Sandy Hook Promise: The "Human" Side of the Gun Debate

Last week, another school shooting took place in Parkland, Florida, and cut short the lives of 17 high-school students.  The epidemic of school violence is a public health issue and warrants development and implementation of evidence-based prevention strategies.  Each school shooting begins long before the fatal shots are fired; studies show most have been planned up to 6 months beforehand.  The answer to gun violence cannot be found in the halls of Congress; the responsibility to protect our children lies with every parent, teacher, politician, student, and community member in America.  It is time to direct our efforts toward preventing violence BEFORE it happens by recognizing the warning signs of a child at risk and intervening. We must change the conversation about gun violence to alter the course of the future for our children.

On December 14, 2012, 20 children and six adults were gunned down inside Sandy Hook elementary school in Newtown, Connecticut.  A core group of parents who lost children that tragic day saw past their grief and created Sandy Hook Promise (SHP), a non-partisan national nonprofit organization focused on preventing gun violence BEFORE it occurs. SHP has trained 2 million adults across 50 states.  Since inception, their programs have helped stop multiple school shootings and suicides, reduced bullying and victimization, and ensured hundreds of youth receive mental health and wellness assistance.

Their three-part program is extraordinarily simple and effective. 

1.      Know the Signs to identify when a child is feeling alienated and connect with them by “starting with hello” and “saying something” to a trusted adult.

2.      Educate parents, teachers, and community members using evidence-based violence prevention strategies. 

3.      Focus on the “human” side of gun violence and be “above the politics.” 

“Start with Hello” is a program which encourages social inclusion and community connection. Our children can be taught to recognize isolation, marginalization, and rejection in their peers.  Parents and teachers can create a more inclusive school culture by training children to reach out to those who seem lonely and support growth of their coping skills.  Adverse childhood experiences can devastate even the most resilient among us.  The value of connectedness between children cannot be overstated.

 “Say Something” is designed for middle and high school-aged children to better recognize the warning signs of escalating behavior on social media in particular.   When adolescents are struggling, they tend to confide in their peers, many of whom are not equipped to intervene.  The second part of this program teaches young people to notify a trusted adult with their concerns.  By looking out for one another, and taking all threats seriously, whether written, spoken, in photo or video form, our schools and communities will be made safer. 

Safety Assessment and Intervention (SAI) is a cornerstone of the Sandy Hook Promise program that was developed by Dr. Cornell at the University of Virginia and has been rigorously evaluated for more than a decade.  SAI trains multidisciplinary teams within schools and communities to identify, assess, and respond to threats of violence while paying special attention to address the underlying conflict which led to concerning behavior in the first place.  Scientific studies show SAI-trained teams are capable of evaluating threats, distinguishing when they are serious, and intervening to prevent violent acts.

Hilary Clinton once said, “there’s no such thing as other people’s children.”   Every child is mine.  Every child is yours.  Every child adds value to the world.  By preventing just one child from bringing a gun to school, we could transform the life of not only that child, but also every student in attendance that day, plus every teacher, administrator, parent, grandparent, and community member working to support vulnerable young people.  

Laws will not change the mindset of a school shooter; we can only make an impact by altering the outlook of the school shooter.  It is time for meaningful action where we can find consensus.  It is too late to go back and save the children who were already gunned down at their schools, however we should honor their lives by supporting programs like Knowing the Signs, focusing on the delivery of mental health services to children and adolescents, and protecting at-risk individuals from firearm access and ownership.  We must talk with each other and our children about gun violence before more children die.

You can learn more about the Sandy Hook promise at www.sandyhookpromise.org. Additionally, I urge Gov. Jay Inslee and Washington State Superintendent of Public Instruction Chris Reykdahl to review the Sandy Hook Promise program and consider sharing the materials with every school district in Washington State.   

CMS Quietly Launches an Offensive Against Direct Primary Care

CMS could be a wolf in sheep's clothing 

Our healthcare system is self-destructing, a fact made more obvious every single day.  A few years ago, a number of brave physicians who were fed up with administrative burden, burnout, and obstacles to providing care for patients started a movement –known as Direct Primary Care (DPC.)  This is an innovative practice model where the payment arrangement is directly between a patient and their physician, leaving third parties, such as insurance or government agencies, completely out of the equation. 

The rapidly growing number of DPC physicians have organized into a group called the DPC Coalition (DPCC); suddenly, the Centers for Medicare and Medicaid (CMS) is paying attention.  As of February 2018, there are 770 DPC practices across the United States with new clinics opening each week as brave physicians leave the “system” behind, never looking back. Breaking free from the chains of insurance and government, this group is restoring the practice of medicine to its core, a relationship between a physician and their patient.   

CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted.  All evidence indicates the DPC model is not only capable of generating significant cost reduction, but also saving the federal government billions if administered on a large-enough scale.  As fewer physicians accept Medicare and convert to DPC practices, CMS wants a piece of the pie. 

CMS has chosen to hold focus groups in four cities, two meetings occurred in Boston and Dallas this past week; two more will be held in Denver on February 19th and 20^th, and in Seattle on February 21^st and 22^nd.  One day is for independent FFS physicians and the other is for DPC physicians.  Last week, questions for the groups were reportedly: “what do you think is wrong with Medicare,” “what needs to change,” and “what will make it better?”  I find this approach patronizing as the majority of DPC docs (and many FFS) have OPTED OUT of Medicare entirely.

Two physician organizations supporting the DPC model are the American Academy of Family Physicians (AAFP) and the Direct Primary Care Coalition (DPCC.)  Representatives from both organizations were secretly present at the “listening sessions” last week, however neither organization openly disclosed the CMS meeting to their general membership.  These organizations should work to preserve and protect physician autonomy rather than invite the government to the table and conceal that fact from their membership.  DPC physicians already opted out of government control.  Why on earth would DPCC and AAFP entertain inviting a third party back into the fold? While some members of AAFP or DPCC might be interested in a Medicare program that incorporates DPC, the vast majority of the small independents are vehemently opposed to this approach. 

