Helping Primary Care NOW!

In regards to a proposed 8 percent increase in reimbursement rates to primary care physicians in the 2010 Medicare fee schedule, an email from the American Academy of Family Physicians notified me that "As you would expect, the subspecialists are mobilizing their members to oppose this change."
On the other hand: Below is the "comment" I left at the Regulations.gov webpage to show my support, and if you believe so too, you can do so too here.

I am happy/relieved to hear of this proposed 8% increase in Medicare reimbursement rates to primary care physicians. Happy because it is the first I have learned of an indication that consideration for primary care is valued; relieved because even in my brief introduction into medicine so far it has been hard not to become cynical sometimes about where I was headed.

Whereas access to primary care has

proven to be the leading indicator for an individual's and community's health, the reputation of primary care medicine has sunk to the bottom of the barrel, in the eyes of this whole generation of students entering the medical profession. Primary care physicians "make the least," "are the most ignored and undervalued in society," and they "are not respected"--these are just a few of the "truisms" I have heard mentioned by many peers so far.

I am on my way to become a second year medical student, and one of the few medical students remaining these days thinking of pursuing primary care medicine (down to only about 1% of us, in fact, despite an exponential explosion in the nation's impending need). I urge all of my peers & our political leaders to push & pass this increase in reimbursement to primary care physicians. If so, this will help encourage more future physicians to fill the much-needed primary care roles that will accompany America's increasing demand and (hopefully) expanded health insurance coverage. If not, the alarming trend of medical students' aversion to primary care will continue, and folks like me will be even lonelier, and maybe even altogether discouraged.

Sincerely, Abraham Young

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NYT: Wisdom on ankle injuries!

How to Fix Bad Ankles

By Gretchen Reynolds

July 8, 2009, 10:30 am

[Click on link above to NYT article for video on ankle exercises!]

Ankles provide a rare opportunity to recreate a seminal medical study in the comfort of your own home. Back in the mid-1960s, a physician, wondering why, after one ankle sprain, his patients so often suffered another, asked the affected patients to stand on their injured leg (after it was no longer sore). Almost invariably, they wobbled badly, flailing out with their arms and having to put their foot down much sooner than people who’d never sprained an ankle. With this simple experiment, the doctor made a critical, if in retrospect, seemingly self-evident discovery. People with bad ankles have bad balance.

Remarkably, that conclusion, published more than 40 years ago, is only now making its way into the treatment of chronically unstable ankles. “I’m not really sure why it’s taken so long,” says Patrick McKeon, an assistant professor in the Division of Athletic Training at the University of Kentucky. “Maybe because ankles don’t get much respect or research money. They’re the neglected stepchild of body parts.”

At the same time, in sports they’re the most commonly injured body part — each year approximately eight million people sprain an ankle. Millions of those will then go on to sprain that same ankle, or their other ankle, in the future. “The recurrence rate for ankle sprains is at least 30 percent,” McKeon says, “and depending on what numbers you use, it may be high as 80 percent.”

A growing body of research suggests that many of those second (and often third and fourth) sprains could be avoided with an easy course of treatment. Stand on one leg. Try not to wobble. Hold for a minute. Repeat.

This is the essence of balance training, a supremely low-tech but increasingly well-documented approach to dealing with unstable ankles. A number of studies published since last year have shown that the treatment, simple as it is, can be quite beneficial.

In one of the best-controlled studies to date, 31 young adults with a history of multiple ankle sprains completed four weeks of supervised balance training. So did a control group with healthy ankles. The injured started out much shakier than the controls during the exercises. But by the end of the month, those with wobbly ankles had improved dramatically on all measures of balance. They also reported, subjectively, that their ankles felt much less likely to give way at any moment. The control group had improved their balance, too, but only slightly. Similarly, a major review published last year found that six weeks of balance training, begun soon after a first ankle sprain, substantially reduced the risk of a recurrence. The training also lessened, at least somewhat, the chances of suffering a first sprain at all.
Why should balance training prevent ankle sprains? The reasons are both obvious and quite subtle. Until recently, clinicians thought that ankle sprains were primarily a matter of overstretched, traumatized ligaments. Tape or brace the joint, relieve pressure on the sore tissue, and a person should heal fully, they thought. But that approach ignored the role of the central nervous system, which is intimately tied in to every joint. “There are neural receptors in ligaments,” says Jay Hertel, an associate professor of kinesiology at the University of Virginia and an expert on the ankle. When you damage the ligament, “you damage the neuro-receptors as well. Your brain no longer receives reliable signals” from the ankle about how your ankle and foot are positioned in relation to the ground. Your proprioception — your sense of your body’s position in space — is impaired. You’re less stable and more prone to falling over and re-injuring yourself.

For some people, that wobbliness, virtually inevitable for at least a month after an initial ankle sprain, eventually dissipates; for others it’s abiding, perhaps even permanent. Researchers don’t yet know why some people don’t recover. But they do believe that balance training can return the joint and its neuro-receptor function almost to normal.

Best of all, if you don’t mind your spouse sniggering, you can implement state-of-the-art balance training at home. “We have lots of equipment here in our lab” for patients to test, stress, and improve their balance, Hertel says. “But all you really need is some space, a table or wall nearby to steady yourself if needed, and a pillow.” (If you’ve recently sprained your ankle, wait until you comfortably can bear weight on the joint before starting balance training.) Begin by testing the limits of your equilibrium. If you can stand sturdily on one leg for a minute, cross your arms over your chest. If even that’s undemanding, close your eyes. Hop. Or attempt all of these exercises on the pillow, so that the surface beneath you is unstable. “One of the take-home exercises we give people is to stand on one leg while brushing your teeth, and to close your eyes if it’s too easy,” Hertel says. “It may sound ridiculous, but if you do that for two or three minutes a day, you’re working your balance really well.”

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4 emails debating health care reform! (Please chime in w/ comments!)

EMAIL #4

Hi all classes,
Glad to see this "healthy" debate among Brandon, Kate, and Anthony, and probably others (like me) who would be itching to jump into this conversation and interact with everyone's viewpoints--if not for these damn things they call exams.

But just wanted to throw in this article from this week's The Economist (a right-leaning magazine in regards to business/economy, as its name gives away; but I find a very smart, clear-minded, progressive, and not-shy voice in-general): it provides no blanket verdict of "Yay" or "Nay" on the issue of the Medicare-based public plan, but it does succinctly elicit the subtleties and nuances of the whole situation.

