Monthly Archives: August 2010

The “humble” neighborhood health center.

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The Great Brook Valley Neighborhood Health Center in Worcester changed names this Thursday, becoming the Edward M. Kennedy Community Health Center, a tribute to Ted Kennedy’s role in bringing Community Health Centers into being. Seems like a good time to review the history and role of a neighborhood health center.

Technically, a Federally Qualified Health Center is a community based organization which provides comprehensive primary and preventive care to a community, regardless of their ability to pay. They are generally governed by a locally based board of directors, and one of the unique features of the governance structure is that 51% (or more) of the board members must represent the population of the community (and generally receive their care there). Health care reform funding is expected to modernize existing centers, and significantly expand the network of centers nationwide.

Since health centers are a much cheaper way of providing health care, this can help save money for the health system overall, especially the parts of the system paid for by tax money. At the same time, people served at these health centers will generally be healthier, because the same research shows that the reason people who receive care at health centers have lower costs is because “providing quality primary care services can reduce the need for other ambulatory and hospital-based medical care, thereby lowering overall medical costs”.

Unfortunately, neighborhood or community health centers still carry the stigma of being places where poor people get their care-not a place you’d like to go if you had the chance to get out. People have a love/hate relationship with them-sort of like coming from a bad neighborhood that you still love, because it’s home. The stigma is in some sense justified-most of the people (70%) who get their care at neighborhood health centers are living in poverty by the federal definition. This is another way of saying, though, that they do one of the toughest jobs in health better than any other model of care delivery, for less money.

The facts suggest that we’d be served a lot better, most of us, if we got our primary care through a place which used the community health center model. Health care is almost never just about medicine, because so many other things impact your health. If your house is being foreclosed, it affects your health. If you’re having trouble handling your teenager, that affects your health. If your neighborhood is in the middle of an epidemic of flu, or norovirus, that affects your health. If your drinking is out of control, that affects your health. None of these problems are directly the responsibility of your doctor, but wouldn’t it be nice if, when you went to see her about them, she had the resources to work on the whole problem or set of problems, rather than just bandaiding over your symptoms?

That is what neighborhood health centers are designed to do; treat the whole person, in their family unit, in their community. And whatever you think of Ted Kennedy, I think that’s evidence of solid service to the nation.

Study shows more young adults have health insurance after Massachusetts health reform

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The Massachusetts health reform law (often called “chapter 58”) made several special provisions for young people (defined as those between 19 and 26), because they represented a disproportionate share of the uninsured population, and were less likely to have access to insurance through work (as most of the jobs available to people in that age group don’t come with insurance). The Urban Institute recently reported a study of the impact of chapter 58 on insurance rates among young people which showed that these special provisions have worked as intended. The uninsurance rate in this group fell 60% (from 21% to 8%, in round numbers).

Achieving this goal, though, required some compromises. Young adults were largely brought into the insurance fold via “Young Adult Plans”, insurance plans with important exclusions and relatively high deductibles. In addition, many have annual maximum coverage amounts (usually around $50,000). Most young people will be fine with these restrictions, as most people in this population are healthy. These plans are similar to the “college plans” which were available before reform; unfortunately, these plans were cited in a 2009 article in the Boston Globe for having higher administrative costs, and that slightly less than 1% of covered students exceeded the $50,000 cap on benefits (951 people)(Link to complete study result). A more recent investigation by the New York attorney general reported in the Chronicle of Higher Education showed that these issues are neither limited to Massachusetts nor have they stopped due to the investigations in Massachusetts.

Regardless of the potential downsides to Young Adult Plans, they do bring important benefits. Access to primary care, in particular, is an enormous benefit (all Massachusetts plans require at least three routine primary care visits be covered). And in the spirit of beginning as we mean to go on, getting people insured in their youth may form a habit of receiving regular preventive care which can translate into benefits in later life, as well as benefits now through the screening and teaching which are big components of the primary care visit. There hasn’t yet been an analysis of the downsides, and while the statistics suggest there are few people who outrun the limitations of a young adult plan, for those who do the impact, financially and personally, can be devastating.

Palliative care helps you live longer and better at the end of life

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Many of you will remember the “death panel” controversy during the health care reform debates last year. For those who don’t, a proposal to create a better payment mechanism for discussions between physicians and patients about end-of-life choices was derided by opponents of reform as funding for “death panels” which would make sure that elderly people chose the option of “dying early” to save on health care costs. Now it appears that early palliative care not only helps you be more comfortable and more in control of your health during serious illness, it can help you live longer as well.

A recently completed study from the Massachusetts General Hospital, researchers studying end of life care in a group of lung cancer patients found that the group assigned to early palliative care had higher quality of life and less depression than patients who received “standard care” (without early palliative care). Alone, this wouldn’t be a surprise; the surprise came when they found that the patients who received early palliative care lived longer, as well.

The policy implications of this finding are profound and seem to run counter to common sense. People have the idea that they can either fight disease as aggressively as possible, to live as long as possible or opt for care whose very name – palliative – seems to say that you’ve given up, and you’re just going to paper over the disease. The research from MGH is telling us that this is a false choice. Early palliative care-care which pays attention to relieving the symptoms of the disease-as well as fighting the disease through the usual means, you can live longer and feel better.

Far from demanding that we “die early”, advocates for palliative care want us to live as long as possible, but to help us keep our dignity and our humanity while we fight, and to make us ready for whatever our next step may be. Death is still inevitable; it doesn’t have to be miserable as well. We have it in our power to ease the transition, as well as delay it, and there doesn’t have to be a choice between the two. Promoting better and earlier use of palliative care is good healthcare policy choice, as well as a good use of our healthcare dollar.