Sun Tzu once said all war is based on deception.  Wise commanders take measures to force opponents to react only to the wrong circumstances. Diversionary attacks, feints, and decoys are effective tactics.  CMS has incorporated a new one, raising the false flag -- an ancient ploy where ships were permitted to fly the enemy flag, so long as they raised one with their true colors just prior to attacking their foe.

One year ago, CMS introduced their “value-based” care model at the listening session I attended.  Now, CMS insinuated themselves into the leadership at the AAFP and the DPCC before unveiling their Direct Primary Care Prototype pilot program.  DPC physicians are satisfied with their practice model, who asked for a pilot program?  CMS has realized they need one.  They have designed a prototype which requires that physicians re-enroll in Medicare (capture), accept pre-determined payments of $90-120/monthly based on patient age and complexity (control), and entails submission of patient data for payment (capitulation.)   What appears on the surface to be a DPC-friendly endeavor will destroy the system from the inside. 

The DPC movement offers the first successful and innovative alternative health care approach to emerge in years.  CMS is focusing on physician capture, control, and capitulation, yet should not underestimate the fortitude of independent physicians.  We are steadfast, experienced in trench warfare, and refuse to succumb to their demands.  We will continue to fight relentlessly against mounting administrative burdens which interfere with the provision of patient care.   CMS will raise the flag with their true colors before long.  If you own a DPC or micro-practice, do not be fooled by this wolf in sheep’s clothing.  Stand strong and remain resolute.  Government, insurers, and hospitals will try to silence us, but physicians are absolutely essential to the delivery of proper healthcare.  Make no mistake, CMS is the enemy of independent physicians everywhere and our best defense is to have a good offense – leading with transparency to our patients and the public. 

If you are a physician who has been invited to these clandestine CMS listening sessions, have information to share, or wish to anonymously assist Denver or Seattle physicians who have not been invited to attend, please reach out on Twitter to me @silverdalepeds, or contact @IndDrs (Association for Independent Doctors), @IP4PI (independent physicians for patient independence), or @PPA_USA (Practicing Physicians of America.) 

This post was authored in collaboration with independent physicians who wish to remain anonymous.  May the force be with you all in the challenging days ahead.

MD + DNP = Dr.² (Doctor Squared): The Alternative to MOC Burden

The 4th amendment of the U.S. Constitution shields an individual (or business) from unreasonable government intrusion. It is inferred this right extends to ALL people, regardless of profession.  Advanced nurse practitioners are independently practicing medicine in 23 states yet are not subject to onerous Maintenance of Certification (MOC) requirements-- physicians are not equally protected under the law.  Physicians must fight, as one group, against the burden of MOC.  We have two choices:  become a Doctor Squared (Dr. ²) or join an alternative certification organization such as the National Board of Physicians and Surgeons (NBPAS.)

A Doctor Squared (Dr. ²) denotes one who obtains both an MD and a DNP (Doctor of Nurse Practitioner) degree.  This allows independent practice and eliminates the power of MOC.  Reviewing a list of affordable DNP programs in the country shows a degree from the University of Massachusetts – Boston DNP program only costs $10,180.  Coursework is online, and will take only 3 years if attending part-time.  Renewal of an MD license in Washington State costs $697 biannually while DNP license costs $125, putting more money in my pocket.  Additionally, the continuing education requirement is different; advanced practice nurses must complete 15 hours annually while physicians need 50 hours annually even though both professions are independently practicing medicine.  According to Medscape, malpractice insurance rates are $12,000 yearly (2012) for a family physician, while a family nurse practitioner pays $1200, one-tenth as high.  Remember, the cost of MOC for internal medicine is $23,600 every 10 years. 

While the American Board of Medical Specialties (ABMS) argues MOC participation makes for better doctors, no credible proof supports this assertion; only initial board certification has been scientifically validated.  Seven states already eliminated MOC compliance to maintain licensure, physician hospital employment, or insurance contracting, however this same freedom must be extended to the other 43.

Until then, an alternative certification pathway through the National Board of Physicians and Surgeons exists.  In 2015, the Washington State Medical Association resolved to allow alternative certification, yet MOC remains a requirement for licensure, hospital employment, and insurance contracting.  Recently, HB 2257 was introduced, precluding MOC as a condition for state licensure, though overlooks the fact hospitals and insurance companies require physicians, but not nurse practitioners, to comply with MOC.

Why are hospitals and insurance companies enforcing MOC compliance?  Conflict of interest (COI) is defined as a person or organization experiencing multiple benefits, financial or otherwise, which can corrupt motivation or decision-making.  ABMS appears full of corruption.  If there is a risk one decision could be unduly influenced by a secondary interest, a COI is present.  Margaret O’Kane serves on the Board of Directors at ABMS, and her secondary interest is her role as Founder and President of the National Committee for Quality Assurance (NCQA), the organization certifying insurance companies.  She has each hand in a different MOC cookie jar. 

NCQA requires that insurers credential only physicians who comply with MOC programs.  It appears Ms. O’Kane is profiting from the NCQA requirement on one hand while forcing physicians to spend millions completing MOC on the other.  While the average internist earns $150,000 annually, Ms. O’Kane appears to be handsomely profiting from this “arrangement.”  Wikipedia defines collusion as “an agreement between two or more parties, sometimes illegal–but always secretive--to limit open competition by deceiving, misleading, or defrauding others” to gain leverage. It is an agreement between individuals or corporations to divide a market or limit choice and opportunity.  Through Ms. O’Kane, ABMS and NCQA have a connection while misrepresenting themselves as being independent. 