Enjoy! And in any case hope U.S. health care gets some form of huge overhaul for the better in the next year(s), otherwise Healthcare itself may become the cause of morbitiy & mortality not only on the growing uninsured, but also on all other sectors of American society by the time we're retired (as the article aptly forecasts).
-Abe

PS. I have copied the article below, along with all the discussion so far (Kate and Anthony, if you'd like me to remove your responses from the website I'd be glad to do so) on the website:
http://DownstateCafe.blogspot.com/
Please feel free to continue the lively discussion there (via "leave a comment"), or if there is any other articles/items you'd like to suggest for the website, please let me know.

THE ECONOMIST: "The future of health-care reform"

The moment of truth

Jun 4th 2009 | WASHINGTON, DC
From The Economist print edition

Congress is about to tackle health care, for the first time since the debacle of 1993-94. Do the reformers stand a chance this time?

Corbis

A PICTURE of a handsome young man riding a bucking bronco hangs in the office of Max Baucus. The Democratic senator from Montana was a novice in the rough world of rodeo three decades ago, but when challenged he did not hesitate. The nerve-racking ride that ensued foreshadowed his current wild adventure. As chairman of the Senate’s Finance Committee, this relatively unknown figure has emerged as a central force in the struggle over health reform.

Barack Obama has made health care a domestic priority. But rather than designing his own plan, he is leaving it to Congress to take the lead by crafting a bill which he hopes to sign before year’s end. Last month he gathered insurance and health-industry executives at the White House. This week he called in leading Democratic senators working on the issue. And on June 6th Organising for America (a political group that sprang from Mr Obama’s presidential campaign) plans to raise the heat further. Its website declares that “in thousands of homes across the country, we’ll gather to launch our grassroots campaign for health care.”

For the first time since Hillary Clinton’s failed attempt of 1993-94 Congress has taken up health reform in earnest. On May 20th Senator Tom Coburn from Oklahoma and three fellow Republicans (including the up-and-coming congressman Paul Ryan) introduced their version of a health-reform bill. On June 2nd Judd Gregg, a conservative Republican senator, introduced another. An innovative earlier bill by Ron Wyden, a Democratic senator, has a number of Republican co-sponsors. All this, says Mr Gregg, proves that his party is willing to participate in, rather than obstruct, efforts at health reform this time round.

That pledge of bipartisanship may not survive. And it may not matter much, for Mr Obama has made it clear that he will sign health reform as part of the budget reconciliation process if necessary—a controversial manoeuvre that would need only 50 votes in the Senate, not the normal 60. So the reins are firmly in the hands of two senior Democrats: Mr Baucus and Edward Kennedy, the head of the Senate’s Health Committee. Both are expected to deliver their own bills this month. Although Mr Kennedy’s is expected to tilt further to the left, insiders expect that the two will be merged fairly easily. That hybrid bill will be the one that matters.

For much of the presidential campaign, the debate on health reform seemed to hinge on cost versus coverage. John McCain appeared more concerned about reining in runaway health inflation, while Mr Obama seemed more concerned about extending coverage to the nation’s uninsured. Confronted by the financial crisis, however, the new president has made it clear that he now wants to tackle both objectives. Christina Romer, the head of Mr Obama’s Council of Economic Advisers (CEA), believes that “there are linkages in both directions”.

She points out that extending insurance to all can save money because tens of billions of dollars are spent today on the uninsured, who get late and expensive care in emergency rooms. In a new report the CEA argues that any reform that slowed the annual growth rate of health costs by 1.5% would boost America’s economic output by over 2% and increase the average household’s income by $2,600 in 2020. The CEA analysis suggests that universal coverage would lead to a healthier, more mobile and more productive workforce.

Those forecasts are probably a bit rosy, but the report also spells out the implications of failure. The CEA forecasts that health spending, which will account for perhaps 18% of America’s GDP this year, will soar to over one third of output by 2040. More politically salient is its warning that health inflation will squeeze wages hard as an ever larger share of compensation comes in the form of health insurance (see chart). A new report from the Urban Institute, a think-tank, adds that doing nothing means the number of uninsured will grow from perhaps 49m today to 62m in a decade. Taken together, all these factors explain why there is such momentum behind health reform.

Details please

But what will the reformers actually come up with? Although the final details will not be known until the Baucus and Kennedy bills are unveiled, a few important elements are already clear. Despite the hopes of some, there is, in the words of Mr Baucus, “no chance” of a single-payer system advancing in legislation this year. “We’re not Sweden, Britain or Canada,” he says, “and we’ll come up with an American solution” that will involve both government and the private sector.

That points to a fight over some form of government-run insurance plan. Many on the left, including Mr Obama, argue that reform must include a “public plan” that would provide an alternative to rapacious private insurers. But industry types are convinced that any government plan would enjoy unfair advantages, like implicit government guarantees and huge pricing power, and suspect it would serve, in Mr Gregg’s words, as “a stalking horse for a single-payer system”.

Who is right? Neither side, perhaps. Andrew Stern, the head of the Service Employees International Union and an influential labour boss, believes a compromise is possible. But Douglas Elmendorf, the head of the non-partisan Congressional Budget Office (CBO), observes wryly that “the closer a public plan is to a private plan, the less the gain.” Old lags of health reform suggest that some in Congress want to pick a fight over the public plan issue to distract from other, bigger reforms in the works.

One of those is the once controversial notion of an individual “mandate” to purchase insurance. Without such a requirement in place, too many healthy people choose not to pay for insurance. This leaves less money to cover the sick, and some of the uninsured inevitably turn up at emergency rooms. A mandate would need to be coupled with comprehensive insurance-market reforms. This would involve stronger regulation of insurance firms to force them to offer insurance to everyone, the creation of central exchanges for buying insurance, and subsidies for the poor.

Pioneering reforms in Massachusetts have helped win over many liberals to the mandate idea. Mr Kennedy’s bill is likely to be an expanded version of those reforms. And a U-turn by the industry is also winning over Republicans. The health insurance lobbies now say they are willing to live with rules forcing them to accept all patients without regard to pre-existing medical conditions—but only if this is accompanied by an individual mandate. Mr Gregg’s proposal has just such a requirement, while Mr Ryan’s bill has a similar proposal for “automatic enrolment” of people into private insurance schemes.

