Category Archives: Disparities in Care

Big Ben, Covent Garden and The Thames: Lessons Learned from a Visit to London—Collaboration Improves Outcomes

This past week I had the honor and pleasure of introducing my book on Women and Cardiovascular Disease in London. During the book-signing event, I was able to meet with many of my European colleagues from both the media as well as the healthcare space. As the evening’s discussions continued into the night, I once again realized just how much we have left to do in addressing gender disparities in care—it is not just a problem of a single country, it is truly a global issue.   More importantly, I once again became aware of just how small the world really is—and how many problems we share as a world community of healthcare providers. While we are separated by oceans and answer to different governments, healthcare systems and regulations, one thing remains constant—our devotion to the care of our patients as well as our desire to improve care and outcomes for all patients.

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In the US, we have worked diligently over the last ten years to raise awareness for women and cardiovascular disease. We have made great strides in the identification and treatment of women with occult heart disease. While the numbers are improving, disparities in care remain. The American Heart Association and the annual Go Red Campaigns have made a remarkable difference in promoting awareness, advocacy and research. We cannot, however, rest on our accomplishments—we must do more in the US to continue to close the gap. In Great Britain, I think that we can and must do even more. After my discussions during the book signing I realized that the level of awareness in the UK among women, media and healthcare providers is even less than in the US. During the event, I was able to chat with numerous bright and motivated attendees who are excited to be part of a wave of change in cardiac care for women throughout the UK. We identified many ways in which we may be able to improve education and awareness of women and heart disease in Britain and throughout Europe.   Even though the event lasted a little more than 2 hours, we were able to brainstorm numerous ideas and made plans for future discussions. It struck me that through collaboration and cooperation across oceans and among different nationalities that we can not only make an impact in our own countries–We make even bigger impacts (both at home and abroad) through a more global approach. When we work together towards a common goal we are able to tap ideas and harness the potential of larger numbers of professionals with disparate academic and social backgrounds. This can lead to novel solutions.

Collaboration is a way in which individuals or groups can work together to generate solutions. However, collaboration is a complex process where people from different backgrounds must come together to effect change.

But how can we be effective and make the biggest impact?

  1. Collaboration is a Journey: Collaboration does not happen overnight. Relationships develop over time. Some of the most important keys to success are communication, mutual respect and compromise as well as a commitment and “buy in” from all invested parties. There are always initial periods of brainstorming and conversation that lead to even bigger ideas. As we work together to solve global issues such as disparities of care for women with heart disease, we must pursue a common goal. Teaming up with others is a powerful way to improve outcomes and improve success.
  2. Collaboration may be best when spontaneous: Collaboration cannot be forced. We must learn to appreciate the talents of others and leverage those talents in a way that produces successful ideas. Working sessions followed by dinner or other gatherings in social settings often produce the most important breakthroughs. Amazing ideas commonly result when we least expect them.
  3. Collaboration requires that we Know Ourselves and Manage Diversity Effectively: The benefit of collaboration is the ability to bring together a diverse group of people with different backgrounds. Collaboration requires that we have cooperation both horizontally and vertically—there must be mutual respect and while maintaining structure and leadership within the group. The diversity of opinions allows us to attack issues from unique angles. The most important factor in producing measurable results for patients is the assimilation of ideas into a new and coherent way of thinking about common problems.

I am excited about the opportunity to collaborate with others throughout the world in order to improve care for women. I believe there is a great opportunity to raise awareness of disparities in care in the UK and throughout Europe. It is my hope that through cooperation and collaboration with my European colleagues, we will be able to improve cardiac care for women all over the world.

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More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….

 

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The Doctor Shortage of Tomorrow: Fact or Fiction?

This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.  Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur.  The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October).  Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…

How can there NOT be a physician shortage?

Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed.  However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California.  Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA.  (its like comparing apples to oranges).  They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows.  They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”

Really?  We are already doing more every day with much much less than we have had in the past….