ABMS assumed physicians would never contest corruption, however numerous brave physicians are fighting:  Dr. Wes Fisher, Dr. Ron Benbassett, Dr. Meg Edison,  and Dr. Paul Tierstein, who created the National Board of Physicians and Surgeons, (NBPAS).  While NBPAS has made headway with hospitals, not one insurance company will credential physicians who refuse MOC.  Should insurance companies be in charge of our healthcare system?   

The Maintenance of Certification (MOC) program was initially voluntary; however when billions in potential revenue were realized, participation became mandatory.  My brave friend and colleague, Meg Edison, MD refused to re-certify for the third time, yet was forced to bend to the insurer demands.  We have two choices:  1) Become a Dr² –having all the knowledge and experience of a medical doctor without the regulatory capture or 2) Credential with NBPAS and leave ABMS and NCQA in the dust.  Regulations will not disappear until physicians realize there is no healthcare without our blood, sweat, and tears.  May we all find our way once more. 

If you are struggling under the weight of MOC requirements, please consider taking this survey developed by a Dr. Wes Fisher, who is leading a crusade against forced MOC compliance.  Choice.  Transparency.  Autonomy.  https://www.surveymonkey.com/r/PPA_MOCSurvey.

National Women Physicians Day: We Stand on the Shoulders of Titans #NWPD

Februrary 3^rd is officially recognized as National Women Physicians Day (NWPD), commemorating the birthday of Elizabeth Blackwell, the first woman in the U.S. to earn a Medical Degree.  Allegedly admitted to medical school as a practical joke, she completed her studies despite vocal critics who viewed her gender as inferior. From my perspective, this holiday honors many brave women who trailblazed the path toward gender equality – one we continue to negotiate today. 

A hugely instrumental figure in the movement was born and raised here in Kitsap County, Dr. Esther Clayson Pohl Lovejoy.  She was a pioneering medical doctor, a suffragist, a health policy advocate, and later, a congressional candidate.  Born in Seabeck, Washington Territory in 1869, she spent her formative years in Kitsap County, where she attended primary school, attaining high marks. 

She had a working-class upbringing, spending her youth employed at the Bay View Hotel, which her family operated.  As a result of her conscripted childhood, she vowed to find a career she loved which had a meaningful impact.  After her family moved to Portland, Esther met Dr. Callie Brown Charlton, who became both a friend and mentor.  Despite being widowed with a young daughter, Dr. Charlton made her way in medicine against social and financial obstacles.  When asked for career advice, Charlton told her medicine “was the best vocation possible for a woman.”  Dr. Charlton was right.

Medical education for women in the United States in the nineteenth and early twentieth centuries was shaped by region.  Attitudes in the West were more favorable to women doctors, affording some advantages. Esther Lovejoy began coursework at the University of Oregon Medical Department (UOMD) in the fall of 1890, earning tuition money by working as a department store clerk.  Despite earning a medical degree with honors, professors rejected her application for an internship, and male physicians refused to work with her.  Even with these impediments, she opened a medical practice in Portland with her husband, a surgeon. Her notoriety grew, and her practice flourished. 

Dr. Lovejoy was appointed as the Health Officer for Portland, and in that role, was a staunch public health advocate, believing healthy communities were the responsibility of citizens and their government.  At the same time educational and vocational opportunities expanded for women, the suffragist movement gained momentum.  Dr. Lovejoy thought voting rights for women were pivotal to keep homes and cities healthy.  She had a hand in women being granted the right to vote in Oregon, which was achieved in 1912.   She continued working with the National American Woman Suffrage Association (NAWSA) to pass the Nineteenth Amendment, a feat considered the single greatest achievement for women in the last century. 

Today, female physicians are standing on the shoulders of titans.  These women not only left the medical profession better than they found it, but also the nation.  In the mid-1890’s, women were only 7% of medical students across all institutions.  Today, one-third of all physicians and almost half of matriculating medical school students are female. Now it is our turn to collaborate, mentor, and inspire the next generation. 

National Women Physicians Day represents all that is possible for men, women, and children.   Despite facing ridicule for breaking down barriers, Drs. Blackwell, Lovejoy, and countless others refused to accept the status quo.  While occupational disparities remain more than a century later for women and minorities, it is through honoring the trailblazers who went before us that their mission endures.   Our culture needs to change so women feel valued and respected, comfortable and safe in the workplace, and are provided ample opportunities for leadership and growth.

Recently, a little boy and girl came into my office for check-ups.  The boy shared his dream of becoming a doctor.  His older sister incredulously said, “boys can’t be doctors, only girls are allowed to be doctors.”  Amused, I informed her the field of medicine welcomes all individuals regardless of gender, race, religion, ethnicity, or disability. We must only bring a heartfelt pledge to heal the sick and comfort the suffering with us to embark on a medical education.  There is no other endeavor in the world more rewarding than saving a life using your hands and your hard-earned knowledge.

On National Women Physicians Day, we should honor the courageous women who lighted the way and be mindful of the awesome responsibility of passing the torch to the next generation.   The onus is on the medical profession as a whole to foster an environment of encouragement, collaboration, and mutual respect.    Looking to the future, it is important to understand our past.  Thank you Dr. Blackwell, Dr. Lovejoy, and every medical doctor who continues fighting for equality.

Mayo Clinic Health System: Truth, Falsehood, and Ice Cream

The Mayo Clinic in Rochester has held the top spot on the U.S. News and World Report hospital rankings for the past two years, despite the closure of community hospitals that negatively impact rural Minnesota towns. 

Citing staff shortages, reduced inpatient censuses and ongoing financial challenges, Mayo decided to move all inpatient services from the hospital in Albert Lea, Minnesota, including labor and delivery, to a town more than 20 miles away. In response to pleas for reconsideration, Mayo Clinic Vice President Bobby Gastout callously remarked that 23 miles is not ideal — but “people are driving 23 miles to get their favorite ice cream.” 

A grassroots group, Save Our Hospital, galvanized the community by answering “we like our ice cream and inpatient care in Albert Lea.”

