtle distinction that while expanding coverage may provide insurance, it is in no way akin to delivering patients unfettered access to health care. 

As I fend off increasing government regulations in my quest for survival as an independent physician, Dr. Price (and Seema Verma – Mr. Slavitts’ replacement at CMS) seem like an oasis in the desert.  Below are some basic tenets of the Price Plan, The Empowering Patients First Act. 

1.     Tax credits so individuals may buy insurance on the private market. It starts at $1,200 a year and increases with age, but is not adjusted for income. People on Medicaid, Medicare, and Tricare, could opt to buy private insurance and receive this tax credit.

  1. Expansion of health savings accounts, which allows people to save pre-tax money which can be used to pay for premiums, copayments, and deductibles.
  2. Individuals with existing medical conditions cannot be denied coverage if they had continuous insurance for 18 months before selecting a new policy. This continuous coverage provision incentivizes individuals to purchase insurance while young in the hope of creating a long-term insurance pool, (something Obamacare has been unable to accomplish.)

4.    Federal money would be given to individual States to create high-risk pools. These are government-run health plans for people with existing medical conditions who cannot obtain affordable health insurance on the private market. Price has suggested using $3 billion in funding for high risk pools—which comes to $1 billion a year.  This approach carries some inherent risk because cost predictions may underestimate reality.  Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded. It is possible the annual cost of high risk pools at closer to $2.5 billion a year. Fine, make sure we fund this adequately this time.

  1. Balance billing could be allowed, which evens the playing field for physicians and patients alike.  It would offset the exorbitant “facility fee” hospitals are allowed and independent offices are forbidden to charge.  Allowing physicians leeway on reimbursement could significantly alter the dismal trend of physicians leaving clinical medicine in droves. 

Dr. Price has criticized “government takeover of healthcare.”  I agree with him wholeheartedly.  His socially conservative stances have angered many; he is pro-life, votes against insurance coverage for women’s health issues, additional funding of CHIP (Children’s Health Insurance Plan), and LGBT issues.  However, the more I struggle to stay afloat in independent practice, the less these differences of opinion actually matter.  Sylvia Burwell and I probably agree on Womens, LGBT, and childrens’ health issues, but my bleeding heart, ironically, has worsened my chance for survival in a career I love.  Reality is what brought this very liberal physician to advocate a different approach to healthcare reform. 

Dr. Price recently stated, “Premiums have gone up, not down. Many Americans lost the health coverage they were told time and time again by the President that they could keep. Choices are fewer.”  He is correct.  Choice for all of us has evaporated from the system in many small rural areas suffering from physician shortages already. Frustration at the overwhelming increases in insurance premiums is palpable everywhere in this country.  Maybe it is time to give Dr. Price and Seema Verma a chance.  There will be many compromises as in all things, but allowing physicians and patients more control over their lives and livelihoods is a revolution worth celebrating. 

Tuesday, December 6, 2016

Nixing the Louse

It is about time I cover a well-known parental nuisance known as head lice.  This is one of those time-honored childhood rites of passage for many of us.  Some make it through childhood unscathed.  I was not one of the lucky ones.  The first time I was in 4th grade and itching like mad before my parents figured it out.  The second time I was a pediatric intern, unwittingly having had head-to-head contact with an unknown infected child. 

A few call nights later, I discovered I had contracted head lice. The hospital pharmacy only had Lindane in stock, which is an older shampoo-type remedy, with negative side effects; but I was desperate.  There was no hot water in the hospital to make matters worse.  Basically, I took an ice cold shower, put on the medicine, stood there crying and shivering for 10 minutes, and then rinsed it out.  That was the “longest ten minutes of my life.”  A fellow intern with experience working in inner-city clinics sat on the toilet in the ladies room “nit-picking” at me for three hours.  Bless her heart.  One week later, I used Nix (permethrin) to finish off the job. 

Over the last 16 years, I have been exposed countless times.  Whenever I am aware of contact, I pick up a bottle of Nix, take it home, and prophylactically fight the theoretical louse that might have hitched a ride.  This method has kept me lice-free for over a decade. 

Yesterday, I was accidently exposed by head-to-head contact with another child.   Our nanny planned to stop by the drugstore on her way home from my office, so I asked if she would pick up some more Nix for me.  She obliged.  After picking my children up after school, I had 1 hour to do a prophylactic treatment before evening activities began.  I anxiously opened the box ready to get things started and to my utter shock and dismay, both bottles were completely empty.  I did not know this was thing!

Apparently, someone had purchased Nix, used it at home, put the nearly empty bottles back inside the box, and glued the top shut (in hindsight, there was a lot of glue inside the box top.)  Sadly, I returned to the store, explained what had happened, purchased another two bottle package, and headed home for some “louse and me” time.  Hopefully, you are laughing because I was not last night heading back to the store. 

I have had more than my fair share of experiences with head lice and various remedies over the years.  Personally, I like Nix as it is the least damaging for my hair.  However, recent reports suggest the bugs are resistant to this particular chemical.  Malathion works well and 98% of lice are susceptible, but apparently this chemical is flammable, so I am not confident it is worth the risk.  There is new Ultra Nix, a product on the market using dimethicone type chemicals, which destroy the little bug bodies and the lice eggs as well without being a pesticide.  The hair looks greasy for about three days afterward but returns to normal after a few baths or showers. 

There are “other” remedies, such as tea tree oil (possibly more preventative than curative), mayonnaise, olive oil, dawn dishwashing soap, and additional homemade approaches.  The science is still out on these, but many patients swear by these methods so I include them here for completeness.  Finally, it is worthwhile to mention an antibiotic medication called Bactrim.  Taken twice per day, this medication damages the louse when it feeds on blood from the scalp.  Somehow it ruptures their intestines. They did not even teach us this good stuff in medical school!

Last but not least, the often overlooked, yet most effective way to treat head lice in children: manually pulling nits and combing out every single tiny little louse.  This can take hours and is mind-numbing work; however it is truly the best way to end an infestation in your child and in your home. 

While there are some hard lessons in contracting lice, I do hope you have more knowledge to rid your child of this pesky critter. “Nit-picking” could be considered spending quality-time with your child.  I know the return trip to Walgreens to exchange used bottles of Nix gives new meaning to the word ‘memorable’ for me and always will.