The other surprising area of possible agreement concerns the most important question: how to pay for these reforms, which may cost $1 trillion or more over the next 10 years. The biggest available pool of money is the tax exclusion granted on employer-provided health insurance. Jonathan Gruber of the Massachusetts Institute of Technology thinks eliminating this distorting giveaway would net some $2.3 trillion over the next decade or so. When Mr Wyden proposed abolishing that tax break to pay for universal coverage in 2006, many thought the notion outlandish, but it now looks likely to happen, at least in part.

Mr Stern warns of a “middle-class riot” if any such reform is seen as a tax increase on working folk with insurance. But as everyone involved in reform piously vows their plan will be “budget neutral”, this cow is suddenly no longer so sacred. Mr Ryan’s bill would end the tax break for the most expensive of these plans. A cap on this benefit is proposed by Mr Gregg, who reckons this is “the most logical way to raise money.” Mr Baucus also supports capping this perk, though not abolishing it. One problem for Mr Obama is that, during the presidential election, he excoriated Mr McCain for exactly this idea. He also opposed individual mandates. This week, though, he hinted in a letter to Democrats at a compromise on both issues.

There are many other good ideas to cut costs making the rounds. They range from investing in prevention to expanding the use of health information technologies to rejigging incentives so that doctors get paid for health outcomes rather than for treatments. Alas, most of these ideas will not get counted by the Congressional Budget Office, which is charged with evaluating such proposals, as savings, either because their pay-off is too uncertain or because they require short-term investments that pay out far off in the future.

Three decades ago, as he got on that bucking bronco, the Western senator was given this advice: “Don’t look at the ground, because if you do that’s where you’re going to end up.” There has been an air of civility and bipartisan co-operation around health reform so far, but it may not last long. Mr Baucus should keep looking forward and hang on tight.

EMAIL #3

On Sat, Jun 6, 2009 at 4:06 PM, Anthony wrote:

Greetings Classmates,

After reading the Action Alert, I would like to make one change:

Update: Support a Medicare-based public plan

I am firm supporter of a move towards a public funding source for health care in this country.

And with no offense intended towards my esteemed acquaintance Brandon, I would like to applaud Kate for helping us all to see both sides before acting on Action Alerts.

Cheers to Brandon and Kate for encouraging us all to think critically about health care as a political issue and educate ourselves about both sides.

I've written some arguments for a move towards a public plan below, with links.

Anthony Accurso, COM 2010
Member: American Medical Student Association
Member: Physicians for a National Health Program



Reasons for a move towards a public plan:

AMSA: our medical student professional organization - openly supports a single-payer Medicare-for-all system.

- The U.S. is the only industrialized nation in the world that relies primarily on a for-profit privately funded health care system. We pay more for our system than any other nation, but it lands us between 20th and 30th worldwide in Life Expectancy and Infant Mortality. Frontline.

- Polls show that upwards of 62% of U.S. citizens and 59% of U.S. physicians would prefer a single payer system, publicly financed, privately delivered (resembling Medicare Parts A and B). ABC/Washington Post Poll Question 47, Annals Int Med, p566

- AHIP (America's Health Insurance Plans) and other powerful lobbies have vested interests in sustaining their industry. Data from the rest of the world shows us that public options would likely cover all Americans, ensure choice of doctor, prevent discrimination against people with pre-existing conditions and provide improved efficiency that would help to control costs.

For more information about the potential of publicly funded health care:
- PNHP is a professional organization of 14,000+ physicians who support creation of a publicly funded, privately delivered health care system. Also PNHP-NY
- California Nurses Association
- PHIMG

EMAIL #2

On Sat, Jun 5, 2009 at 9:42 PM, Kate wrote:

Hello,

I am writing to encourage all of you to contact the numbers below to
encourage our senators to support a government-run insurance option.
I'll try keep my response brief, but there are a few things that I feel
should be addressed.

First of all, President Obama's proposal would not mandate that all
American's enroll in a government run health plan; it would potentially
mandate that all Americans posses some form of health insurance,
private OR public, unless they are found to be unable to pay for it.

Consider the following:

18% of people under 65 in the US are uninsured and rising

The percentage of people with employment-based health insurance has
dropped from 70 percent in 1987 to 62 percent in 2007. This is the
lowest level of employment-based insurance coverage in more than a
decade

Rapidly rising health insurance premiums are the main reason cited by
all small firms for not offering coverage. Health insurance premiums
are rising at extraordinary rates. The average annual increase in
inflation has been 2.5 percent while health insurance premiums for
small firms have escalated an average of 12 percent annually.

Lack of insurance compromises the health of the uninsured because they
receive less preventive care, are diagnosed at more advanced disease
stages, and once diagnosed, tend to receive less therapeutic care and
have higher mortality rates than insured individuals.

The United States spends nearly $100 billion per year to provide
uninsured residents with health services, often for preventable
diseases or diseases that physicians could treat more efficiently with
earlier diagnosis.

The uninsured are 30 to 50 percent more likely to be hospitalized for
an avoidable condition, with the average cost of an avoidable hospital
stayed estimated to be about $3,300.

The majority of us, I hope, entered this field because we are dedicated
to caring for others and serving them to the best of our abilities. I
have no desire to underplay the frustrations we all experience from
being underpayed for our hard work, however we are, as physicians, a
relatively well-off group (I'm looking at you, future anesthesiologists
of America!). In the end, I am certainly more concerned with adequate
coverage and care for all of my family and friends than I am about my
own income, which, even with Medicare/Medicaid reimbursement will prove
adequate.

Please look into this issue on your own. This is a chance for our
country and our profession to provide effective care for everyone.
It's a chance to truly save lives -- and not just the lives of those
who are fortunate enough to be able to pay for the high insurance
premiums that allow private insurance companies to reimburse us more
"adequately."

http://www.nchc.org/facts/coverage.shtml
http://www.nytimes.com/2009/06/05/opinion/05krugman.html?scp=3&sq=krugman&st=Search

