Food & Health Archive

At This Year’s Conventions, I’ll Be Watching the Doctors

Monday, September 3rd, 2012

Lately, when the topic of elections comes up, and someone casually asks, “When do the conventions start?” I find myself rattling off dates — “The Republican Convention starts this Monday, August 27th, in Tampa.” To the surprise of friends and acquaintances I could go on, like I was rattling off my kids’ birthdays. I’m not known for my political wonkishness or even my ability to manage my own calendar. But this convention season has special meaning for me: I’ll be watching and cheering the Patients Over Politics Bus Tour organized by Doctors for America, a grassroots group of 15,000 physicians and medical students.

Doctors have traditionally been an apolitical lot, staying “above” partisan politics and carrying out their own solitary idealism under the radar screen — quietly seeing patients who can’t pay and serving patients’ interests above their own. The growing complexity of modern medicine and the alarming rise of corporate influence on our health care over the past decade has changed all that. Doctors realize that they can no longer protect their patients’ interest one encounter at a time. We are organizing, educating the public, and making our voices heard.

The Doctors For America Bus Tour is an example of this type of patient-centered activism. Doctors and their supporters will be rallying at the GOP Convention, meeting with politicians, and carrying thousands of signatures of support. The message : “We believe in an America where everyone has quality, affordable health care and where doctors and the public work together to build a health care system that works for all.” Over the next week they will steadily make their way north, stopping at five cities along the way to hold informational town halls and provide free health screening clinics. On September 5th the DFA bus will arrive in Charlotte, NC, where the doctors will again bring our message loud and clear to the Democratic National Convention.

Politicians whose purposes it serves to dismiss such activity will shrug this off as the voice of a noisy socialist minority. How often have you heard from the status quo crowd that doctors don’t like Obamacare? That myth vacillates between urban legend and baldface lie. Doctors support of health care reform in general and the Affordable Care Act in particular is a matter of record, and certainly not limited to progressive activists. Who officially and actively endorses the ACA? The American Medical Association for starts — the largest physician organization in the country. Then there’s my personal favorite, the American Academy of Pediatrics. The list also includes the American College of Physicians, the American Academy of Family Physicians, the American Congress of Obstetricians and Gynecologists, the American Psychiatric Association, the American Osteopathic Association, and the American Academy of Cardiology, among others. We work in private practices, community health centers, and in academics. We are seasoned clinicians and passionate students, primary care docs and health policy experts. We are pragmatic as well as idealistic, both credible and trustworthy.

Doctors for America will indeed be making noise at the conventions. But they are not alone. For every one, determined white-coated doctor you get a glimpse at through a convention lens, know that there are thousands more of us across the country cheering him or her on. And we will continue to cheer, through the election season and beyond: “Patients over politics! Move health reform forward!”

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

No turning back on R.I. health reform

Tuesday, June 26th, 2012

It has been two years since the rollout of the Affordable Care Act, and almost half of its provisions are already in effect. For example, two years has been enough time to establish protective measures that prevent insurance companies from denying coverage for pre-existing conditions, to let young people remain on their parents’ plans through age 26, and to provide annual preventive health visits and screening to an insured patients without added out-of-pocket expense.

It has also been enough time for foes of the law to bring their legal challenges to the U.S. Supreme Court, which is expected to rule as early as this week on the constitutionality of individual mandates, interstate insurance exchanges and federal involvement in Medicaid expansion. But however the court rules, there is no turning back on health-care reform.

Election-year rhetoric notwithstanding, slashing such existing programs as Medicare and Medicaid is not a reasonable alternative to substantive reform. That’s like deciding not to fix a leaky roof so that your household budget looks more flush. You’ll just keep buying buckets until you finally have to take out a loan to replace the whole rotten roof. With health care as with roofs, it’s about maintenance and prevention.

This is the ACA’s track record so far in the Ocean State.

As of 2011, over 7,500 young people in Rhode Island (and over 2.6 million nationally) who previously would have had no way to afford health insurance, through employers or otherwise, were able to remain enrolled in their parents’ plans. That is thousands fewer people clogging emergency rooms because they had no access to timely, affordable primary care.

In 2010 alone, more than 15,000 Rhode Island Medicare recipients who fell into the prescription-drug “doughnut hole” received rebates to help with the costs, and in 2011 almost the same number of Rhode Island seniors got 50 percent discounts on prescriptions when they reached the doughnut hole, saving them more than $8 million.

In 2011 nearly 130,000 Rhode Island Medicare recipients, and another 200,000 of us on private insurance plans, received free preventive services, including wellness exams, mammograms and colonoscopies, with no cost-sharing. People who were delaying these services because they hadn’t met their deductibles or their insurance didn’t cover them now have fewer obstacles to these life-saving, cost-effective screens.