So how will our country, from the Midwest to here in Kitsap County, ensure health care access doesn't continue to come second to profits? 

Price transparency must be mandatory at non-profit hospitals if runaway healthcare costs are to be contained. Behemoth institutions are decimating rural areas after a decade-long buying spree. A study in Health Affairs magazine found nearly half of rural counties in the United States are without hospital-based OB services, a change affecting more than 2.4 million women. According to the University of North Carolina's Center for Health Services Research, 83 rural hospitals have closed since 2010. Hospital systems complain they are crumbling under the weight of lower reimbursements, rising bad debt from high-deductible plans, and dwindling admissions.

However, communities are entitled to see the proof in the pudding.

While touting $13 million in losses over two years as the central force behind the closure decision, in reality, Mayo misrepresented their facts and figures according to tax returns posted by ProPublica. Dr. Mark Ciota, CEO of MCHS-Albert Lea, reported the hospital lost $4.6 million in 2015, but the nonprofit's IRS 990 form showed a net income of $2.56 million. In 2016, the Albert Lea hospital projected a loss of $8 million, though residents eagerly awaited release of Mayo's tax returns to separate fact from fiction. Mayo conveniently overhauled its tax reporting process and filed a group return, a format which obscured financial performance of individual campuses, including Albert Lea.  Allen Baumgarten, a Minneapolis-based independent healthcare analyst, utilizes public records to calculate hospital profits and losses — he estimates the Austin-Albert Lea campus generated a net income of $1.2 million in 2016. 

Earlier this year, Dr. John Noseworthy, CEO of Mayo Clinic, feigned financial woes, complaining Mayo had to “prioritize commercially insured patients” over those on Medicaid and Medicare in the interest of long-term survival. Yet they had no reservations investing in the Destination Medical Center Project, a 20-year, $5.6 billion economic development initiative which will position Rochester (actually Mayo) as a global center to provide high-quality medical care to the wealthy across the world. Astonishingly, third quarter earnings show Mayo operating income more than doubled from $86 million to $182 million, with total revenue increasing 9 percent, from $2.72 billion to $2.97 billion.  In 2016, international investment income was $2.7 billion, while close competitors, Cleveland Clinic and Johns Hopkins, produced less than half that amount. 

Mayo benefits handsomely from public tax revenue while exempted from paying city, state, or federal taxes in exchange for “improving” healthcare access for struggling communities. While no one is questioning legality of these investments, ethically the loss of rural hospitals is hard to reconcile when Mayo pours $1.34 billion into offshore tax havens to reduce their tax liability.   

Ice cream may melt on a 23-mile drive, but ill and injured people may actually die traveling that same distance. Movements like “Save Our Hospital” are garnering national attention with good reason, as they are David bravely taking on Goliath.

To ensure access in rural communities, non-profit hospital institutions should provide transparent pricing to patients and share financial performance data with communities. Benjamin Disraeli said, “there are three types of lies – lies, damn lies, and statistics.” Mayo has fractured trust by misrepresenting operating losses in Albert Lea to justify hospital closure, Dr. Noseworthy condoned prioritizing patients based on their pocketbooks while third quarter earnings went through the roof, and hospital leadership condescendingly compared driving 23 miles in labor as being equivalent to buying ice cream. 

Places like Mayo are systematically dismantling rural care facilities without accountability for the generous tax exemptions they receive. The loss of one more rural hospital this year will be a loss for the entire nation. The battle for affordable, accessible, and high-quality health care is one worth fighting. Rural health care is far more important than ice cream. 

Is the Marital Status of a 5 year old Child Important?

My pediatric practice is one which harkens back to days long ago when physicians knew their patients and pertinent medical histories by heart.  My 81-year-old father and I were in practice together for the past 16 years; he still used the very sophisticated “hunt and peck” to compose emails.  The task of transitioning to an electronic record system seemed insurmountable, so we remain on paper.  Our medical record system has not changed in almost five decades.  I would not have it any other way.  

This past spring, he walked into my office shaking his head in disbelief after thumbing through a stack of faxes.  “Can you believe this 16-page emergency room note has no helpful information about the patient?”  This was not a shock to me.  The future of medicine will include robots who are paid to collect reams of useless data to provide nothing in the way of health or care.   Regardless, the government and third-party payors will extoll upon the virtues of their inept system as life expectancy falls. 

Fifty years ago, there was a close relationship between a physician and their patient grounded in years of familiarity.  Physicians took a history, performed a physical exam, and developed an assessment and plan.  Diagnosis in a child with fever would be descriptive, like Bacterial Infection, Otitis Media, Fever of Unknown Cause, or Viral Illness.  Parents were advised to provide supportive care, involving clear liquids, fever medication, and follow up precautions if the child worsened.    

At the dawn of the technological age, the effortless simplicity previously existing between physicians and patients has all but evaporated.  It was traded away without our consent, relegating the role of physician to that of a data-entry clerk.  Physicians are discouraged from synthesizing information and utilizing it to guide our decision making.  Today, a 16-page document “appears” to contain crucial elements such as chief complaint, past medical and surgical history, medication list, and allergies, however, the information is then followed by more than a dozen pages of waste.

The particular case to which my father was referring involved a 5-year-old child with fever.  The provider documented the sexual history of this child, whether he was single or married, and whether or not he had children of his own.  My dad and I started chuckling as we contemplated collecting this kind of extraneous information from a child who had not even entered puberty.  As one would suspect, our young patient was single, as in not married; he had no children (which is physiologically impossible), and his years of formal education were noted “not pertinent to his medical situation.”  Interestingly enough, I volunteer at the school where this young boy attended kindergarten; his classroom was next door to the one with my second oldest child.  Three of his classmates were out with febrile illnesses, however technology cannot incorporate this kind of alternative data. 