EMAIL #1

-----Forwarded by Brandon on 06/05/2009 07:41PM -----

To: Brandon
Date: 06/05/2009 06:16PM
Subject: Action Alert

Action Alert Update: Oppose a Medicare-based public plan More Info Contact your Senators TODAY! Last week I sent an Action Alert asking you to contact your U.S. Senators and urge them to oppose a Medicare-based public plan. If you have not yet taken action, I urge you to do so immediately. Your action on health care reform has never been more crucial. As a result of developments this week, it appears all but certain that the key Senate committees are proceeding with legislation that includes a public plan option - a government sponsored health plan that would compete with commercial health insurance products. Though the ASA has not taken a stand either for or against a public plan, we have a strong stand against any public plan whose payment to anesthesiologists is based on Medicare rate. Please urge your Senators to reject a Medicare-based public plan, and to ensure that physicians can voluntarily participate. Please contact your Senators today: Call the Capitol Switchboard, (202) 224-3121, and ask to be connected to your Senators Use CapWiz to send emails (templates are provided at this link) Recently released documents suggest that key U.S. Senate health care committees-the Senate Finance Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee-are likely to propose the creation of a new government plan when they unveil their health system reform legislation in the coming weeks. According to one document circulating around Capitol Hill, this new plan or "public option plan" would be based upon Medicare payment levels. Additionally, participation in the plan would be mandatory. Just days ago, President Obama sent a letter to Senate Finance Committee Chairman Max Baucus (D-MT) and HELP Committee Chairman Edward Kennedy (D-MA) urging inclusion of "a public health insurance option operating alongside private plans." As ASA has consistently stated, we remain open to a wide range of options for health reform. However, any public plan option considered by Congress must NOT be based on Medicare's unacceptably low payments. As it stands, Medicare pays 33% of what private insurers pay for anesthesia services (according to the U.S. Government Accountability Office - GAO-07-463) and significantly discounts payments for pain services. An extension of this broken payment system would severely damage our specialty. Further, physicians should be able to voluntarily participate should a public plan be established. For those of you who have already responded to this action alert, thank you. Your involvement in our efforts will help ensure that Congress understands the unique challenges that our specialty faces. Your ASA Washington Office staff is available to answer questions or provide additional information. You can reach the office at (202) 289-2222. To stay up-to-date on the latest health care reform news, please use the following ASA tools: Visit ASA's Health Care Reform webpage Subscribe to ASA's RSS feed Sign up for the ASA Grassroots Network Join "ASA Grassroots Network" on Facebook Follow @ASAGrassroots on Twitter We are at a critical juncture. Please contact your U.S. Senators and urge them to oppose a Medicare-based public plan, and to allow physicians and hospitals to voluntarily participate should a public plan be created.

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NYT: New trends in practicing medicine!

If All Doctors Had More Time to Listen

By JULIE WEED

Published: June 6, 2009

(Dr. Lili Sacks moved to a clinic in Seattle that focuses on longer appointments. She now sees up to 12 patients a day instead of 25.--->)

(<---Dr. José Batlle invested in technology to reduce administrative costs, saving enough to move into a new office in Manhattan.)

WHEN Dr. José Batlle met his 93-year-old patient in her small Bronx apartment, she didn’t have much furniture beyond a small TV, a sofa and a wheelchair. What she did have in abundance were pills — 15 types from a variety of doctors, including a pulmonologist, a cardiologist and a gerontologist. He discovered that some medicines had expired, others were unnecessary and some were dangerous if taken together.

Sitting with his patient and her son, Dr. Batlle cut the number of her medicines to four. He also gave the family his personal cellphone number.

Before coming to see him, the woman had endured several emergency-room visits and hospital stays. With Dr. Batlle, she was able to avoid all of that.

Calling a doctor on his cell? No waiting for an appointment? It’s the type of service that Dr. Batlle tries to offer to all of his 1,500 patients. “I prefer to keep them healthy than treat them when they are sick,” he says.

The efforts of Dr. Batlle and other primary care physicians may get a boost at the federal level. The Obama administration is considering ways to persuade medical students to pursue careers in primary care by raising their pay, and is channeling them to work in underserved rural areas. And the White House has already set aside $2 billion for community health centers through the economic stimulus package.

But more far-reaching health care reform remains an uncertainty, and in the interim a small but growing number of doctors are trying to take matters into their own hands.

By stepping off the big-clinic treadmill, where doctors are sometimes asked to see a different patient every 15 minutes, Dr. Batlle has joined the vanguard of physicians trying to redefine health care. These doctors spend more time with patients, emphasize prevention and education to keep them healthy and can handle many medical problems without referrals to specialists.

In many cases, this kind of care can reduce a patient’s medical bills. That’s more crucial than ever: according to a study published online by the American Journal of Medicine, 60 percent of all bankruptcies in the United States in 2007 were driven by health care costs.

Exact numbers are hard to come by, but doctors involved in this movement, called “patient centered” practices, say its popularity is growing.

“I travel to a lot of medical conferences, and I’m meeting more and more doctors embarking on this path,” said Dr. L. Gordon Moore, who runs IdealMedicalPractices.org, a program to help small practices become more innovative and efficient. The Web site IdealMedicalHome.org has about 800 doctors who post and trade ideas, while more than 700 physicians have adopted methods from HowsYourHealth.org. Many of these doctors see fewer patients per day than they did before.
To make personalized care possible in an era when compensation is often tied to the number of patients they see, doctors use technology to streamline processes and reduce administrative costs. Dr. Batlle, for example, uses online appointment scheduling and manages his medical records electronically. He prescribes medications from his computer and offers virtual visits by phone and e-mail.

It cost Dr. Batlle about $25,000 to buy the technology to make all of this possible, but he estimates that he saves close to $100,000 a year in salaries and billing costs. And he has made enough money to begin renovations on a new office in Washington Heights in Manhattan.

The model seems to be working, according to a 2008 study by Dr. John H. Wasson at Dartmouth Medical School. His research showed that patients in patient-centered practices were more likely to say they were informed about how to manage chronic diseases and got the care they needed, compared with those in a national sample of medical practices. They also were less likely to say they had to wait for an appointment.

“If the goal is to deliver patient care when and how they want and need it, this is the way to go,” Dr. Wasson said.

Of course, even doctors in this movement acknowledge that it is not a panacea for the country’s health care problems. Privacy advocates warn that electronic patient records can be breached, and computer glitches can make patient records inaccessible for hours. Big clinics can be better for people who have several health problems and need easy access to a variety of specialists. Moreover, some doctors may not want to leave a big clinic because they feel they lack the technical or business skills they need — or because a salaried job there may be more stable in this economy.

And while the patient-centered movement is growing, the nation may not be able to afford to have all its primary care doctors reduce the number of patients they see. Across the country, primary care physicians are in short supply, in part because average salaries for family practitioners are the lowest of any medical specialty. According to a 2008 survey of physician salaries by the American Medical Group Association, their average annual salary is $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon.

“Medical school loans can be so high, you need to be a specialist to pay them back,” Dr. Batlle said. “But our country doesn’t need yet another sleep apnea specialist.”