The ACA put into place protections against unreasonable premium-rate hikes by insurers, and Rhode Island has received $4.7 million to fight these kinds of practices. This is only a temporizing measure — plugging up those leaks until we have more rational payment systems in place — but it offers some immediate relief to employers and individuals struggling with rising premiums.

The ACA has removed lifetime limits on health benefits to those with chronic illness. No longer do seriously ill people have to watch in horror as their benefits dry up. So far 374,000 Rhode Islanders have come under this protection, including 89,000 children.    Rhode Island has received $64.7 million in grants under the ACA to develop and implement state insurance exchanges that will let individuals and employers shop around for the most affordable coverage.    Some $14 million has gone to expand Rhode Island’s community-health centers, and there have been grants to our state for school-based health centers, Medicare outreach, maternal and early-childhood home visits, and other programs that promote wellness.

Look to these kinds of settings for the sort of innovations that will move our health-care system into the future: emphasis on prevention and health maintenance, payment models that incentivize quality of outcome rather than quantity of procedures, and a broad commitment to cost-effectiveness.

Thanks to the ACA, we are all getting our first glimpse at what smart, cost-effective health care looks like when it puts the needs of patients first. But there is so much more that we need to do. Regardless of how the Supreme Court rules, health-care reform is already working. We simply cannot afford to turn back.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

The Contraception Controversy as Seen Through a Doctor’s Lens

Friday, March 2nd, 2012

Your doctor’s exam room is getting overcrowded. Modern U.S. health care means that, like it or not, you and your physician are sharing that once private space with an insurance executive constantly hissing in your doctor’s ears to move it along. You are also sharing it with pharmaceutical marketers, lobbyists from the food industry… special interest groups of every stripe.

Now move over and make room for one more interested party: your employer.

Ever since the HHS ruling last month that employers cannot exclude contraception from the preventive services that their insurance plan covers, the country has worked itself up into a fever of self-righteous indignation, framing the controversy around women’s rights and religious freedom, and magnifying it with political posturing. As a doctor, I see it through a different lens. I see the primary symptom of our dysfunctional health care system as being the unrelenting erosion of the doctor-patient relationship — a relationship that is central to health and healing. And I see this latest distraction from meaningful health care reform — an employer’s wish to define what kinds of access to health care are appropriate for his employees — as just one more assault on that very intimate and healing dynamic. Now, in addition to trying to shut out the noise from all the parties that want to make a profit from your visit, doctors now have to consider: “So what does your employer think of all this?”

How many more parties are we willing to invite into the therapeutic conversations we have with our health care professionals? If a CEO of a major company is an anti-vaccine activist, can she refuse to let her company’s health plan cover routine immunizations for children, as a matter of conscience? Could an animal rights organization like PETA refuse to allow coverage of chemotherapy regimens that relied on animal research, based on that group’s deeply held convictions? This week the governor of Virginia called for legislation that would require women to have vaginal ultrasounds before undergoing an abortion. It used to be that you had to go to medical school before ordering an invasive medical test; now apparently all you need is political ambition and a microphone. In our current divisive political climate, the conversation about our health care has become less and less about what is happening between doctor and patient, and more about what individuals or groups want for themselves — and don’t want for the rest of us.

We will know that our health care system is functioning well when the one overriding question that drowns out all the other noise in any doctor-patient encounter is this: What is best for my patient? We can measure our health care system — and our society as a whole — by how hard we make it for health professionals to ask and answer that fundamental question, whether it be due to punitive financial pressure, marketing strategies or political agendas. Cost effective health care can only result from sound health policy. The role of political leaders is to recognize and implement sound policy, not define it. Meaningful health care reform will require that all the self-serving noisemakers, from pandering politicians to profiteers, and yes, even people of deeply felt but not widely held convictions, get out and stay out of the exam room. If we fail to do this, the doctor and the patient will end up having the smallest voices in the room.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

Modern Pediatrics Needs Health Care to Evolve

Tuesday, November 1st, 2011

Why can’t the United States have a smarter health care system?

That was the frustrating question that kept poking through my train of thought as I read a study from the most recent issue of Pediatrics, the official journal of the American Academy of Pediatrics (AAP). The study, out of UCLA, examined the association between length of well-child visits and quality of the visits, including things like developmental screening and what doctors call anticipatory guidance (”Is Suzy using a car seat?”). No big surprise that the longer the duration of the well-child visit, the greater the likelihood that the visit adhered to recommended guidelines.