As doctors often do in clinical practice,  I respectfully disagree with their assessment.  Obamacare will soon flood the system with millions of newly insured patients.  As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates.  Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates.  Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems.  Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.   The concept of a completely free standing private practice will no longer exist within the next 3 years.  Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage.  Medicine is becoming less attractive for young bright students considering a career in healthcare.  Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn.  Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards.  Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care.  However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future).  Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized.  These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes.  But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless.  Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship.  Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond.  We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care.  In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention.  While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process.  We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Are We Simply Losing Our Way As Medicine Remains in crisis….

Ultimately, time will certainly determine the state of physician supply.  If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage.  Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality.  Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

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Better Health Care for America’s War Heroes: Its Time to Get Serious About Providing Mental Health Services to Veterans

Today I am blogging because I am angry.  Like many Americans, I am saddened by the deaths of twelve innocent people in Washington DC this week.  My emotions have been difficult to reconcile over the last 48 hours.  Often, blogging can be therapeutic for me–today this is particularly true.  Typically, my musings are less than 750 words in length–please forgive me but today I may have to go a bit longer…

The tragic events that occurred at the Naval Shipyard in Washington, DC on Monday have forced all of us to reflect and many of us have begun asking very specific questions:  why did this happen? how could this happen? and, most importantly, could this have been prevented?  As details have emerged, it has become apparent that the alleged gunman Aaron Alexis was suffering from significant mental illness.  The reports of his symptoms suggest psychotic features such as those seen in patients with schizophrenia.  As the investigation continues, it appears that the gunman was a veteran (navy reservist) and had sought mental health counselling and care from the VA hospital system.  Unfortunately, the “system” failed him—failed those who were killed in the Naval Shipyard shooting– and ultimately has failed all of us. Our veterans deserve better.  The VA healthcare system is a proud institution with a rapidly increasing number of patients as the wars of the last 10 years continue to produce ailing servicemen and women in need of care.

Mental health care in the VA system has been identified as a major weakness by those in the VA administrative offices in Washington DC as early as the end of the Iraqi war.  As reported on National Public Radio (NPR) in 2012, the VA has not been keeping up with mental health demands.  In response to the increasing number of veterans entering the mental health system, the inspector general made it a priority to improve mental health services and decrease wait times for veterans requesting help.  In the last five years, the number of veterans requesting mental health services has increased by 33%.  In response, the VA appropriately approved increased funding and beefed up standards for patient evaluation and management.  However, it has become apparent that the ways in which the VA measures itself against a “standard” is rather dysfunctional.

In a hearing in Atlanta in July, 2011, Senator Patty Murray, Chair of the Senate Veteran’s Affiairs Committee, questioned the way in which the VA has been handling mental health care claims.   The Inspector general issued a report and admitted before the Congressional Committee that the VA had skewed the statistics in order to make wait times appear shorter than they really were.

In an opening statement, Senator Murray states:

“In the face of thousands of veterans committing suicide every year, and many more struggling to deal with various mental health issues, it is critically important that we do everything we can to make mental health care more accessible, timely, and impactful.  Any veteran who needs mental health services must be able to get that care rapidly, and as close to home as possible”.

As I mentioned above, during the hearing data was presented that seemed to indicate that most patients were receiving timely mental health care and referrals–the standard is that any patient requesting mental health services is contacted within 24 hours and an appointment is scheduled within 14 days.  However, upon closer inspection, it was determined that the way in which the VA tracked this data was flawed.  They only counted the time until an appointment was scheduled.  Real data from veterans in mental health referral situations shows that the average wait for mental health services in the VA system is actually 50 days.  In some centers (Seattle, for instance) the average wait is nearly 80 days!  Mental health requests will continue to increase as more brave soldiers return from battle.  Those who have served must be afforded with easily accessible, timely healthcare.  Certainly, in the case of naval shipyard shooting suspect Aaron Alexis, better access to more comprehensive mental health care may have made a difference and this week’s tragedy could have been averted.