LILI SACKS, a primary care doctor in Seattle, says she began thinking differently about her work on the day she realized she was beginning each appointment with the words, “Sorry I’m late.”
Scheduled to see as many as 25 patients a day at a large clinic, she lacked the time for thorough examinations and discussions. Because of this, she said, primary care doctors are often forced to order tests and send patients to specialists.

“Could I have helped some people without specialists and tests? Absolutely,” said Dr. Sacks. “Would it have saved the patient and the insurance company both money? Absolutely. Is the system set up for the best care and cost efficiency? Absolutely not.”

Dr. Sacks said she worried that seeing so many patients would lead to errors. Last year, she moved to a clinic that focuses on longer patient appointments, 30 to 60 minutes. This translates to 10 to 12 patients a day. Patients also communicate directly with her by phone or e-mail.
During those longer appointments, Dr. Sacks can perform basic lab tests and simple procedures, so patients see fewer specialists.

“I probably head off a handful of emergency-room visits and hospital stays every month because patients can see me as soon as they have a problem, and I can be thorough rather than rushed,” she said.

One patient who avoided the emergency room was Todd Martin, a store manager in Seattle who went to Dr. Sacks’s clinic on a Saturday.

“I couldn’t stop coughing and was having trouble breathing,” Mr. Martin said. “They were able to see me and give me a chest X-ray.”

Mr. Martin said he spent $40 for the resulting prescription but the rest was covered by a monthly fee he pays Dr. Sacks. “A weekend visit to the E.R. would have easily cost $1,000,” he said.

Dr. Sacks charges patients a direct monthly fee of $54 to $129 based on age, and she doesn’t take insurance. Her office calls its philosophy “direct practice” because it’s a direct contract between doctor and patient. But she advises patients to obtain insurance plans to cover large, unexpected health costs like those to treat cancer or a heart attack.

“We say it’s like having a car and paying for your own oil changes and tuneups, but getting insurance in case you need a big repair,” she said.

Dr. Garrison Bliss, who in 2007 founded the group where Dr. Sacks works, has offered direct-practice services since 1997. He says patients can save 15 to 40 percent of their medical costs by using this model, based on his examination of insurance rates and his belief that good primary care can fill most of a patient’s needs.

Insurance plans that cover every little thing can be very expensive, Dr. Bliss said. He said that a patient who paid an annual fee at his clinic and took out a higher-deductible insurance plan would usually come out ahead, even if the patient’s health needs meant that he or she had to pay the entire deductible.
Dr. Bliss’s office operates with just two administrative employees for seven doctors. He estimates that if he took insurance, one or two administrative workers would be needed per doctor.

Insurance administration costs can take a big bite out of a practice’s revenue. A recent Weill Cornell Medical College study found that a third of the money received by primary care physicians pays for interactions between a doctor’s practice and patients’ health plans.

Patricia Rogers Caroselli, a retired assistant principal who is a patient of Dr. Sacks, dreaded going to her former clinic. “The waiting room was always noisy and crowded,” she said. In the examining room, she felt that she should “get in and out and not waste the doctor’s time with questions,” she said.
In contrast, she said, she appreciates the friendly calm of Dr. Sacks’s new surroundings and the personal attention. “Everyone should have this kind of patient care,” she said.

Dr. Sacks said the financial mechanics of the direct-practice model match her medical goals. When she was compensated based on insurance, she was paid every time she saw a patient. Now, if she can use education and prevention to reduce office visits, she and her patients benefit, she said.

“Having more time to sit with each patient has made me a better doctor,” she said. “I had a disabled patient that I saw for 13 years. Until she came to my new clinic, I never had the time to learn the details of her accident and the resulting complications. I was always treating whatever the immediate concern was.”

TECHNOLOGY has helped many doctors reduce costs. Dr. Batlle says he has been building his arsenal of technology solutions one by one, with “lots of trial and error,” for eight years.
Recently, he saw a 52-year-old patient with hypertension. As he examined the patient, noting blood pressure and other vital signs, he entered the information into his laptop computer to add to the patient’s electronic medical record. He also typed in the codes for billing and insurance.

The patient wondered if he was due for a prescription refill, so Dr. Batlle checked his computer again, found that he was, and hit a button to send the refill request to the pharmacy. As the patient left, Dr. Batlle hit the keyboard to send the bill electronically to the insurance company.

“He’ll even go to the Web to schedule his follow-up appointment,” Dr. Batlle said. “I don’t pay a receptionist to sit and answer phones.”

Dr. Batlle says other doctors could outfit an office for less than the $25,000 he spent on technology.
“Most doctors think they need to hire two receptionists, a billing person and two nurses to run a primary care office,” he said. “But they can learn about these technologies from other doctors, and the software salespeople do some training.”

Some physicians hire consultants to find and install the right equipment. Doctors who want to switch to electronic health records may also receive financial support from the government through the stimulus package.

By using new technology and streamlining processes, small primary care practices can reduce their costs to half of what a typical practice pays, from about 60 percent of income down to 30 percent, Dr. Wasson said. He said that doctors who focus on reducing their costs can see fewer patients without sacrificing income. Dr. Sacks said she and her colleagues didn’t have to take a pay cut when they moved to Dr. Bliss’s practice.

As Congress and the Obama administration begin to focus more closely on health care, some primary care doctors are weighing in. Dr. Bliss, for instance, has been to Washington twice in the last month to share his ideas with legislators. He knows he’s in a debate with powerful voices, especially insurance companies and hospitals. So he and other doctors are encouraging patients to speak up as well.

“We need to bring the patients to the barricades with us,” Dr. Batlle says.

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NYT: Shortage of Doctors Proves Obstacle to Obama Goals

http://www.nytimes.com/2009/04/27/health/policy/27care.html?hp

By ROBERT PEAR

Published: April 26, 2009

WASHINGTON — Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.