We kept reading and laughing.  Occupational history was recorded as not on file; running a bustling lemonade stand in his neighborhood apparently was not clinically relevant.  It came as quite a relief that at the tender and impressionable age of five, this boy had managed to steer clear of regularly smoking cigarettes.  It was comforting to discover he had never used smokeless tobacco either; and for some reason, I never thought to inquire about such things before (insert eye roll.)  He also denied alcohol use, restoring my faith in the fact that not every youngster was consuming alcohol during their formative childhood years. 

Just when I thought things could not get more absurd, I came upon the sexual history; contemplating whether or not a five-year-old child was engaging in consensual intercourse was nauseating.  I reminded myself that data entry clerks were devoid of emotion and instead were tasked with collecting “critical” details to practice by protocol.  Sexual history: Not on file. 

The final summary and diagnosis section was the most entertaining part, which read: “primary diagnosis:  none.”   Seriously, are you kidding me?  No diagnosis?  This is the future, technology will seal the fate of our profession as one entirely devoid of the need for any cognitive skills.  This earth-shattering conclusion after sixteen (16!) pages of documentation was utterly astonishing.  Despite the considerable time and effort invested asking a febrile five-year-old whether he was married or having consensual sexual intercourse in his spare time, little to nothing was provided in regard to healthcare.

At this point, my father and I laughed so hard that tears were running down our cheeks.  There is no other reasonable response to the sheer waste of time, resources, and education invested in becoming a physician.  Doctors have spent decades honing their clinical skills and should be entitled to choose the documentation method they find most effective and efficient.  Some physicians find electronic records helpful and should be encouraged to use them.   My pediatric practice will keep surviving on a shoestring, a prayer, and good old-fashioned paper.  It warms my heart to know each chart note contains helpful information and not one human being leaves with NONE as their diagnosis. 

Footnote:  Page 16 states: “This chart is intended to document the majority of the information from this patient’s visit today.  Other items, such as the patient’s care timeline, are reported elsewhere and should be reviewed to better understand this encounter.”   (More eye rolling.)

By all means, if 16 pages did not cut it, twenty more should make sense of arriving at no diagnosis.  Forgive me for not running out and requesting those records immediately.  

Life Expectancy Declined Again... No Surprise

Newborns born in 29 other countries of the world have life expectancies exceeding 80 years; yet, an infant born in the US in 2016 is expected to live only 78.6 years according to recently released statistics.  While death rates fell for 7 of the 10 biggest killers, such as cancer and heart disease, they climbed for the under-65 crowd.  The irrefutable culprit is the unrelenting opioid epidemic. 

Last year life expectancy declined for the first time since 1993.  The last two-year decline was in 1962 and 1963, more than a half-century ago.  I predicted (accurately) it would decline again this year unless there was a dramatic change in the primary care physician workforce.  We are dying at a younger age today than two years ago– two months earlier to be exact.  It might not sound monumental, but life expectancy is the king of noteworthy health statistics, making it quite significant in the grand scheme. 

In the past, epidemics by definition were temporary; the narcotic epidemic will be anything but transient; there is no foreseeable end for the scourge of opioid addiction sweeping the nation.  In my humble opinion, the solution to this dilemma is no different than it was last year, we must correct the primary care physician shortage.   Time is of the essence.  The last three-year decline occurred in 1912- 1914 as a result of the Spanish flu.  Unfortunately, life expectancy will continue to decline until the nation makes comprehensive changes. 

One in five Americans live in a primary care shortage area; the ratio of the population to primary care providers is greater than 2,000 to 1 (Bodenheimer & Pham, 2010), when it should be closer to 1,000 to 1.  I am a third-generation primary care physician, with a unique historical perspective on how medical practice has changed since my grandfather made house calls back in 1940.   My practice is currently located in a shortage area and the difference in volume compared to 16 years ago when I first hung a shingle, is extraordinary.  Only 37% of doctors serve in primary care, yet 56% of the office visits are completed by that particular group of physicians (Health Resources and Services Administration, Bureau of Health Professions, 2008.)  In my grandfathers’ time, primary care physicians made up 70-80% of the physician workforce.

Adding one primary care physician per 10,000 population, reduces mortality by 5.3%, avoiding 127,617 deaths annually. As an added bonus, primary care has a high rate of return on lives saved per dollar invested. Some healthcare policy experts believe the answer to the primary care physician shortage is to encourage physician extenders, such as nurse practitioners or physician assistants, to practice independently, a role for which their education was not originally intended.  The misguided belief that the comprehensive education of a physician can be condensed into less than 5 years is preposterous.

The number of opioid prescriptions written in this country has doubled from 109 million in 1998 to over 200 million by 2011.   As one example, studies show mid-level providers have markedly different prescribing practices when compared to their physician counterparts, a visit-by-visit comparison showed PA’s prescribe narcotics 19.5%, NP’s 12.4%, and physicians at 10.9% of visits overall.  The differences between NP’s and physicians prescribing practices were most dramatic in rural areas, where the primary care physician shortage is most palpable.  In the 2014 Drug Trend Report, NP’s and PA’s wrote 15.8% more opioid prescriptions for injured workers in 2013 than physicians. 

Mid-level providers deliver high quality care in their role as physician extenders, however, if practicing independently right out of school, their fewer years of education reveal significant variations.   Mid-levels report their patients are more satisfied when compared to patients with primary care physicians.  Ironically, it is a well-established fact that the happier and more satisfied the patient, the more likely they are to die. 

Life expectancy number will worsen in direct proportion to the primary care shortage.  No one needs a crystal ball to predict the number and frequency of narcotics prescriptions will continue to increase nationwide when financial incentives emphasize the “satisfied” patient over one that is alive.  A recent Huffington Post article lamented the fact the Canadian government ignored primary care physicians who predicted the impending physician shortage. “It’s precisely the front-line healthcare workers that know where the flaws and inefficiencies are.  It’s time for governments to connect with them… to help fix the problems in healthcare.”  Primary care physicians in the U.S. have been relegated to the back room.  As a result, people are dying younger than before.  One year ago, I asked whether declining life expectancy was just the tip of the iceberg, suggesting we should turn our attention to the dwindling supply of primary care physicians.  What will it take for those in charge sit up and pay attention? How low will life expectancy have to go?  Stay tuned…

Does Parenting Style Matter?