Senator Murray, after the Atlanta hearings in 2011, issued a summary statement that we should take notice of again today:

“This report confirms what we have long been hearing, that our veterans are waiting far too long to get the mental health care they so desperately need. It is deeply disturbing and demands action from the VA. This report shows the huge gulf between the time VA says it takes to get veterans mental health care and the reality of how long it actually takes veterans to get seen at facilities across the country…this report clearly shows that the VA is failing to meet their own mandates for timeliness. Clearly the VA scheduling system needs a major overhaul.  The VA also needs to get serious about hiring new mental health professionals in every corner of the country.”

The Senator goes on to say  “…the VA is failing many of those who have been brave enough to seek care. It is hard enough to get veterans into the VA system to receive mental health care. Once a veteran takes the step to reach out for help we need to knock down every potential barrier to care”

It is clear that we must do more.  Large agencies such as the VA must eliminate the bundles of red tape that those seeking mental health evaluation and assistance must navigate.  Every single day there are multiple suicides among veterans.  Although money has been allocated for hiring new mental health professionals, a report issued as recently as February 2013 indicated that although roughly 1900 new mental health professional positions have been created, they are not yet filled.  In fact, other previously approved vacant positions have yet to be backfilled.  Our veterans continue to suffer.

When are we going to get serious about providing timely access to mental health services?  Now, more than ever, we have been given a solemn wake up call.  Shall we wait for another mass shooting rampage before we seriously attack the problem?  Do we continue to tolerate those that manipulate data to meet predefined metrics or do we say ENOUGH!  We need action NOW to prevent future tragedies.  The VA system was created to SERVE those who have SERVED.  It is time to live up to that lofty charge and provide prompt mental health care services to those who need it.  Hopefully, with time, those who are grieving losses at the Naval shipyard will heal–lets honor the memory of the fallen by working to provide better mental health services in the US today.

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Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

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Limiting Choices and Destroying Relationships: Early Consequences of the Affordable Care Act

Providing healthcare to all is a noble goal.  Providing choice, however, is an entirely separate issue.  Successful partnerships between doctor and patient are developed over time.  These partnerships do not happen easily and most, just like a long standing marriage, take a great deal of work.  As I have mentioned in previous blogs, when patients are engaged and participate in their care, outcomes are improved.  It is easy to see how costs can be lowered through improved outcomes–the focus is shifted to prevention rather than “salvage”.

Last week in the Wall Street Journal, author Anne Mathews discusses the issues surrounding “choices” in the healthcare marketplaces that begin functioning in October.  Many insurers are making “deals” with hospitals and physicians–they will be included in their plans as preferred providers if they are willing to settle for pre-negotiated lower reimbursement rates.  Many major healthcare systems such as UCLA in California, Rush and Northwestern in Chicago and Vanderbilt in Tennessee are being excluded as preferred providers in many plans due to the fact that they are unwilling to accept the terms dictated by the insurers.   These institutions,  and many others like them,  employ many of medicine’s leaders in patient care and research.  Many patients have developed long standing relationships with physicians at these institutions and are now forced to make a “choice”—either continue with their preferred provider at an increased out  of pocket cost or change physicians and start over in their new healthcare plan.

Starting over with a new physician is a lot like divorce.  Divorce is not easy–it is fraught with uncertainty and can be emotionally painful.  It is difficult to face change when so much time has been invested in building a productive doctor-patient relationship.  However, with the pending implementation of the Affordable Care Act (ACA), patients are now being forced to choose between a doctor they trust and lower insurance premiums.  Physicians and hospital systems are being forced to accept payments at whatever level the insurers choose to dictate–irrespective of the cost of the procedure or the staffing and overhead incurred.  Once again, the reform of healthcare in the US is doing little to assist the patients who need help the most.  Instead of working to build relationships, streamline care and focus on prevention, the ACA is forcing “divorce” proceedings on many doctors and their patients.  Moreover, the “choice” that is supposedly supplied by the pending healthcare exchange marketplaces will be severely limited when they open in October.  The government cites a lack of time to prepare for the healthcare law rollout–Others cite a poorly thought out, complicated and unworkable plan.  More than a dozen ACA “deadlines” have already been missed and there will certainly be more to come.

