Health Care Reform by Increasing Primary Care Physician Salaries (Yes, a Necessary Evil)


Here are some thoughts by primary care internists and pediatricians.  Individual physician names have been removed (except NEJM article author)

Fixing primary care is critical to health care reform but will require simultaneously fixing several problems, including those related to remuneration, the work environment, and medical education.1 The most critical of these issues is remuneration.

The week of June 15 to 26, 2009, was bittersweet for those of us who care about primary care. President Barack Obama addressed the American Medical Association, emphasizing the central role that primary care must play in health care reform.2

We then learned of the death of Dr. Lynn Carmichael, a founder of the modern field of family medicine.3 The roller coaster continued with the publication in the Journal of two articles about the crisis in primary care, detailing the moribund state of primary care4 and the policies proposed for resuscitating it.1

I believe that these proposed policy reforms are doomed to fail, because they ignore the impact of managed care on remuneration. Primary care was supposed to be paramount under managed care. “We need you to be gate keepers,” we were told, “and we’ll pay you well to perform that service.”

In actuality, remuneration for primary care decreased under managed care, as contracts were negotiated solely on the basis of cost. Continuity of care was disrupted, as managed care relegated primary care doctors to ambulatory settings, replaced them with nurse practitioners or physician assistants, and utilized hospitalists for inpatient care.

Worse, patient panels were dissolved and reassembled annually during open enrollment, as companies negotiated not with doctors, but with employers.

So how can we fix the problem? Why not simply mandate that all payers, public or private, pay a capitation fee or salary designed to assure that primary care doctors can achieve a professional standard of living? In exchange, primary care doctors would provide continuing, comprehensive primary care (including night call and preventive services) for a reasonably sized panel of patients.

For the sake of discussion, I would suggest a salary and fringe benefit package of about $300,000 per year (in 2009 dollars) to care for 2000 patients, ($150 per patient), with incentives for special circumstances (e.g., working in underserved communities) or special services (e.g., delivering babies). All other fees, deductibles, and copayments would be waived. The problem of physician-generated demand would be eliminated, which would radically reduce costs to insurers. Billing would disappear. Patients would have open access to their primary care physicians.

Freed from the constraints of billing for the traditional encounter, primary care doctors could employ innovative methods to deliver primary care, including the Internet and group encounters.

Arthur M. Fournier, M.D. University of Miami Leonard Miller School of Medicine Miami, FL This article (10.1056/NEJMopv0907129) was published on August 19, 2009, at NEJM.org.

References Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med 2009;360:2693-2696. [Free Full Text] President Barack Obama addresses the American Medical Association, Chicago, July 15, 2009. (Accessed August 13, 2009, at http://www.ama-assn.org/amednews/2009/06/15/prsc0615.htm.)

 Brecher EJ. Dr. Lynn Paul Carmichael dies at 80: pioneered family medicine at UM. Miami Herald. June 23, 2009. (Accessed August 13, 2009, at http://www.miamiherald.com/511/story/1109334.html.)

Steinbrook R. Easing the shortage in adult primary care — is it all about money? N Engl J Med 2009;360:2696-2699. [Free Full Text]

Comments by other Physicians:

The operating word here is salary. On average 50% to 60% of insurance payments and copays go towards covering the office overhead. I would be more than happy with a salary including fringe so long as the overhead of my office is covered in addition to this payment. Too often when these plans are put together small details are missed and then, what was designed to help becomes a major headache to us.  (written by a pediatrician).

 Primary Care Remuneration — A Simple Fix Date: Fri, 21 Aug 2009 11:06:24 -0400 This is very good suggestion and an alternate to a Single Payer. However something would have to be in place to assure that managed care would not be shifting patients. Obviously there would be no need for them to cherry pick. Also over all cost to the system should be easier to predict.  (written by another pediatrician).

Last updated September 7, 2009 by Dr. Vee

Here is the link to the Parents’ Journal Podcast of “Rear Facing Car Seats Safer until Age Two”


 

The Parents Journal 072909-One Hour Show

The Parent’s Journal Topics & Guests (start times in parentheses)

Fruits and Veggies for Your Little Ones – Eileen Behan (01:00)

Baby on the Move – Dr. Laura Jana (06:00)

Parent’s Notes – A Practical Parenting Tip from a Mom or Dad (24:40)

Teaching Kids to Say NO to Bully Behavior – Barbara Coloroso (29:03)

Rear-facing Car Seat Safety – Dr. Vandana Bhide (51:06)

Download Podcast

http://www.parentsjournal.com/radioshow

Last updated August 24, 2009 by Dr. Vee

Top 12 Must-Have Items for a Senior’s Medicine Cabinet


1.  Advanced Directives–Also known as a Living Will.  Includes your determination of your Healthcare Surrogate, or who you want to make medical decisions for you. 