A recent study found that toddlers with permissive parents had more than double the risk of internalizing behaviors (having anxiety or somatic complaints) and triple the risk of externalizing behaviors (bullying or being destructive) compared to peers whose parents used an authoritative or authoritarian parenting styles.  The fact parenting styles could influence the long term behavior and development of children was first hypothesized by Dr. Baumrind in 1967.  She described three styles of parenting:  authoritative, authoritarian, and permissive. 

Authoritative parents, also known as democratic, are those with high demands and high levels of responsiveness to their children.  Their children tend to be happy, confident, independent and have better mental health overall.  Authoritarian parents are those with high expectations yet low responsiveness to their children. This style produces children who are unhappy, insecure, and have more behavior problems. 

Permissive parents, also known as indulgent, place few demands on their child, yet are highly responsive to every whim.  These children have difficulty following rules, poor self-control, and struggle with emotional self-regulation.  As a group, they tend to withdraw socially, have the highest risk of developing mental health disorders, and are more likely to become addicted to drugs or alcohol. 

Parenting is never easy.  It is like navigating one thousand miles through a tunnel with uneven terrain while blindfolded.  Sometimes, using our “gut instinct” to wing it is all we can do; the story below is one example which comes to mind.

A little over a year ago, my strong-willed daughter needed a slight adjustment in attitude.  We were driving home from the dance studio close to our home.  “I don’t like my dance bag and I want a new one.”  I was quiet.  “You are going to buy me a new one because I said so.”  I was pondering a suitable response.  “I don’t like you and I don’t like my dance bag. I want a new mom and a new bag.”  My reaction to her outburst needed to leave a lasting impression.

There is a park and ride between the dance studio and our home.  After turning into the parking lot and swinging a U-turn, I pulled up next to the covered bus stop.  Putting the car in park, I opened the minivan side door and tossed the dance bag outside onto the ground.  “What are you doing?” she demanded.   “You said you did not like your bag, we should leave it here for another little girl who would love a bag like this, so she can take it home.”

Eyeing me suspiciously, she gently unclipped her car seat straps, and got out of the minivan to retrieve her dance bag.  I continued, “While we are at it, I think you would be happier if a different mother was raising you.  Why don’t you get out and wait here (at the covered stop) until you find another mother you like better who wants to take you home?”

Reaching down to pick up her dance bag off the ground, I began to close the van door, knowing the child safety feature would not allow complete closure.  This really got her attention.  She grabbed the bag, used her body to block the door, and hopped back into the van.  “Wait! I want you as my mother.”  She even wanted to go home with me.  Skeptical, I clarified, “Are you sure?  It means you must commit to being my daughter from now on?”  She nodded. 

We drove home in silence.  I was wondering if my approach had been over the top; she was reflecting on the event also.  As we pulled into the garage, she said “Mom, I am sorry for what I said to you. I do want you to be my mother.  Can you promise never to drop me off at the park and ride again?” I smiled before responding, “Ok. I promise never to leave you at the park and ride again, but the next time you tell me you want a new mother, I might try the mall instead.” Having an incredible sense of humor, my daughter giggled and gave me a hug. I returned her affection heartily.    

While an unconventional example of the authoritativeness, high demands were made; after all, she had to pick out a mother (symbolically, at least) for herself.  This was balanced by a high degree of responsiveness on my part in supporting her choice.   Be authoritative whenever possible, remember to “mix it up” sporadically to avoid being predictable, and be open to learning a great deal from mistakes along the way.  Raising a child who is independent, determined, and clever has many challenges, but I would not have it any other way.  Apparently, neither would she.     

Could Dignity Health + Catholic Health Initiatives = Micro Hospital?

Bremerton has a large population of elderly, disabled, economically disadvantaged and medically fragile individuals. A targeted, viable solution to meet their healthcare needs is absolutely imperative; strategies must expand access to inpatient, outpatient, and emergency services for everyone. 

My “field of dreams” would be the development of a Harrison Community Campus, bringing together a micro-hospital, a small emergency department, a primary care clinic, and an assembly of satellite offices from multiple social service agencies. And there’s reason to believe it could happen here.

This week Dignity Health officially announced a merger with Catholic Health Initiatives (CHI), the entity that Harrison Medical Center is part of. Their new organization will be the largest non-profit hospital system in the nation, employing roughly 159,000 employees at hospitals and clinics in 20 states. Dignity Health already supports construction of micro-hospitals as a cost-effective solution for healthcare delivery in urban, suburban and rural areas. Peggy Sanborn, Vice President of strategic growth for Dignity Health, said “micro-hospitals have a shorter build time, allowing the health system to bring healthcare services to patients in the community faster.”

Micro-hospitals are independently licensed facilities with approximately 8 to 25 inpatient beds, fully-equipped emergency departments and ample ancillary services, such as pharmacy, laboratory and imaging. Micro-hospitals already exist in 19 states, including Arizona and California, and have the capability to handle acuity levels equivalent to those of any standard community hospital. The micro-hospital concept is gaining traction across the nation because construction costs are considerably lower — between $7 million and $30 million — than traditional hospital facilities, according to Advisory Board statistics. 

Micro-hospitals are best suited to handle short-stay admissions anticipated to be less than 48 hours. Costs are slightly higher than for an urgent care center, yet lower when compared to traditional hospital settings. Micro-hospitals can meet 90 percent of patients’ basic healthcare needs and tend to flourish most in markets with critical service gaps by preventing at-risk populations from falling through the cracks. Ideally, micro-hospitals should be located within 20 miles of a full-service hospital, to facilitate transfer of patients to larger institutions should higher acuity healthcare needs arise.     