Unfortunately one-third of visits were reported as being less than 10 minutes in duration; these occurred to a greater degree in private practice. Longer visits of 20 minutes or more made up 20 percent of the encounters and were more likely to occur in community health centers. The big winners in the pinch for time? Guidance on immunizations and breastfeeding were offered in 80 percent of even the shortest visits. The biggest loser — developmental assessments, which don’t even achieve a mediocre occurrence of 70 percent until we pass the 20-minute mark for visit duration.

What’s behind all this? A profound disconnect between our medical resources and our health care delivery. Nowhere has modern pediatric care evolved more dramatically than in the arena of well-child care and preventive medicine. What has not evolved along with our scope of knowledge is our delivery system. Our fee-for-service approach to health care dictates that procedures and tests pay well while addressing a child’s emotional problem gets a doctor little more than a backed up waiting room.

Whether we think about it or not, the notion that health insurance companies and the pharmaceutical industry shape medical practice — and our collective health — through their policies, marketing and aggressive lobbying is one that is embedded in our health care culture. The result is a lopsided distribution of health care that overmedicalizes the well-insured while undertreating the underinsured. Consider that a whopping 25 percent of U.S. children are on chronic medications while, according to this UCLA study, half the children in pediatric practice are not receiving basic screening and advice.

The obsolete business models that the health care industries rely on are like the tyrannosaurus rex in the room, emphasizing expensive, short term productivity rather than cost-effective long term quality, while cognitive care — a high level of skill and expertise delivered face to face in a personal manner — is in danger of becoming extinct. The scope and challenges of our health grow ever more complex, and chronic conditions like obesity and diabetes overtake acute threats. Yet we keep trying to squeeze our health care delivery into the model we used back when you only went to a doctor to treat your pneumonia, or to have a farm implement removed from your foot.

It is not surprising that community health centers are associated with longer, higher quality well-child visits. The doctors are salaried, which means they are somewhat insulated from the array of financial disincentives that currently infuse primary care, like the need for rapid patient turnover. The centers are also likely to utilize a more rational division of labor, so that every issue doesn’t immediately make its way to the most expensive professional in the room (and the one with the prescription pad) simply because that is the only person we know how to par for the visit. Nurses at all levels of skill are used for a wider scope of encounters, and there are often ancillary resources — nutritional and mental health services for example — that expand the kinds of care the patient receives, approaching the ideal of a comprehensive medical home for all patients. It is also not surprising that the practice settings that are successfully evolving into medical homes are largely publicly funded. By their very nature, they put patients’ best interest above profit, and have a vested interest in long term outcomes as opposed to short term productivity.

So back to the study from UCLA. We know what every child should receive in the way of well-child care, and we know that quality primary care saves money in the long run. We have professionals at all levels of training and pay scales capable of delivering high quality care. We have incredibly skilled and dedicated pediatricians who can coordinate this kind of teamwork. So why are we wasting our time arguing about how to pay for obsolete delivery models and payment systems? Why not design a system that offers what we are capable of, and saves us money in the long run.

We all know what is standing in our way: Profit. Special interest. Self-serving politics. That is why we need to keep asking the fundamental question: Why can’t we have a smarter health care system?

This article was originally published on The Huffington Post, where you can read the original and comment.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

Why Medicaid Cuts Harm Us All

Thursday, August 4th, 2011

I usually write about health care reform from a pediatrician’s viewpoint, but what grabbed my attention recently was a story my husband, Randy, told me about an adult in his practice — a patient on Medicaid.

Randy is a neurologist in a private practice and Medicaid patients come from every corner of Rhode Island to see him. They make this cumbersome pilgrimage because he is a member of a dying breed: Randy still accepts Medicaid. He does this for $27.

That is not a copay; that is the total per patient reimbursement he gets from the state. It is clearly not a good deal for Randy, who will start losing money about 10 minutes into the visit. And it is often not a good deal for his patients, who may have to travel a very circuitous route to receive simple, appropriate care. But it is also a terrible deal for taxpayers. The American taxpayer needs to understand how this Medicaid patient ended up in Randy’s office.

Randy’s patient was a slightly overweight, balding man who would hardly stand out in a crowd if it weren’t for his obvious reliance on a medical escort to gently help him move about and answer questions. His speech was clear but simple, and he stayed on message: “My toe hurts.” They had driven about 75 miles to deliver this message.

Randy spoke directly to his new patient, slowly teasing essential information out of a person whose most reliable verbal tools were “yes” and “no.” This unhappy fellow had had a sore toe for several days and was trying not to bear weight on it. The only symptom the staff at his group home noticed was that he seemed to be losing his balance. One morning he was so distracted by the discomfort that he stumbled in the shower, causing a minor cut on the toe. They were not surprised to see that the injured toe was swollen and tender.