No one argues that the current healthcare system in the US is on life support and badly in need of reform.  However, the current ACA plan is not the answer.  Based on the basic tenet of coverage for all at affordable prices, the ACA is not living up to its billing.  Now, as the law begins its rollout process, many of the finest academic medical institutions in the country are not going to be accessible to many Americans due to contractual issues with the insurance industry.  Ultimately this will create more of a medical care divide in the US.  Academic teaching hospitals provide cutting edge care and access to new potentially life saving technologies before these are available in the mainstream.  Those with rare diseases or those with disease processes that have failed other treatments often turn to academic institutions such as Vanderbilt, UCLA and Rush for experimental therapies that may provide hope for a cure.  Now, as long as the healthcare exchange plans are able to dictate which physicians and institutions are included in their respective plan, only the wealthy and privately (non government exchange or marketplace) insured will be able to have an opportunity to participate in ground breaking and potentially life saving clinical trials.  Ultimately patients will suffer.  Ultimately human beings will be denied potential life saving therapy–all because of limited choice and the coverage “assigned” by insurance companies hoping to limit cost–but at what price?

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Healthcare Law Rollout “Delays”: Primum Non Nocere

Recently, President Obama’s healthcare law has been met with more challenges and “delays” than when it was rapidly pushed through Congress during his first term.  Many critics of the legislation argued that the rush to produce a product (predictably in time for the re-election campaign) would result in poorly thought out, overly-complex law that would be nearly impossible to understand and implement.  Four years ago, there was insufficient infrastructure at both the Federal and State levels to roll out such a piece of legislation–not surprisingly, things are no different today.  Rather than focusing on preparing for the implementation of sweeping reform, court battles have been fought, billions of tax dollars spent and complex decisions have been rendered by the Supreme Court.

Now, we are beginning to see that many of these critic’s concerns were in fact quite valid.  A few weeks ago, it was announced that the Obama administration would “delay” until 2015 the mandate that business provide healthcare insurance or pay a fine.  As I recall, this was one of the cornerstones of the healthcare law–statements from the White House indicate that it was “delayed” because there was insufficient infrastructure to provide more than one choice of insurance in the October premier of the Healthcare marketplace–the law promised multiple choices for small businesses. (surprised? C’mon,not really)

Today, the New York Times reported that yet another provision in the healthcare law is going to be “delayed” due to the fact that those that must comply need “more time”.  Interestingly, this provision was another one of Obama’s cornerstone promises–there will be limits set for individual out of pocket expenses.  Today, buried deep within other unrelated legislation, it was discovered that this particular consumer protection provision has been “delayed” until 2015 due to the fact that the poor, over-burdened insurance companies need “more time” to work on readying their computer systems to handle these particular co-pay limits.  (yea, right).  In my experience, insurance companies seem to be able to deny claims and disapprove treatments, drugs and procedures for my patients at an alarmingly quick pace.  It’s all a matter of priorities I guess.

What’s my take on all of this?  It’s the patient (or potential patient) that ultimately suffers….

The government and the healthcare law is playing favorites.  The law was supposedly passed in order to protect the individual American from escalating healthcare costs.  The law was created to provide affordable, sustainable healthcare to every American citizen.  The law was created in order to ensure quality care and contain costs.  All of these goals are extremely important and certainly worthy of our nation’s leaders time, resources and focus.  However, as is often the case in politics, much of this law is about partisan politics, re-election aspirations, campaign support and legacy. Forgotten in the midst of all of the debate is the patient.  The patient is the reason healthcare exists in the first place.  The patient is the reason most physicians and other healthcare providers go to work early each day.  In the latest “delay” in the healthcare law, consumers (and hence, the patient) will now have no protection from insurance company charges and co-pays.  By allowing the out of pocket limits to go unenforced, the Obama administration and Congress are effectively providing the insurance companies with a license to charge as much as they can–make as much profit as they can–until the legislated limits are actually enforced.  Many potential patients may not seek care because of the burden of cost.  Many of these patients will suffer with devastating but curable disease.  Many will die.