An organization called Emerus is the nation’s largest proponent of micro-hospitals, with 22 fully operational and almost two dozen projects currently in development. Structures range in size from 15,000 to 50,000 square feet and function as “healthplexes,” with primary care and specialty clinics. According to Vic Schmerbeck, executive VP of business development at Emerus, the objective is to provide services “in a place where people work, live and play.” 

A community facility, including a micro-hospital, would not only benefit patients, but also providers and insurers, who are crumbling under the weight of increasing costs.  Bringing together primary care, specialty care, and social services in one place would facilitate enhanced care coordination and follow-up. A single, convenient location would lead to healthier outcomes for patients and lower hospital readmission rates, especially for “high utilizers” of emergency services.

Involvement from organizations like Kitsap Connect, the pilot program focused on uniting the “social service silos” under one umbrella, would be crucial to the success of a community campus. Currently, they are compiling data to evaluate whether this innovative, connected approach provides tangible economic savings. If statistics support their assertion, this social service infrastructure must be incorporated into the community health improvement strategy to ensure long-term gains.

Some experts are concerned smaller hospitals may hinder access for larger, underserved populations; however, being slight in scale allows for considerable flexibility, an essential attribute when serving the unique needs of diverse communities. The only drawback to this plan is that right now micro-hospitals exist only in states without certificate of need (CON) laws, and Washington State has strict CON regulations. Building a micro-hospital in Bremerton will require CON approval, an obstacle that may be challenging, yet not entirely insurmountable. 

Population health strategies, focusing on value over volume, are being touted by industry experts as the next frontier toward achieving improved health outcomes. A Harrison Community Campus is an innovative answer for delivering high quality services in cost-effective manner. Micro-hospitals are a highly successful model, delivering convenient care, closer to home, while being suitably-sized to meet the fluctuating needs of evolving communities. 

Primary care, specialty care, inpatient, and emergency services must be affordable and accessible to everyone.  With careful planning and conservative execution, construction of a community “field of dreams” is feasible and would be a worthwhile investment in our children, our neighbors, and ourselves. If we build it, they will come. 

This article was originally published by the Kitsap Sun Newspaper and can be found here:  http://www.kitsapsun.com/story/opinion/columnists/2017/12/17/could-micro-hospital-work-here/956420001/

Does the CVS-Aetna Merger Condone Segregation in Healthcare?

photo credit: the Economist

Last week, pharmacy giant CVS has agreed to purchase Aetna for an astounding $69 billion dollar sum.  The company allegedly plans to reduce health spending by developing an integrated system touted as “a new front door for health care in America.” This merger is actually an acquisition, entailing transfer of ownership.  The central aim of an acquisition is to increase market share, expand the scope of services provided, and improve financial stability.  CVS hit the jackpot on all three objectives.  While Wall Street investors celebrate, many of us knowledgeable in the delivery of healthcare services are wondering who will bear the responsibility for the patients harmed by this experiment?

Aetna has compiled vast amounts of data from 22 million health plan members.  CVS provides pharmacy benefits management to nearly 90 million consumers.  Together, with 10,000 stores and 1,100-minute clinics already in the CVS network, this acquisition will create a ‘Walmart for Healthcare.’  Applying bulk-purchase business strategies to the sale of merchandise is one thing, while providing healthcare services by ‘trial and error’ to human beings is another matter entirely.  Bypassing physicians to deliver healthcare by protocol categorically jeopardizes patient safety. 

Executives at Aetna-CVS plan to utilize pharmacists and nurses in the evaluation of acute illness and management of chronic disease.  If an insurer, drugstore, and pharmacy benefit manager unite as one, it will usher in an era of medical “segregation,” defined as the isolation or separation of a race, class, or group by enforced or voluntary restriction, by barriers to social intercourse, by separate educational facilities, or by other discriminatory means. 

CVS-Aetna executives are hypothesizing these clinicians working independently can provide “separate but equal” healthcare services at a lower cost than physicians.  There is no scientific evidence their assertion is true or even possible.  Their innovative business model will be, in a word, an experiment on citizens of this nation.  In Brown v. The Board of Education in 1954, the Supreme Court unanimously agreed “separate educational facilities are inherently unequal” and are in violation of the Fourteenth Amendment equal protection clause (“no state… shall deny to any person…the equal protection of the laws.”)   Why is “separate but equal” suddenly acceptable for healthcare?  It is absolutely not.

For example, recently, a mother brought in her 18-month-old with a fever, runny nose, and ear pain.  On examination, he had an ear infection and was prescribed Amoxicillin.  The next evening, he refused oral intake, and developed a rash in his mouth, hands and feet.  The mother took him to a retail clinic after work that evening. “Minute Clinics” are convenient because they accept walk-ins, charge by the visit, and order tests by protocol, as if ordering dessert, a la carte in a restaurant.   

At the retail clinic, a rapid flu test was negative and a rapid streptococcal test was positive.  Using this “information” to guide diagnosis and treatment by protocol, his “Strep Throat infection” in conjunction with a rash was assumed to be Scarlet Fever, which was theorized to be “resistant to Amoxicillin.” The clinician prescribed Omnicef, believing something “stronger” was required for Streptococcal bacteria.

Having regular commercial insurance, the mother returned to my office for medical care when her son continued complaining of ear pain despite the “stronger” antibiotic two days later and his oral lesions continued to multiply.  His exam revealed Herpangina (a variation of the hand, foot, and mouth virus) and his eardrum was now bulging with pus.  I recommended restarting the amoxicillin and for her son drink cool liquids until the oral lesions resolved; the child recovered uneventfully.