Medicaid, like every other public and private payment program in our fee for service (FFS) system is based on a model of productivity — high patient volume — rather than quality. Fee schedules provided by Rhode Island’s Department of Human Services indicate that a primary doc could have expected a reimbursement of $20.50 if she saw this Medicaid patient in her office. Physicians who accept Medicaid often feel pressured to increase patient turnover by speed-reading records, keeping conversation to a minimum and quickly offering a prescription or tests.

If there is any reasonable way to put an “urgent” slant on the situation, the primary care doctor can completely avoid a money-losing office visit by referring the patient to an emergency room. In this case, “loss of balance, difficulty walking” provided the admission ticket for this patient to be referred directly to a local ER. From the primary doc’s perspective, the underinsured patient will still get medical attention and the local hospital, rather than the doctor, will now be absorbing the cost.

It is the very nature of an urgent care setting to emphasize quick, decisive action over conversation — especially with a patient who is slow of thought and speech. This man’s ER encounter ($92 for the provider plus “institutional” fees for the hospital) consisted of little more than a hurried doctor considering the reason for referral and ordering a CT scan of the head ($156) to rule out an intracranial cause, like a stroke or tumor, for his loss of balance. With that test normal, the patient was referred to a neurologist to sort out the strange mystery of why he could not walk.

Two weeks later, sitting face to face with this man, Randy slowly, methodically pieced together this story; what it lacked in detail it more than made up for in focus: the quiet man who would not walk was not concerned that he was losing his balance or even that he fell in the shower. His toe just really hurt, and it had been hurting for what he felt was a very long time.

The records Randy received were flimsy, but he noticed that the patient was on allopurinol, a treatment for gout. As any first year medical student can tell you, gout is a very painful form of arthritis that is caused by high uric acid levels in the blood that deposit as crystals in the joint, causing pain that has been described as a fiery volcano in the … you guessed it.

The most common site of gouty arthritis is the big toe. Randy stooped to help the wincing patient off with his tennis shoe and tube sock. There, where a normal toe should have been, was a swollen, angry Mt. Vesuvius.

A flare-up of gout should have been promptly managed by a properly reimbursed primary care physician. Instead, the total cost erupted as steadily as the condition and included three weeks of unnecessary pain, a whopping dose of radiation and expensive medical encounters that accomplished nothing. Finally, there is the cost that is at the heart of the taxpayer’s problem: the cost to Randy that the $27 did not cover. This unfunded cost is what drives the expensive game of medical hot potato we play with underinsured patients.

Our current FFS system, which rewards productivity, tests and procedures rather than quality, is wasteful and ineffective at every step for all patients, but is particularly harsh for Medicaid patients. We have to move out of our narrow FFS mindset to appreciate what other models of care — like medical homes and federally funded community health centers — have to offer. We — the sweet, slow-thinking man with the fat toe, the new mother with lots of questions, the frail, worried senior with a handbag full of medications, the overweight child, the conscientious physician, the small business owner, and yes, the U.S. taxpayer — desperately need a smarter, more cost-effective healthcare system. Simply cutting programs like Medicaid is like putting a Band-Aid on a gouty toe.

Reposted from The Huffington Post, where you can read the original and comment.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

Rethinking Health Care Spending

Wednesday, June 15th, 2011

Recent attempts to fundamentally alter Medicare — and the public outcry that followed — provide a working template for how to view broader health care reform. Everyone agrees that our healthcare system — and Medicare in particular — is financially unsustainable. Any step we take to address this requires a choice to either cut services or be smarter about the way we deliver them.

Since health care discussions can quickly get bogged down with complex terminology and political rhetoric, let’s consider instead how such a decision process plays out on a simpler landscape: a family’s food budget.

Picture the Ryan family of four: smart, responsible and hard working. They want to live well, but worry that their monthly food budget has skyrocketed out of control. They rely a lot on the high-end grocery store down the street, where they can pick up prepared filet of sole francaise in butter sauce – We really should eat more fish! — on the way home from work. A couple of times a week they stop somewhere for pizza or burgers, and the kids just love going to one of those national chains of neighborhood restaurants after soccer games. As for portion size — well more is always a better deal, isn’t it?

But the cost is adding up. And that’s not the only problem. Everyone’s putting on a few extra pounds, the nutritional content of the prepared food (when they are able to determine it) is far from ideal and, more subtle but just as important, taking personal responsibility for their nutrition has devolved into a search for comfort and convenience.