On psychiatry

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Some of you have heard my psychiatry rant. In short, it goes like this: Psychiatrists are not doctors, in the “physician” sense. They don’t do any of the things I recognize as “being a doctor”; they don’t examine patients or their pathologic equivalents (xrays, tissue slides, lab values-doctors do that stuff in some specialities and are still “physicians” in my book). Yes, they went to medical school, they learned all the stuff I learned, and then proceeded to enter a field where most of that knowledge is largely unnecessary.

It’s not that mental illness isn’t disease-it is, in the truest sense of the word; patients with mental illness are some of the most tormented people I’ve seen. But the discipline which cares for them is “mental health” (an umbrella term which most people use to include psychologists, social workers, various subsets of counseling and “life coaching”, etc.), not “psychiatry”. And it’s an entirely different mindset.

Recently I picked up a copy of “Unhinged”, a critique of psychiatry by Daniel Carlat, a psychiatrist in Newburyport. It’s an excellent read, I recommend it highly. But here, in a nutshell, is the issue with “psychiatry”, as per Dr. Carlat:

“It is called “medical school” for a reason. Its purpose is to teach students how to combine patient interviews, physical exams, and laboratory tools to diagnose biomedical diseases, and then to combine advice, medications and technical procedures to cure them [ed note: I would add “or control them”, but that’s a quibble] The basis for it all is an understanding of pathophysiology. But in psychiatry, we do not know the pathophysiology of mental illnesses, and therefore we do not use physical exams or laboratory data to diagnose” [emphasis mine]

He goes on to say trenchant things about why psychiatrists should not go to medical school, arguing persuasively that it’s bad for psychiatry and mental health in general (psychiatrists often try very hard to be kings of the mental health hill, because they’re doctors, you see), bad for medical school, and bad for patients. He argues for a new model of mental health professional, with a wholly revamped training program, combining the best of the various disciplines which now constitute mental health (psychology, social work, etc.)

I think it’s an intriguing idea. And like I said, an excellent book.

(And to hopefully forestall some ranting: yes, there is a neuroscience of mental illness. It isn’t ready for prime time. When I can measure your serotonin or norepinephrine, and use that to diagnose your illness or gauge your treatment response, then we’ll have another conversation. When I can do a depression scan, or a schizophrenia scan, or a bipolar scan, with some idea of exactly what I’m measuring and use that knowledge to guide treatment, reconsideration may be in order. But psychiatry *isn’t there yet*. Mental health has made *immense strides* since Freud invented the idea, and kudos to all the people working in that field both treating patients and working to advance the understanding of their disease. That work needs to keep happening. And medicine and mental health need to work together to care for *our* patients. But psychiatry has become an empty shell of a once proud profession IMO, as understanding of non-mental illness (or perhaps “less mental” illness) has advanced faster than the understanding of mental illness. What that says to me is that mental illness is a hard, complex problem, not that it’s less prestigious or not a problem)

What, exactly, counts as “health”?

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The health reform law (now mostly called the Patient Protection and Affordable Care Act, or just the Affordable Care Act (ACA) requires many insurers to maintain a “medical loss ratio” of at least 85%. The medical loss ratio is the percentage of premiums which the insurer must pay out as health care. So if the premium for health insurance is $100 per month, the insurer must, on average, spend $85/month on payments for health care used by everyone insured by the company.

Naturally, health insurers are interested in maximizing the kinds of things they get to call “spending on health care”. For instance, is utilization review “spending on health care”? Generally, I would argue it is not; it is generally of little benefit to the individual person insured, but of significant benefit to the insurance company. (Utilization review is the process an insurance company uses to assess whether you still need to be in the hospital, or if you really need that MRI, or if you could manage with a less costly medication). Is there a benefit to these programs? Well, yes and no; the individual doesn’t benefit that much. The group of beneficiaries as a whole benefits some, since every dollar saved by UR is a dollar which can potentially be spent on other health care. But UR is much hated by patients and doctors, not because it is done (it’s done some useful things for length of stays, which were arguably way too long when UR started in the 80’s), but because it’s so haphazard. Everyone has their own rules, the rules are often arbitrary, or arbitrarily enforced, and the appeals process is arduous and uncertain.

The National Association of Insurance Commissioners (the group of state insurance commissioners; this is a government organization, like the association of governors, etc,) has recently come out with a guidance document which has a relatively narrow definition of “health care spending”. And unsurprisingly, the insurance companies, led by Karen Ignani (the remarkably effective president of America’s Health Insurance Plans, or AHIP), are incensed that their favorite spending categories, (investments and fraud prevention) are not counted as “health expenditures”. Naturally, they couch this in language calculated to frighten patients into calling their congresscritters: “the current proposal could have the unintended consequence of turning-back-the-clock on efforts to improve patient safety, enhance the quality of care, and fight fraud” according to Ms. Ignani.

Uh-huh. Investments did so much to improve patient safety. And fighting fraud is a cost of doing business, not a direct cost of health care. Now Ms. Ignani is a smart woman; she knows the buttons to push. But I wish they insurance companies would, just once, recognize that the exemption from anti-trust law they enjoy is at least in part a statement of the public’s faith that they will act in the public’s interest. You know, from time to time. So far their record is spotty to a kind reading. (To a fair reading it’s exploitative, in my opinion, but I’ll stick with spotty for now).