If you have a “DNR” form that specifies that you do not want paramedics to resuscitate you in the event your heart stops beating or lungs stop breathing, this should be prominently placed near the entrance of your home or attached to your refrigerator.

2.  List of your medications, including specific doses.  Include medication allergies, including any allergy to latex.

According to a survey by AARP and the National Institutes of Health (NIH), two-thirds of people aged 50 and older use some form of complementary and alternative medicine (CAM). Less than one-third of those who use CAM talk with their doctors about it. Remember that supplements are not evaluated by the Food and Drug Administration.

The term Medicine Cabinet is used in the title of this article to emphasize the fact that supplements should be treated like other medicines. Share with your doctor any supplements you may be taking to find out any side effects or interactions with other medicines you may be taking.

3.  First Aid Kit with topical antibiotic, alcohol pads, gauze pads, paper tape, Ace wrap and bandages.

4.   I call Vitamin D the Superstar Supplement–studies suggest it may reduce the risk of high blood pressure, diabetes and certain cancers.   Vitamin D helps the absorption of calcium in the stomach.  Many more people are vitamin D deficient than previously known.  Vitamin D is important for healthy bones.  It helps the absorption of calcium in the stomach.

5.  Calcium is important to prevent osteoporosis or thinning of the bones.  Calcium supplements typically contain vitamin D as well. 

6.   Continuing this discussion about healthy bones, the combination of glucosamine and chondroitin were shown to improve the pain of moderate to severe arthritis, but was no better than placebo in mild arthritis in the GAIT study  funded by the National Center for Complementary and Alternative Medicine.

7.  Healthy joints may also benefit with omega-3 fatty acids, more commonly known as “fish oil.”  Studies show that omega-3 fatty acids may help patients with an inflammatory arthritis called rheumatoid arthritis. 

Omega 3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have also been found to improve memory. 

Fish oil is best known for helping increase the good cholesterol in the body and lowering  bad cholesterol and triglycerides (fats).  The best way to get omega 3 fatty acids is to eat fatty fish such as  salmon, sardines, tuna or mackerel twice a week. 

A landmark study conducted in Italy showed that omega 3 fatty acid supplementation after a heart attack helped reduce the risk of recurrent heart attacks.    The American Heart Association recommends 500 mg of omega 3 fatty acids daily for healthy people and 1 gm of omega 3 fatty acids for people who have known coronary artery disease. Check with your doctor before taking omega 3 fatty acids because they may increase the risk of bleeding.

8.   Cholesterol levels can also be improved by eating fiber in the diet.  The best sources of fiber are whole grains such as barley, oat bran or quinoa.   Fiber also helps prevent diverticulosis (small pouches inside the large intestine).   The more fat in the diet, the more diverticula that form.  They can become inflamed and infected and may even require surgical removal of part of the colon.    Some patients with irritable bowel syndrome or constipation benefit with fiber supplements in their diet. It is very important to drink lots of water when taking fiber supplements–approximately 64 ounces a day. 

9.    Probiotics are supplements that also help maintain good colon health.  Probiotics are microorganisms which replenish the good bacteria that normally live in our colon or large intestine.  Probiotics are especially helpful when you have a stomach virus or have to take antibiotics.

10.  A study carried out by Harvard Medical School researchers showed that regular use of aspirin after developing colorectal cancer decreased the risk of death from colon cancer.  The most common use for aspirin, though, is to prevent heart attack and stroke.  The U. S. Preventive Services Task Force (USPSTF) encourages men aged 45-79 to consider taking low dose aspirin to prevent heart attack. Women ages 55-79 should consider aspirin therapy to prevent stroke.

Like other blood thinners, aspirin should not be used by patients who have had bleeding ulcers, patients over the age of 80 (except under a doctor’s supervision), patients with bleeding strokes or people at high risk for falls.  Always consult your doctor before starting aspirin.