The Ryans’ solution to this budget catastrophe? Keep doing the same thing, only less of it. That may show a certain lack of imagination, but does offer an appealing ring of righteous self-discipline. They cut back to eating just breakfast and dinner.

“Get over it, kids; lunch is for wimps.”
They buy the fancy filets just for the adults.
“Mmmmm. Frozen fish sticks are yummy.”
Each family member gets a one-dollar coupon to bring to the fast food joint.
If you want more than fries, Suzy, better bring your piggy bank. (This will make Suzy a savvier consumer.)
They insist to the restaurant manager that they are only willing to pay half the price of the menu items.
What do you mean you won’t seat us?

Sure enough, the food budget shrinks. Everyone’s unhappy and the family’s nutrition has only gotten worse, but hey, mission accomplished!

Now picture the Ryan family’s neighbors who live just across the street — another busy family of four who have developed similar habits and attitudes. They, too, recognize that they need to cut back their food spending significantly. They also recognize that, just as importantly, they need to eat better. So they decide to buy basic foods that have no hidden ingredients and do their own simple preparation and cooking, including packing their own lunches. This family serves plenty of food, but not in excess. Why in the world would they? They plan ahead for meals on busy nights. Everyone has to help out.
“Aw, Mom. Couldn’t we just color on placemats while you guys have a drink?”

Conversation starts to flow in a more natural way, as the social and practical aspects of mealtime blend. Saving money for this family, it turns out, also means eating and living better. And they can still budget for those special occasions that call for a higher priced meal. Who would argue against such a plan? It turns out that the entire food industry lobby and the politicians they fund would.

What does the Ryan family’s approach to a food budget teach us about healthcare spending? Think about less primary services, while still funding overpriced and unnecessary tests and procedures. Think vouchers that shift the burden of cost to the patient, and a lowering of physician reimbursements that only limits access and delays treatment. Think short-term savings and long-term complications. Measures of quality don’t even factor into the equation.

What happens when we cross the street to the Ryans’ neighbors? Imagine us using our limited health care dollars more wisely: payment systems that rely on specific measures of quality and outcome, that incentivize good primary care instead of rapid patient turnover or unnecessary procedures. Think of strategies like medical homes and accountable care organizations, where bundled payments encourage teamwork and coordinated care. Think about the Affordable Care Act. It’s not perfect, but it at least moves us across the street.

This is our choice now, not only for Medicare but also for every aspect of healthcare spending: less or smarter. Less will sound especially good to people who believe that cuts will only apply to others.

Could you pass the ketchup please? You sure won’t be needing it.

For the more sensible among us, a strategy for more cost-effective healthcare is the smarter approach.

Read the original post at HuffingtonPost here.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere.

Healthcare Reform: Doctors Shaping the Narrative

Sunday, May 15th, 2011

With the roll out of the Affordable Care Act and perhaps more significantly the approach of the 2012 elections, public discussions of healthcare reform has been drowning in an alphabet soup of ACOs (not to be confused with the above ACA), CMS, SCHIP, and RUVs, just to name a few. The challenge is twofold. Most of these plans/systems/agencies deal with how to better pay for a seriously flawed system. But just as significantly, this crazy swirl of acronyms can make the whole topic of health care seem too complicated and inaccessible for most of us. Somebody call a doctor.

Doctors and other health care providers are carrying around a powerful tool in their little black bags: stories. We call them anecdotes. Most people consider doctors to be wise, trustworthy storytellers, and our simple, unsensational narratives can get to the heart of even the most complicated topic. Sure we may have to disguise the characters, and maybe leave out the part about the purulent drainage or the philandering husband, but our everyday stories brim with simple truths about human suffering, and about the obstacles we face everyday in relieving that suffering. They can provide something that the nation badly needs right now – the chance to drown out the politicians and pundits so we that we can focus on the essential questions. Doctors’ stories matter, and we should find ways to share them in a way that can shape the narrative of health care reform.

One simple story that comes to mind for me involves the worrisome role I had in the evaluation and treatment of serious mood disorders. The story of how I was placed in that role is an echo of many of the crucial yet neglected questions in our national healthcare debate, and my unassuming patient, Marissa, can help focus our attention.

Fifteen-year-old Marissa was brought unwillingly to the office by her mother, who was concerned that Marissa was depressed. Mildly overweight, sullen expression, stringy hair falling in her eyes, she sat slumped against the wall.

“I don’t know why I’m here. Go ask my mother. She’s the one who made me come.” Her tone is more petulant than defiant.

“I think it would be better if you could tell me what’s been going on.”