That’s capitalism right?  But should it be allowed to function at the expense of human lives?

For too long, the debate over healthcare costs and reform has centered around physicians, physician payments and hospital costs.  Isn’t it time we considered holding insurers responsible for years of abuse?–charges to consumers for insurance are far in excess to claims paid.  Most insurance companies that I deal with on behalf of my patients have lots of people trained to “deny” requested medically indicated treatments and procedures.  It is time for government to step up and advocate for the patient.  We must hold all players accountable for healthcare reform–physicians, hospitals, lawyers as well as insurers.  Lets stop playing favorites.  Lets focus on the patient.  Primum non nocere should apply to government, insurance companies, lawyers as well as physicians.  Primum non nocere…Primum non nocere…

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Going Up In Smoke: The Falling Lifespans of Women in the US Today

As I have stated many times in the past, women are undertreated and underserved when it comes to cardiovascular disease and stroke.  Now, more than ever, this may even be more important due to several recent studies that have been published in the last few weeks.  Several investigations have demonstrated two troublesome facts:  In certain areas of the country, life expectancy for women is decreasing AND women who smoke are much more likely to have lung cancer than men who smoke.  These facts argue for more aggressive treatment of women and more targeted gender specific prevention efforts–no longer can women’s risk for disease be discounted. Although awareness efforts are continuing, we continue to fall short in identifying and treating women with cardiovascular disease.

In a study published last week in the journal Health Affairs, researchers compared mortality rates from 1992-96 with those from 2002-06 in 3,140 counties in the United States.  In the study, female mortality rates increased in 42% of counties while rates in men only increased by 3.4%.  Factors associated with lower mortality rates in women included higher education, location not in the south or west and non use of tobacco.  These findings are incredibly troubling in that over the same time period, mortality rates in men have fallen in these same counties.

In a related article published this year in the New England Journal of Medicine, it was found that smoking in women is associated with a higher risk for lung cancer, cardiovascular disease and death as compared to smoking in men.  Among men, the risks of death from smoking have plateaued since the 1980s.  In the 1980s women who smoked were 13 times more likely to die from lung cancer –in contrast, women are now found to be 26 times more likely to die as compared to those who do not smoke.  However, there are data that show that smokers who quit by age 40 are able to reduce their risk for death significantly and in fact add 10 additional years to their life span.

So, altogether, it seems that smoking for women is a significant public health issue.  Women are smoking in greater numbers and those that began smoking in the 1960s are now seeing the long term effects–this cohort of women is truly the first group of long term female smokers that have been studied.  The results are truly sobering.  As healthcare providers we must do our best to prevent chronic disease.  Certainly in this era of cost containment and the new Affordable Care Act, we must strive to modify risk.  Smoking cessation is something that all providers, regardless of specialty, must work to encourage.  In fact, I believe that individual cost and  access to insurance coverage should be based on one’s smoking habits.  Those who choose to smoke should pay significantly higher premiums as they will be using more resources down the line.  Physicians will be held accountable for documenting smoking status and smoking cessation counselling–why then can’t patients and consumers of healthcare be held accountable for their own reckless behaviors (such as smoking).

But, back to the issue at hand.  Once again, we find that women are under treated and underserved.  According to recent studies, women are less likely to be referred or counseled for smoking cessation. In addition, data from the NCBI indicates that women have more difficulty quitting.  According to NCBI researchers, unique factors affecting a woman’s ability to successfully stop smoking include concerns over weight gain,  mood variability and withdrawal symptoms associated with hormonal changes during the menstrual cycle.