11.  Lutein is an antioxidant supplement which has been shown to  help slow down or prevent vision loss in patients with age related macular degeneration.   The macula is the part of the back of the eye called the retina which is involved in central vision.  

Age related macular degeneration leads to loss of central vision, sparing the peripheral vision. The macula is the part of the retina that is also most sensitive to blue light the part of the visible light spectrum that, along with ultraviolet light, can damage your eyes.  Sunglasses also prevent  penetration of blue and ultraviolet light to the macula.

12.  Sunblock SPF at least 15 should be used daily to exposed skin.  Broad spectrum sunblock prevents ultraviolet A and ultraviolet B rays.  UVA rays cause premature aging of the skin.  UVB rays can cause sunburns.  

Exposure to both types of ultraviolet rays can lead to the development of skin cancer, including melanoma, a very serious type of skin cancer.   Look for agents that contain titanium and zinc oxide. Most people do not use as much sunblock as needed to protect the skin.   One ounce, enough to fill a shot glass, is  needed to protect each of the exposed parts of the body. 

Sunblock should be rubbed into the skin, especially on the face, ears, arms and hands, 15-30 minutes before sun exposure.  It must be re-applied frequently, every two hours, even the water-resistant kind.   

The American Academy of Dermatology recommends daily use of sunblock to exposed areas of the body, not just on days you are out in the sun.   On cloudy days, up to 80% of the sun’s rays are still present to cause sun damage. This article is for informational purposes only and should not substitute for medical advice from your healthcare provider.

The author is not providing personal medical opinion, diagnosis or course of treatment. Do not delay or substitute this information for medical treatment.

Last updated May 1, 2010 by Dr. Vee

Eradication of H. pylori Reduces Risk of Stomach Cancer


A recent metanalysis (pooling the results of different studies on the same research study) of randomized research studies, motly done in Asia, showed a significant reduction of stomach cancer when a bacteria called Helicobacter pylori was eliminated from patients who were originally found to have the bacteria. 

 

The bacteria is found when a tissue sample of the antrum section of the stomach is tested (by looking at the stomach with an endoscope, a long tube with a maginfying lens on the end).  It can be treated with different combination of medicines which include certain antibiotics and stomach acid reduction medicines called proton-pump inhibitors.

This finding suggests that the risk of stomach cancer can be reduced by treating the bacteria in patients where stomach cancer is endemic, such as certain Asian countries.

Last updated August 16, 2009 by Dr. Vee

Bacteria Growing on Cell Phones of Healthcare Workers


doctor cellphone

A recent study conducted in Turkey showed that cell phones used by doctors, nurses and other health care staff have significant growth of bacteria.  Ninety percent of health care workers said they never cleaned their cellphones.  

200 doctors, nurses and other health care staff agreed to have their hands and their cell phones tested for bacteria.  95% of mobile phones had growth of bacteria, and the bacterial species matched those cultured from the hands of the owners.   Even more concerning is that 52% of the staph species cultured from the phones and 38% from the hands of health care workers grew a resistant species called methicillin resistant Staphlococcus aureus (MRSA).  MRSA is often a resistant organisms which grows in hospital and other settings where patients have received many antibiotics, resulting in the proliferation of hardier strains of a bacteria.

Studies show that bacteria is found on doctors’ ties, cell phones and hands.  Handwashing and keeping personal items clean are two important things that health care workers can do to prevent the spread of bacteria to patients.

Reference:

Ulger F, et. al. Ann Clin Microbiol Antimicrob. 2009:8:7.


Last Updated August 13, 2010

Treatment of Influenza A H1N1 “Swine Flu” with Anti-Viral Medicines in High Risk Groups


Blue Swine Influenza Molecules from CDC

 

Electron MicrographView of Influenza A H1N1 Virions 

 

Two classes of antiviral drugs are available for the prevention and treatment of influenza: neuraminidase inhibitors and adamantanes, which inhibit a viral protein called M2. Influenza A H1N1, formerly known as swine flu, has been found to be resistant to adamantanes (amantadine and rimantadine). Oseltamivir (Tamiflu) and zanamivir (Relenza) are the two neuraminidase inhibitors currently available by prescription. These drugs reduce the median duration of symptoms by approximately one day and reduce the chance of contracting influenza by 70 to 90 percent when used for known influenza exposure.