My preliminary fact finding revealed how stupid mom was, how lame step-dad was, what a waste of time school was, what jerks all the rest of the kids were. Marissa grew slightly more animated as we talked, shrugging or waving her hand dismissively now and then. I slowly teased out more details – who’s fighting at home, who’s drinking, what substances Marissa herself uses, her sexual experiences, just who her friends are, what she likes to do in her free time. We slowly achieved mutual eye contact, exchanged facial expressions. I tried really hard not to look at my watch. This was the kind of work that primary care physicians do well, but it can take time, and conversation between doctor and patient is the most undervalued commodity in our health insurance system. After the first fifteen or twenty minutes of the visit, it was my dime. But the crushing economics of primary care practice would have to be ignored for the moment.

“Do you ever feel sad?”

Marissa looked down at the floor with great concentration and grew completely still, almost frozen, trying to will herself not to cry. Silent streams of tears rolling down her cheeks finally betrayed her. I handed her a box of tissues and she pulled one out, waving it like the flag of surrender that it was.

“I just don’t know what to do,” she whispered.

She wasn’t the only one.

I spent four weeks out of my three-year specialty pediatric training working in child psychiatry, and this involved mostly talk therapy. (Compare this to the 6 months of round-the- clock training I spent in the newborn intensive care unit.) Yet he number of patients that pediatricians are called upon to evaluate and treat for serious mental and behavioral problems has been growing steadily, as insurance coverage has greatly limited the availability of outpatient psychiatrists and psychologists to young patients, and turns any encounter other than a pill prescription into financial loss for the physician. Here, as in so many areas of health care, health insurers’ payment strategies and a lack of informed public policy, not specialty training or best clinical practice, determine what a physician is expected to do.

Marissa needed help; that much I knew. But how much help? How urgently? We called Mom in to join us, and I explained that we needed to set Marissa up with a therapist. I knew Mom’s next question before she asked it.

“Will insurance cover that?”

I advised her to check with her insurance company and see which therapists it would cover and for how many visits. Unfortunately, none of the ones I personally knew and had confidence in accepted private insurance; the reimbursement was too spotty and too small. A psychiatrist referral was out of the question – more healthcare economics. A child has to be engaged in pretty destructive behavior, before her insurance will cover that. So Marissa and her parents would have to weigh everything in the balance and go with what they could afford out of pocket. I hoped they wouldn’t just give up and try their luck with herbal teas.

The therapist that Marissa’s family chose, a non-physician, wrote a letter to me three weeks later, recommending a trial of antidepressants and continued therapy, which her family could not afford.

This poses a serious dilemma for many physicians, and we need to draw patients’ attention to this. A 2004 survey of primary care doctors revealed that only a tiny percentage, 16%, felt comfortable in prescribing antidepressants, but a whopping 72% actually did. There is little evidence that this disparity has lessened. Meanwhile, over 16 million US children are currently on antidepressants or are other antipsychotics as the robust pharmaceutical industry spends hundreds of millions of dollars annually marketing these classes of drugs and health insurers continue to reward only quick fixes. I wrote the prescription, full of worry and resentment, feeling like I was flying by the seat of my pants. I scheduled Marissa for close follow-up.

This is not the stuff of TV dramas or medical bestsellers. But if there is one thing that doctors are extraordinarily good at, it is taking complicated issues and framing them in simple, clear ways that patients can understand and relate to, even when they are worried or frightened. We do it everyday. Lets take that skill beyond the exam room and into the arena of health care reform. Lets help focus the attention on questions about what a smart health care system would deliver, and to whom. Lets get everyone thinking about how much they want health insurers to shape clinical practice, or to what extent drug therapies should be driven by profit. I would stack up one good doctor story against a 1000 pages of legislation any day of the week. Its time.

Read the original post on Barkingdoc’s Blog.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere, releasing in January 2011.

Healthcare Reform: We Need to Reframe the Questions

Wednesday, March 23rd, 2011

One year after passage of the Patient Protection and Affordable Care Act, the debate roars on, in Congress and everywhere else. And these debates often revolve around a big question, even when it is left unspoken or implied: Is health care a basic human right?

In 1990 I made a quantum leap from practicing in the Navy’s single-payer, universal-coverage health care system into civilian pediatrics. Having been insulated from the profit end of health care for almost a decade, the move to the U.S. healthcare system of haves and have-nots turned out to be a culture shock.

My first civilian job was at Wood River Community Health Center in Rhode Island, and one of my first patients was Jennie, a three-month-old who had been placed in foster care because of her mother’s drug addiction. Being in foster care meant being on Medicaid.