Multimedia

Graphic

Primary Care Providers in Short Supply

The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans.
One proposal — to increase Medicare payments to general practitioners, at the expense of high-paid specialists — has touched off a lobbying fight.
Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits.
Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs.
The need for more doctors comes up at almost every Congressional hearing and White House forum on health care. “We’re not producing enough primary care physicians,” Mr. Obama said at one forum. “The costs of medical education are so high that people feel that they’ve got to specialize.” New doctors typically owe more than $140,000 in loans when they graduate.
Lawmakers from both parties say the shortage of health care professionals is already having serious consequences. “We don’t have enough doctors in primary care or in any specialty,” said Representative Shelley Berkley, Democrat of Nevada.
Senator Orrin G. Hatch, Republican of Utah, said, “The work force shortage is reaching crisis proportions.”
Even people with insurance have problems finding doctors.
Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”
To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.
Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.
“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.
The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.
Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.
“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”
The Association of American Medical Colleges is advocating a 30 percent increase in medical school enrollment, which would produce 5,000 additional doctors each year.
“If we expand coverage, we need to make sure we have physicians to take care of a population that is growing and becoming older,” said Dr. Atul Grover, the chief lobbyist for the association. “Let’s say we insure everyone. What next? We won’t be able to take care of all those people overnight.”
The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased.
“Some of the newly insured patients still rely on hospital emergency rooms for nonemergency care,” said Erica L. Drazen, a health policy analyst at Computer Sciences Corporation.
The ratio of primary care doctors to population is higher in Massachusetts than in other states.
Increasing the supply of doctors could have major implications for health costs.
“It’s completely reasonable to say that adding more physicians to the work force is likely to increase health spending,” Dr. Grover said.
But he said: “We have to increase spending to save money. If you give people better access to preventive and routine care for chronic illnesses, some acute treatments will be less necessary.”
In many parts of the country, specialists are also in short supply.
Linde A. Schuster, 55, of Raton, N.M., said she, her daughter and her mother had all had medical problems that required them to visit doctors in Albuquerque.
“It’s a long, exhausting drive, three hours down and three hours back,” Ms. Schuster said.
The situation is even worse in some rural areas. Dr. Richard F. Paris, a family doctor in Hailey, Idaho, said neighboring Custer County had no doctors, even though it is larger than the state of Rhode Island. So he flies in three times a month, over the Sawtooth Mountains, to see patients.
The Obama administration is pouring hundreds of millions of dollars into community health centers.
But Mary K. Wakefield, the new administrator of the Health Resources and Services Administration, said many clinics were having difficulty finding doctors and nurses to fill vacancies.
Doctors trained in internal medicine have historically been seen as a major source of frontline primary care. But many of them are now going into subspecialties of internal medicine, like cardiology and oncology.

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AMSA: Is nutrition getting its just desserts in medical school?

Is nutrition getting its just desserts in medical school?
The New Physician, April 2009

by Linda Childers	Volume 58, Issue 3

“An apple a day keeps the doctor away” might be a good mantra for medical students and residents. Experts say physicians-in-training need an increased understanding of nutrition to effectively meet the current and future demands of the medical profession.

“Nutrition is a high priority among medical professionals across the nation, and a huge primary health indicator when it comes to conditions including osteoporosis, cancer, heart disease and diabetes,” says Dr. Patrick McBride, associate dean of students at the University of Wisconsin School of Medicine and Public Health (UW) and a family physician specializing in preventive cardiology. McBride recently served as chairman of the Association of American Medical Colleges committee that drafted curriculum guidelines for teaching students about overweight and obesity.

In the past, nutrition education hasn’t always been a part of the core curriculum at many medical schools. If the subject is taught, it’s often incorporated into other courses, like biochemistry or pathology, or offered as an elective. Responding to concerns about the prevalence of nutrition education in medical schools, in 1994 the National Academy of Sciences called for improved nutrition education at all U.S. medical schools. In addition, the Healthy People 2010 report, published by the U.S. Department of Health and Human Services, also identified the need for physician counseling and education relating to diet and disease.

While nutrition education in medical school has increased over the past two decades, experts say there is room for improvement. A study published in the April 2006 issue of the American Journal of Clinical Nutrition found that 60 percent of medical schools in this country are not meeting minimum recommendations for their students’ nutrition education.

Historically, one of the barriers to medical nutrition education has been a lack of consensus on what concepts should be taught.

Without a clear home for nutrition, some came to view the subject as alternative medicine. “We don’t see nutrition as complementary and alternative medicine. We see it as an emerging mainstream medical specialty,” says Dr. Lisa Neff, who sits on an ad hoc subcommittee within the American Society for Nutrition’s Graduate and Professional Education Committee. “Much of complementary and alternative medicine has not been science-based or evidence-based, although that is changing somewhat…. But nutrition has always been a science-driven field.”

Neff, a clinical scholar at Rockefeller University, believes that views are changing. “There are probably some schools where nutrition is still not as represented as we’d like it to be, by clinical nutrition experts.”

This changed nine years ago when the National Heart, Lung and Blood Institute selected 21 medical schools to receive a five-year, $1 million Nutrition Aca¬demic Award. UW was one of the schools to receive the grant.

In addition to the Nutrition Academic Award, Step 1 now has a nutrition sub-score. Though individual students can’t find out their own sub-score, schools do find out how their students as a whole score on nutrition. Asking the school about its students’ performance on the nutrition sub-score could lend some traction to curricular change.

Learning How to Prevent Disease

According to the Centers for Disease Control and Prevention (CDC), obesity in America has increased dramatically in the past 20 years. As a result, doctors are seeing more patients with metabolic syndrome, a cluster of cardiovascular disease and diabetes risk factors.

McBride co-directs a comprehensive clinical preventive cardiology program with more than 20 professional staff members. The program includes inpatient and outpatient cardiac rehabilitation, one of the United States’ first preventive cardiology and cholesterol clinics, and a diabetes prevention program.

“There’s a bevy of medical literature that says diet and exercise can be just as effective as medication in treating and preventing illnesses,” McBride says.

While most doctors agree on the importance of nutrition education for patients, some disagreement remains about who should provide patients with this kind of counseling. With the New England Journal of Medicine reporting that the average medical office visit lasts 18 minutes, many physicians may feel they don’t have the time, or expertise, to make nutrition recommendations.

Partnering With Dietitians

Lisa Hark, a nutrition expert and director of the Nutrition Education Program at the University of Pennsylvania School of Medicine, advises medical students to shadow a dietitian and for residents and doctors to partner with nutritionists who can help guide their patients in making smart lifestyle choices.

Hark, a registered dietician who holds a doctorate in education, has partnered with Dr. Darwin Deen, a family physician and professor of family medicine at the Albert Einstein College of Medicine, to write several books, including The Complete Guide to Nutrition in Primary Care, that help clinicians counsel patients on diet and lifestyle. The book offers practical guidance on nutrition counseling in the office setting and nutritional recommendations throughout life.

Doctors can use such resources to build a team approach to nutrition education in their practices.