 

zanamivir moleculeWho Should be Treated with Neuraminidase Inhibitors if they Contract Swine Flu?

High risk groups for the development of H1N1 influenza A, formerly known as swine flu, include children and adolescents who are on longterm aspirin therapy (which puts them at risk for the brain abnormality Reye’s Syndrome if they contract influenza), children under the age of five and pregnant women. Adults and children with chronic lung disease, cancer, heart disease, kidney dysfunction, diabetes, sickle cell anemia, HIV infection and transplant recipients are also considered high risk for complications for influenza, and should be treated with antiviral agents.

Adults and children with brain abnormalities which result in decreased ability to clear respiratory secretions should also be treated with oseltamivir or zanamivir in the event they contract or are exposed to Influena A H1N1.  Patients with cerebral palsy, Lou Gehrig’s disease, seizure disorders and spinal cord injuries would be considered at higher risk for serious complications if they were to contract influenza. Elderly patients, especially those who live in Nursing Homes are also at high risk for developing complications of influenza.

Surprisingly, most patients to date who have contracted Influenza A H1N1, formerly known as swine flu, are younger, healthier patients. Use of Neuraminadase Inhibitors in Infants Under the Age of One Treatment should be considered for infants (down to one day of age) and children with moderate to severe influenza, and those at high risk of complications, including children younger than 5 years of age. While antiviral treatment earlier in the course of infection is likely to have a greater impact on decreasing clinical illness, treatment can be started even if the duration of illness is greater than 48 hours.

 

 

virion2

Who Should Receive Preventative Treatment with Neuraminidase Inhibitors?

 

The Centers for DIsease Control (CDC) recommends consideration of antiviral prophylactic (preventive) treatment with medications in patients who have had known or probable exposure to swine flu and are at high risk for developing complications if they were to contract influenza H1N1. Pregnant women, patients over the age of 65, and patients who have the above described chronic medical conditions and who are household contacts of a suspected or confirmed case of swine flu should receive treatment with antiviral medications. A patient is believed to be infectious from one day prior to seven days after symptoms of swine flu start.

Children in daycare and school children who are at high risk for complications of swine flu and who have had close contact with someone diagnosed with swine flu is eligible for prophylactic treatment with neuraminidase inhibitors.

Travelers to Mexico who are at high risk of influenza complications should also receive preventive treatment. Prophylactic treatment with antiviral agents is available to babies under the age of three months, but is only recommended if the infant is critically ill.

Ambulance personnel, emergency medical service providers, first responders, emergency room personnel and other health care workers who are working in areas of confirmed swine flu, and who are at risk of serious influenza related complications may receive antiviral medications to prevent influenza. People who are required to have contact with others in high risk situations such as hospitals or in areas with numerous documented cases of influenza A H1N1 cases should use N95 respirators  to prevent infection.

 

 

Virion Particle

Viral Strains Resistant to Anti-Viral Medications are on the Rise

Antiviral resistance can develop to adamantanes such as rimantadine and amantadine after just two to three days of therapy with the class of antiviral agents called adamantanes. Amantadine is an example of this class of drug.

Resistance to oseltamivir, a neuraminidase inhibitor, can also form in two to three days of therapy. Resistance to neuraminidase inhibitors is being seen in some countries. It is expected that strains resistant to oseltamivir and zanamavir will be resistant to peramivir, another medication in the same class, which is currently in development.

Treatment with oseltamivir in infants under the age of one is based on age, not weight. Dosing of children between age one and twelve is based on weight. Zanamavir, which is an inhaled medication, should not be used in patients with asthma or chronic obstructive pulmonary disease (COPD) because it may cause wheezing or shortness of breath.

There have been rare reports of self-harming behavior that may be associated with neuraminidase inhibitor treatment, primarily in Japanese children. Therefore the risks and benefits of treatment with these anti-viral agents should be taken into account before they are used. Treatment or prevention with anti-viral agents does not negate the need for simple infection control measures such as hand washing to prevent the spread influenza H1 N1 infection.

 

 

Legal Disclaimer: This article is for informational purposes only and should not substitute for medical advice from your health care provider. The author is not providing personal medical opinion, diagnosis or course of treatment. Do not delay or substitute this information for medical treatment.

Last updated August 28, 2009 by Dr. Vee