Poor children on Medicaid have several strikes against them. Not only will a provider often lose money by seeing them, but these children are on Medicaid because they are special needs patients, or in foster care because of abuse and neglect, or from impoverished circumstances that have put them at risk of malnourishment, or exposure to lead or smoke. These are the most labor-intensive patients in a pediatric practice. How well they are cared for is the measure not only of a pediatrician, but also of a society.

By the foster mother’s description, Jennie had a generalized seizure – a convulsion – at home. Her physical exam was completely normal. I called the only pediatric neurologist in the state at that time and faster than I could say “foster care” he understood the kind of reimbursement he could expect. He insisted he did not need to see the child or do any tests. I was shocked. No EEG? No imaging studies? This was the same doctor who routinely performed unnecessary but very expensive EEG’s on every insured headache patient he saw.

“What’s the point?” he challenged. “The mother is a drug addict; this was a withdrawal seizure. You don’t need to rule anything else out. Load her up on phenobarbital.” Phenobarbital is a sedating drug that back then was commonly used to treat seizures in children, but we usually looked harder to document and find a cause for the seizure before we settled into therapy – especially in a three-month-old.

I was angry and backed into a corner. I told Dr. Do-Little that if he would not see her then I would refer her to the ER at the Rhode Island Hospital, and let them contact him. He was on the staff there and would have no choice but to respond. Do-Little begrudgingly relented but got his way in the end. He was rude to the foster mother, and did only the most cursory exam on the child. He started medication without doing any tests.

Practicing pediatrics in the Navy meant I always had the resources to deliver state-of-the-art care – and no excuses not to. But here, no matter how strongly I felt that my patient should receive a certain service, I might not be able to get it for her because of her inability to pay. It was the first time in my medical career that I knew what a patient needed, and had to settle for something less.

Did Jennie deserve better? Did she have the right to the same health care as, say, my daughter? These are awfully solemn questions for public discourse, and are likely to keep us running in circles through a haze of abstractions and ideology. We need to think less like judge and jury over who deserves health care, and more like stewards.

As a nation, even in this recession, we can claim remarkable prosperity relative to the rest of the world. (Nowhere is this truer, incidentally, than in the highly profitable private health care industries.) More inspiring, however, are the brilliant medical advances that continue to emerge from our academic centers and teaching hospitals. This drive for new knowledge and innovation in the pursuit of health and healing is our real treasure – America at its finest. It has always been the best in people, not greed or profit, that has driven meaningful medical progress.

Yet the system isn’t working for us. We are spending too much, and getting too little. We need to be better stewards of our medical riches. We need to see ourselves as stewards, and ask questions from that perspective, rather than who deserves what slice of the pie.

So let’s redirect: Given our considerable medical resources, what moral responsibility do we all share in the fair, prudent, and just allocation of these resources. From this position of stewardship, we are likely to ask more practical questions: What would a smart, compassionate, affordable health care system, released from the stranglehold of special interest, look like? What preventative and therapeutic services should it deliver? What responsibility does the individual hold? Once we have a clearer picture of what we expect of ourselves and the system, we can turn to how we can make it affordable. Stewardship gives us direction and purpose. If we can tune out the noisy rabble-rousers, reframe our questions, and commit to responsible conversation that is grounded in our own common sense and decency, I believe we would find much common ground, and make a lot more progress towards a just and cost-effective health care system.

Read the original post on Barkingdoc’s Blog.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere, releasing in January 2011.

Little Pharma: The Medication of U.S. Children

Monday, January 3rd, 2011

The Wall Street Journal reported this week that a study of prescription patterns in 2009, conducted by IMS Health, showed that 25% of children in the US were on regular medication.

IMS Health is a firm that provides “marketing intelligence” to pharmaceutical companies. The firm’s job is to keep the $800 billion per year global pharmaceutical industry on a continued pattern of growth.  Hopefully these consultants accomplished something quite different this week. Hopefully they provided our citizens with an overdue wake-up call.

One in four children in the U.S. are on chronic prescription medications.  And this doesn’t even include all the prescriptions we write to treat acute illness, or use of over-the-counter products. It is an astounding number.  We either have the sickest pediatric population in the world, or there is something very wrong with the way therapies are driven in our health care system.

The WSJ article goes on to discuss some very significant concerns about the situation – like how difficult it is to run clinical studies on children, and how much of our pharmaceutical data – including dosing and side effects – is drawn from adult populations and applied to children (fingers crossed!)  These are serious concerns to be sure, but it’s a modern version of “The Emperor’s New Clothes.”  Those of us on the sideline are worrying if the emperor’s hat clashes with his shoes, when what we should really be paying attention to – and shouting about – is the fact that Good lord, he’s naked!