Pharmacists and nurses will be thrust into independent roles for which they are ill-equipped to handle; if using this shotgun approach, costs will continue their upward climb.  First, children under two rarely get streptococcal throat infections, so strep tests should not be routinely administered in this age group.  Secondly, symptoms of streptococcal infection are well-defined:  sore throat, fever, swollen lymph nodes, and abdominal pain in the absence of a runny nose and cough.  A positive test in this child indicated they were a carrier which needs no intervention.  Third, scarlet fever looks nothing like herpangina, which is a virus and resolves on its own.  Fourth, Omnicef, at a cost of $150 per course, is not a first, second, or even third-line treatment for Group A Streptococcal infection; the first line choice is amoxicillin, costing less than $5.

If this ill-advised merger between Aetna and CVS proceeds, millions of lives will hang in the balance. This new business model reminds me of the scene from Dickens’ A Christmas Carol, when Ebenezer Scrooge sees the Cratchit family mourning the loss of Tiny Tim.  Research has shown life expectancy is directly proportional to the ratio of primary care physicians available per 100,000 population.  How many children, like Tiny Tim, will be harmed before lawmakers and the public refuse to accept a future devoid of primary care physicians? 

Thankfully, time has a way of revealing truth.  CVS considers having a medical degree to be an “obstacle” to affordable medical care, which they plan to eliminate with “one-stop shopping,” having pharmacists and nurses practicing medicine by protocol.  A segregated, two-tiered healthcare system will ultimately emerge as Aetna members are directed to “Minute Clinics” without access to physicians while those on other commercial insurance plans will see the physician, nurse practitioner, or physician assistant of their choice.  Changing the delivery of healthcare services by circumventing physicians to save money is equivalent to gambling with patients’ lives.  This vertical business model should induce fear and panic in all of us – we should run for our lives, and never look back. 

Honesty, Trust, and Transparency: PA-C and MD

Honesty, Trust, and Transparency

Recently, the New York Times published an article on excessive costs incurred by mid-level providers over-treating benign skin lesions.  According to the piece, more than 15% of biopsies billed to Medicare in 2015 were done by unsupervised PA’s or Nurse Practitioners.  Physicians across the country are becoming concerned mid-levels working independently without proper specialty training.  Dr. Coldiron, a dermatologist, was interviewed by the Times and said, “What’s really going on is these practices…hire a bunch of P.A.’s and nurses and stick them out in clinics on their own. And they’re acting like doctors.”

They are working “like” doctors, yet do not have training equivalent to physicians.  As a pediatrician, I have written about a missed diagnosis of an infant by an unscrupulous midlevel provider who embellished his pediatric expertise.  This past summer, astute physician colleagues came across an independent physician assistant, Christie Kidd, PA-C, boldly referring to herself as a “dermatologist.”  Her receptionist answers the phone by saying “Kidd Dermatology.”

The Doctors, a daytime talk show, accurately referred to Ms. Kidd on a May 7, 2015 segment as a “skin care specialist.”  However, beauty magazines are not held to the same high standard; the dailymail.com, a publication in the UK, captioned a picture of “Dr. Christie Kidd”, as the “go-to MD practicing in Beverly Hills.”  The article shared how Ms. Kidd treats the Kardashian-Jenner family, “helping them to look luminous in their no-make-up selfies.”  While most of us cannot grasp the distress caused by not appearing luminous in no-makeup-selfies, this is significantly concerning for Kendall Jenner.  At the tender age of 21, she inaccurately referred to Ms. Kidd as her “life-changing dermatologist.”  Cosmopolitan continues the charade, publishing an article on the Jenner family “dermatologist.” 

It astounds me how some medical professionals can contentedly live in the gray, south of brutal honesty, yet somewhere north of deceit.  Until a few months ago, the Kidd Dermatology website erroneously listed her educational background as having graduated from the USC School of Medicine with honors and made no mention of her supervising physician.  It was later modified to reflect she graduated from the Physician Assistant program at USC. 

There are laws mandating physicians display diplomas and certifications prominently in the interest of transparency.  According to Title 16, California Code of Regulations sections 1399.540 through 1399.546, a PA in “independent” practice is limited to the scope of his/her supervising physician by law.  A board-certified plastic surgeon is supervising “skin specialist” Christie Kidd, PA-C, not a dermatologist.  The website of the plastic surgeon states, “Trust only a Board-Certified Plastic Surgeon;” which in my opinion, seems astonishingly tongue-in-cheek.   He may believe treating bullous pemphigoid disease is just another day in the life of plastic surgeons everywhere, but plastic surgery is a far cry from practicing dermatology and vice versa.  

credit: dailymail.co.uk 

When asked about this, the Public Affairs Manager, Cassandra Hockenson, at the Medical Board of California responded“there is not a huge difference between plastic surgery and dermatology.”  She suggested contacting the Physicians’ Assistant Board for the State of California instead.  She kept repeating that the supervising plastic surgeon had no complaints against him.  I learned two important lessons from contacting the Medical Board of California:  1) Without complaints, a physician can supervise midlevel providers in any specialty they choose, and 2) while required by law to supervise mid-level providers, the safety of patients is not a high priority for the Medical Board of California. 

At a minimum, physicians complete four years of college, four of medical school, and between 3-7 years in residency.  The years of education required for obtaining a PA degree are considerably fewer than that of an MD.  For all intents and purposes, Christie Kidd, PA-C is running an independent dermatology practice directly under the nose of an apathetic California State Medical Board indifferent to regulations.  PA’s can be fined and disciplined by their own board for misrepresentation, however, her “supervising” physician is, in fact, also out of compliance with the law.

While not all celebrities understand the difference in education between an MD or PA, mid-level providers and their supervising physicians should not be immune to the rules and regulations.  Honesty, trust, and transparency are ideals essential to the medical profession.  Physicians are held accountable for the health and safety of the patients we serve.  Google Business modified the Kidd Dermatology listing from “Dermatologist” to “Medical Spa.”  The unsinkable Christie Kidd struck a compromise, settling on the designation as a “skin care clinic.”  Carpe Diem, Ms. Kidd, Carpe Diem.