Ultimately, we must do a better job helping women with smoking cessation.  Mortality statistics such as the those recently presented serve as a failing report card when it comes to prevention activities in women.  We must identify female patients at risk and push for smoking cessation.  Once again, we must empower women to take an active role in their healthcare and engage them in healthy lifestyle modification activities.

Black Smoke and Fire Rises


Things Aren’t Always As They May Seem: The Challenge of Diagnosing and Treating Cardiovascular Disease in Women

Recently, television personality Rosie O’Donnell was in the headlines after suffering a heart attack.  Her presentation with an acute coronary syndrome (ACS) was atypical; her symptoms were different from the traditional symptoms seen in men having a heart attack.  Earlier in the day  of her event, Ms O’Donnell had helped  a woman from her car.  That evening she blogged that “a few hours later my body hurt, and that  i had an ache in my chest. both my arms were sore. everything felt bruised.”  Ms O’Donnell’s symptoms were persistent and she began to wonder if her symptoms might represent a heart attack.  She decided to take an aspirin (a particularly good idea in her case) but continued to deny the symptoms until she consulted her physician the next day.  She immediately underwent a cardiac catheterization and was found to have a 99% blockage of her left anterior descending artery (LAD).  She had a stent (small metal tube to open the blocked artery) placed and is likely to recover completely.
Her case highlights one of the biggest challenges in caring for women with cardiovascular disease–lack of recognition by clinicians and denial and delay by patients experiencing the symptoms.  Women in the US today account for a large number of the nearly half million deaths from CV disease and Sudden Cardiac death.  Yet, as I have discussed in previous blogs, women remain underdiagnosed and undertreated.  The best way to impact disparities in care is through education and awareness.
Recognizing the signs:
Traditionally, male heart attack victims present with crushing sub-sternal chest pain, shortness of breath, diaphoresis (sweating) and nausea.  Sometimes the pain may radiate into the neck or jaw.  Women and men are biologically quite different as we all know.  There are distinct differences in the way cardiovascular disease develops, progresses and ultimately presents clinically.  Certainly, women can present with classic symptoms.  However, often women present quite atypically.  Moreover, some diagnostic tests are less accurate in women as compared to me.  Diagnosing both acute and indolent cardiovascular disease in women can be quite challenging.Women tend to take care of their children and spouse first, often ignoring their own healthcare needs for long periods of time.  This may dismiss symptoms and carry on with their daily routines in order to avoid disrupting the family.  Coronary artery disease in women tends to be more diffuse (more widespread) and involves more small vessel disease.   Women also tend to present later than their male counterparts and often with more advanced disease.  Some of this may be explained by hormonal and biologic differences.  Symptoms in women may be quite vague and may include feelings of dread or anxiety, fatigue, or flu-like illness.  These vague symptoms can make prompt diagnosis much more difficult.   Women can also present with classic chest pain just as we described in men but often women deny the symptoms could be related to heart disease.
Making a Difference in Outcomes:  
1. Educate women and providers of healthcare to women about the risk factors for cardiovascular disease.  Make sure that every woman understands the signs and symptoms of heart attacks and how they may be different in female patients.
2. Actively screen at risk women for cardiovascular disease.  Ask about risk factors such as hypertension, smoking, high cholesterol, diabetes and family history of CAD.  Aggressively evaluate women with multiple risk factors even in the absence of classic symptoms.  Make sure that female patients understand what the risk factors are  how they can modify those risks.
3. Empower women to take control of their own healthcare.  Actively engage women in the prevention of disease.  Make sure women understand that they must act quickly when symptoms occur.  Denial of symptoms and delay in treatment most often results in much poorer outcomes.
The Upshot:
Rosie O’Donnell was fortunate.  She had symptoms consistent with a heart attack (although somewhat atypical).  For a little while she denied the symptoms but ultimately took an aspirin and sought care.  Luckily, she was able to get to a hospital and have a procedure done to open a blocked coronary artery before significant heart damage was done.  We must all learn from this case and educate our friends, families and colleagues on the risks of cardiovascular disease in women.  Through education, awareness and advocacy we can make a difference and reduce cardiovascular deaths in women.
Rosie O'Donnell in July 2011.