“There are so many resources out there to help doctors,” McBride says. “In many cases dietitians are underutilized.”

“If you are a primary care physician, for example, you are going to get all kinds of questions about nutrition, many of which you may not be able to answer if you haven’t had appropriate training in nutrition,” Neff says.

In this case, physicians need to be able to turn to a registered dietician.

“As busy professionals, [physicians] may not—or probably will not—have the time to keep up on all the literature, and so a dietician, who will keep up on the nutrition literature for you and counsel your patients, that is a really important relationship to have.”

The issue of reimbursement has also been an obstacle in promoting nutrition education among physicians. While in¬surance companies don’t readily reimburse physicians for preventive nutrition counseling, McBride says he has had suc¬cess in working with insurers directly.

“I’ve found many insurers who are very interested in the concept of preventive education and are willing to provide reimbursement for programs that benefit health outcomes,” he says.

Nutrition Begins in the Medical School Cafeteria

Over the years, medical schools have discovered that students become more interested in nutrition when they see how it applies to their own lives. In addition to their classroom nutrition studies, medical students at UW are served a hot buffet-style lunch that meets nutrition guidelines and demonstrates a healthy eating plan.

McBride says these meals show students that healthy food can also taste good, and that moderation is key. Students also learn by logging the food they have eaten over a two-day period in a computer program that tells them how closely their selections match the national food pyramid. Some studies have shown that doctors who make improvements in their own eating habits are more likely to give good nutrition ad¬vice to their patients.

“We also teach our students to ex¬amine their eating habits through the eyes of a person who may have diabetes or high cholesterol to see where they might make dietary changes,” McBride says.

At Gundersen Lutheran Health System in La Crosse, Wisconsin, nutrition is simplified through a healthy eating program called the 500 Club, coordinated by registered dietitians and recommended by physicians. In the hospital cafeteria and throughout the region, grocery stores, vending machines and restaurants carry selections with the 500 Club logo. Those selections contain 500 calories and 15 grams of fat or less.

Doctors and medical residents at Gundersen use the 500 Club brochures when talking to patients about dietary changes. The medical center’s Winning Weighs program complements the 500 Club selections with 12-week programs offering practical dietary advice.

The Future of Nutrition In Medicine

With research showing that lifestyle interventions can be very powerful, often reducing the need for medications, more patients are turning to their doctors for nutrition advice.

“It’s important for physicians to start the nutrition conversation with patients, even if they ultimately refer them to a dietitian,” says Jo Ann Carson, a professor of clinical nutrition at University of Texas Southwestern Medical School, who holds a doctorate in nutritional science. “Most patients view their doctor as a trusted source of information, and they do pay attention to their [doctor’s] recommendations.” Even patients who are on prescription medications can benefit from sound nutrition advice.

“Sometimes prescribing a pill can seem easier than finding out the sources of saturated fat in a patient’s diet,” Carson says. “But learning your patient drinks five sodas a day and suggesting they switch to water can have a significant impact on their overall health.”

With the CDC reporting that 1.7 million Americans die and 25 million are disabled each year by chronic diseases caused or made worse by unhealthy lifestyles, the need for medical students to learn lifestyle medicine has never been greater.

“It’s so important to help patients understand how their daily habits and practices can impact their health and quality of life,” Carson says. “Showing them how to make good nutrition choices and lifestyle changes is often the best medicine.”

Resources

The American Society for Nutrition encourages nutrition education for physicians-in-training through awards and support materials. www.nutrition.org

The American Journal of Lifestyle Medicine is a compendium of prevention-focused, peer-reviewed research that reaches 20,000 physicians every other month. ajl.sagepub.com

The Nutrition in Medicine series is a comprehensive guide to nutrition designed to educate medical students about key health issues. The series is based on the nationally acclaimed nutrition curriculum developed at the University of North Carolina at Chapel Hill. www.pogohealtheducation.com

The book Food and Nutrients in Disease Management (CRC Press, January 2009), developed for doctors by Hopkins-trained Dr. Ingrid Kohlstadt and written by 64 doctors and experts, addresses 60 recurrent and chronic medical conditions where food and nutrients have proven to be beneficial. Recipients of the Nutrition Academic Award came up with a 65-page curriculum guide that includes coverage of nutrition counseling, clinical nutrition care, pediatric nutrition, hypertension and a host of other topics. www.nhlbi.nih.gov/funding/training/naa/curr_gde.pdf

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NYT: U.S. to Compare Medical Treatments

http://www.nytimes.com/2009/02/16/health/policy/16health.html?emc=eta1

By ROBERT PEAR

Published: February 15, 2009

WASHINGTON — The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.

The soaring cost of health care is widely seen as a problem for the economy. Spending on health care totaled $2.2 trillion, or 16 percent of the nation’s gross domestic product, in 2007, and the Congressional Budget Office estimates that, without any changes in federal law, it will rise to 25 percent of the G.D.P. in 2025.

Dr. Elliott S. Fisher of Dartmouth Medical School said the federal effort would help researchers try to answer questions like these:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of “talk therapy” and prescription drugs to treat mild depression?

How do drugs and “watchful waiting” compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient’s blood pressure and weight?

For nearly a decade, economists and health policy experts have been debating the merits of research that directly tackles such questions. Britain, France and other countries have bodies that assess health technologies and compare the effectiveness, and sometimes the cost, of different treatments.

Hillary Rodham Clinton, as a senator, was an early champion of “comparative effectiveness research.” Mr. Obama, who is expected to sign the stimulus bill Tuesday, endorsed the idea in his campaign for the White House.

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.

In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person’s health care by enforcing clinical guidelines and treatment protocols.

The money will be immediately available to the Health and Human Services Department but can be spent over several years. Some money will be used for systematic reviews of published scientific studies, and some will be used for clinical trials making head-to-head comparisons of different treatments.

For many years, the government has regulated drugs and devices and supported biomedical research, but the goal was usually to establish if a particular treatment was safe and effective, not if it was better than the alternatives.

Consumer groups, labor unions, large employers and pharmacy benefit managers supported the new initiative, saying it would fill gaps in the evidence available to doctors and patients.

“The new research will eventually save money and lives,” said Representative Pete Stark, Democrat of California.

The United States spends more than $2 trillion a year on health care, but “we have little information about which treatments work best for which patients,” said Mr. Stark, who is the chairman of the Ways and Means Subcommittee on Health.

In the absence of information on what works, Mr. Stark said, patients are put at risk, and billions of dollars are spent each year on ineffective or unnecessary treatments.