One in four children in the U.S. are on chronic medications!

According to IMS Health data, forty-five million children are on asthma medications, twenty-four million are on ADHD medications, almost ten million are on antidepressants with another six and a half million on other antipsychotics.  Then there are the antihypertensives, the sleep aids, the medications for type II diabetes and high cholesterol, and on and on.

Are the conditions these medications are designed for like ADHD and bipolar disorders real?  Absolutely. Are our diagnostic criteria usually clear and well established?  No.

Is the scientific information that doctors rely on for diagnosis and treatment free of bias and conflict of interest?  Absolutely not.

Do our third party insurers reimburse physicians and psychologists in such a manner that mood disorders, attentional problems and other conditions in the psychoeducational realm are being evaluated and managed by the most appropriate professionals?  The answer, again, is too often no.

Some of these children are certainly benefiting from long term medication. Optimal asthma control, for instance, can be life changing for a child. But over the broad range of approximately one hundred million children taking daily medication in this country, do we have a handle on the degree to which the benefits of a prescription outweigh the risks, or the medication’s effectiveness compared to meaningful nonpharmaceutical intervention?  No.

No.  Absolutely not. No.  No!

Our system of private, fee-for-service insurance is basically a business model that focuses on the top of the health care pyramid (the doctor) and pays for quick fixes (prescriptions) with immediately observable (short term) results.   That works great for bacterial pneumonia; not so much for a kid bouncing off the walls, or gaining too much weight, or who is sad.  Nowhere is this more glaring than in the realm of mental health.

Health insurance companies have determined, by virtue of their reimbursement strategies, that the work of treating serious mental illness would shift to primary care providers. A recent study by the AAP predicts that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice1. To put this trend in perspective, an earlier study that appeared in the journal “Pediatrics” revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did2.  If they don’t, who will?  This is just one example of the growing disconnect between rational medical practice and the way we deliver healthcare.  Furthermore, where do both pediatricians and psychiatrists get most of their information about these psychotropic medications that are now flying off prescription pads?  The pharmaceutical companies that produce them, through the hundreds of millions of dollars they spend each year on marketing and the clinical studies they fund.  The insurers and pharmaceutical companies aren’t necessarily the bad guys here. They are doing what they are tasked to do: run a business.

What should be driving our health care? Should it be evidenced-based medical science, wrapped up in a little common sense and kept at a distance from special interest? Should the emphasis be on clinical effectiveness rather than customer service? Should the financial incentives foster improved longterm health for all of us rather than enhanced quarterly profits? If that’s what we want than we need to redesign the system from the bottom up.

If we are to frame meaningful health care debate in this country, we have to look at the consequences of doing business-as-usual.  This data from the pharmaceutical industry illustrating the degree to which to we medicate our children underscores the ways our health care system has gone off track. We need to acknowledge that naked truth.

One in four children in the U.S. are on chronic medications.


1.  AAP department of Community and specialty Pediatrics. “Resources Help Primary Care Clinicians Address Mental Health Concerns.” AAP News 31 (7) 34

2.  Jerry L. Rushton, et al. “Pediatrician and Family Physician Prescription of Selective Serotonin Reuptake Inhibitors.” Pediatrics 105 (6): e82

Read the original article on Barkingdoc’s Blog.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere, releasing in January 2011.

Finger-Wagging Doesn’t Work for Societal Ills

Sunday, December 12th, 2010

The following is my response to the Huffington blog post:

Bravo for your clarity on the preventable causes of chronic disease, and the economic toll it takes on our society. Its a good starting point. I applaud the concept of a health coach, rather than a health “provider.­” In fact I believe that should become the predominan­t theme of primary care medicine, placing responsibi­lity and control back with the patient. But the causal relationsh­ips you lay out are a little too simplified­. Asians smoke far more than we do, and many Europeans would laugh at our animal fat phobia, yet as you point out, they are less plagued by many chronic diseases than we are. The reasons we are in this mess are complex and numerous, ranging from the political arena and its misguided pandering to special food interests, to social norms and our affinity for suburban sprawl and a garage full of automobile­s. In my experience­, finger-wag­ging at patients is generally unsuccessf­ul. In fact, the more a pediatrician focuses on a child’s obesity, for example, the worse the problem generally gets.  We are individual­s that need to take responsibi­lity. But we are also social animals that cannot help but be influenced by social forces. We will not be successful in overcoming chronic illness without some significan­t cultural and societal shifts.

Read the original post on Barkingdoc’s Blog.

coloratmosphere Maggie Kozel is the author of The Color of Atmosphere, releasing in January 2011.