Women and Cardiovascular Disease: Addressing Disparities in Care

Over the last 6 years, I have developed an educational symposium for healthcare providers to address women and cardiovascular disease, particularly prevention of sudden cardiac death. This symposium has been well received and I have produced it all over the country. The focus of the event has been to specifically address disparities in care–men are much more likely to receive more advanced, more aggressive and more cutting edge therapy than women in identical circumstances. Many hypotheses have been put forward to explain and address these disparities. Some include access to care, patient concerns and education about CV disease, social stereotypes and patient denial of symptoms or risk. During the development of the symposium, I realized that many women in the US today regularly see OB/GYN physicians as their only healthcare provider. OB/GYN physicians are not always well equipped to provide comprehensive primary care and may have little time to devote to screening for cardiovascular disease–these are highly trained women’s health experts. Most women who see an OB/GYN are more concerned with dying of breast, uterine or ovarian cancer than with CV disease or sudden cardiac death. WIth the OB/GYN, I saw an opportunity to really impact disparity in care. I began to target OB/GYN physicians and developed a quick and easy office screening tool that can be used to pre screen patients for CV disease. A simple waiting room questionnaire is filled out by the patient and handed to the nurse at intake. This questionnaire would then prompt a busy OB/GYN provider to more aggressively screen at risk women. I also produced educational events specifically for OB/GYN physicians and invited cardiologists to attend in the hopes of facilitating interactions between very dichotomous specialties. In some cases this worked well and OB/GYNs and cardiologists began to develop referral relationships following the event.

However, gender disparities in care continue to exist. Despite my best efforts (and the efforts of countless others) over the last 6 years, women with cardiovascular disease continue to be undertreated and underserved. Although we are making significant progress there is still much work to be done. A review article published in July 2012 in Women’s Health by McSweeny et al examined disparities in congestive heart failure (CHF) and other CV diseases in women. In this review, the authors identify reasons why outcomes in women with CHF are poorer as compared to men. Lack of aggressive treatment of the underlying causes of CHF such as coronary artery disease as well as a lack of adherence to medical therapy, late presentation and multiple comorbidities are identified as significant contributors to these poor outcomes. A complete lack of social support is also labelled as a major factor in the outcome of women with CHF.

In 2012, the Minnesota Women’s Heart Summit was held to address issues surrounding disparities in care. Four major points of emphasis were identified:
1. Community Awareness and Prevention. Women’s knowledge of risk of CV disease is improving but is still inadequate. Local events to raise awareness among the general public is an important part of reducing CV deaths in women. We must engage clinicians, healthcare consumers as well as government policy-makers in order to make a difference
2. Symptom recognition and delays in seeking treatment. Often women present atypically with CV disease and we must work to educate women. Public service informational campaigns are needed to promote symptom recognition in women as well as the importance of seeking timely treatment. A parallel campaign to educate primary care physicians and ER providers about the atypical nature of symptoms in women with a focus on avoiding therapy delays should be conducted.
3. Closing the Survival Gap. Women are less likely to receive evidence based therapies such as beta blockers and ACE inhibitors that have been proven to decrease mortality. Women are less likely to have coronary artery bypass surgery, cardiac catheterizations and revascularization. Goal should be to impact this fact through advocacy, better training of physicians and inclusion of more women in research and clinical trials.
4. Patient-Provider Connections. Physicians must strive to develop better relationships and have better communication with patients. Often depression, socioeconomic status and other issues become barriers to care. By seeing the whole patient and addressing some of these issues, a physician may be able to better partner with female patients and improve care.

Disparities in care for women continue to exist. It is a significant public health problem today. More women than men die from cardiovascular disease each year. Although many have worked very hard to reduce these disparities, there is much work yet to be done. We must continue to communicate, advocate and educate in order to improve outcomes in the future.