Steven D. Findlay, a health policy analyst at Consumers Union, said the action by Congress was “a terrific step on the road to improving the quality of care and making it more efficient.”

But critics say the legislation could put the government in the middle of the doctor-patient relationship.

Bureaucrats “will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost-effective,” Betsy McCaughey, a former lieutenant governor of New York, wrote on Bloomberg.com. Rush Limbaugh broadcast the charges to millions who listen to his radio talk show.

Lawmakers and lobbyists agree that researchers should compare the clinical merits of different treatments. Whether they should also consider cost is hotly debated.

Representative Charles Boustany Jr., a Louisiana Republican who is a heart surgeon, said he worried that “federal bureaucrats will misuse this research to ration care, to deny life-saving treatments to seniors and disabled people.”

The House Appropriations Committee inadvertently stoked such concerns in a report accompanying its version of the economic recovery bill. It said that research comparing different treatments could “yield significant payoffs” because less effective, more expensive treatments “will no longer be prescribed.”

A similar proposal was included in a recent book by Tom Daschle, who had been Mr. Obama’s nominee for health secretary, and Jeanne M. Lambrew, who is the deputy director of the Office of Health Reform in the Obama White House.

Women and members of minority groups expressed concern about that approach. Drugs and other treatments can affect different patients in different ways, they said, but researchers often overlook the differences because their studies do not include enough women, blacks or Hispanics.

“Some drugs appear to be more effective in women than in men, while other medicines are more likely to cause serious complications in women,” said Phyllis E. Greenberger, the president of the Society for Women’s Health Research. “It’s important to look for these sex-based differences.”

In a letter to House leaders, the Congressional Black Caucus said, “We are concerned that comparative effectiveness research will be based on broad population averages that ignore the differences between patients.”

House and Senate negotiators tried to address these concerns. The final bill says that the research financed by the federal government shall include women and members of minority groups.

Moreover, in a report filed with the bill, the negotiators said they did not intend for the research money to be used to “mandate coverage, reimbursement or other policies for any public or private payer.”

Congress did not say exactly how the findings should be used. Private insurers can use the data in deciding whether to cover new drugs and medical procedures, but it is unclear how Medicare will use the information.

Under existing law, Medicare generally covers any treatment that is “reasonable and necessary for the diagnosis or treatment of illness or injury,” and the agency does not have clear legal authority to take costs into account when deciding whether to cover a particular treatment.

Andrew Witty, the chief executive of the pharmaceutical company GlaxoSmithKline, said European officials often considered the costs as well as the clinical benefits of new drugs — with mixed results.

“Comparative effectiveness is a useful tool in the tool kit, but it’s not the answer to anything,” Mr. Witty said in an interview. “Other countries have fallen in love with the concept, then spent years figuring out how on earth to make it work.”

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NYT: For Uninsured Young Adults, Do-It-Yourself Health Care

http://www.nytimes.com/2009/02/18/nyregion/18insure.html?emc=eta1

Fred R. Conrad/The New York Times

Alanna Boyd, 28, received bills totaling $17,398 after being treated for diverticulitis at a Manhattan hospital in October. Ms. Boyd is one of the nation's 13.2 million uninsured young adults.

By CARA BUCKLEY

Published: February 17, 2009

They borrow leftover prescription drugs from friends, attempt to self-diagnose ailments online, stretch their diabetes and asthma medicines for as long as possible and set their own broken bones. When emergencies strike, they rarely can afford the bills that follow.

“My first reaction was to start laughing — I just kept saying, ‘No way, no way,’ ” Alanna Boyd, a 28-year-old receptionist, recalled of the $17,398 — including $13 for the use of a television — that she was charged after spending 46 hours in October at Beth Israel Medical Center in Manhattan with diverticulitis, a digestive illness. “I could have gone to a major university for a year. Instead, I went to the hospital for two days.”

In the parlance of the health care industry, Ms. Boyd, whose case remains unresolved, is among the “young invincibles” — people in their 20s who shun insurance either because their age makes them feel invulnerable or because expensive policies are out of reach. Young adults are the nation’s largest group of uninsured — there were 13.2 million of them nationally in 2007, or 29 percent, according to the latest figures from the Commonwealth Fund, a nonprofit research group in New York.

Gov. David A. Paterson of New York has proposed allowing parents to claim these young adults as dependents for insurance purposes up to age 29, as more than two dozen other states have done in the past decade. Community Catalyst, a Boston-based health care consumer advocacy group, released a report this month urging states to ease eligibility requirements to allow adult children access to their parents’ coverage.

“There’s a big sense of urgency,” said Susan Sherry, the deputy director of Community Catalyst. She described uninsured young adults as especially vulnerable. “People are losing their jobs, and a lot of jobs don’t carry health insurance. They’re new to the work force, they’ve been covered under their parents or school plans, and then they drop off the cliff.”

If Governor Paterson’s proposal is approved, an estimated 80,000 of the 775,000 uninsured young adults across New York State would be covered under their parents’ insurance plans. That would leave hundreds of thousands to continue relying on a scattershot network of improvised and often haphazard health care remedies.

In dozens of interviews around the city, these so-called young invincibles described the challenge of living in a high-priced city on low-paying jobs, where staying healthy is one part scavenger hunt and one part balancing act, with high stakes and no safety net.

“For a lot of people, it’s a choice between being able to survive in New York and getting health insurance,” said Hogan Gorman, an actress who was hit by a car five years ago and chronicled her misadventures in “Hot Cripple,” a one-woman show that was a hit at last summer’s Fringe Festival. “There was no way that I could pay my rent, buy insurance and eat.”

Nicole Polec, a 28-year-old freelance photographer living in Williamsburg, Brooklyn, said she has attention deficit hyperactivity disorder and has a client who procures Ritalin on her behalf from a sympathetic doctor who has seen Ms. Polec’s diagnosis. Ms. Polec’s roommate, Fara D’Aguiar, 26, treated her last flu with castoff amoxicillin — “probably expired,” she said — given to her by a friend.

When Robert Voris last had health insurance, in 2007, he stockpiled tubing for insulin pumps, and other supplies. He said the tubing cost $900 a month, so lately he has instead been injecting insulin with a syringe. But Mr. Voris, 27, a journalism student at the City University of New York who works at a restaurant in Park Slope, Brooklyn, is constantly worried about diabetes-induced seizures like the one that sent him to the hospital last summer. (Because it happened at work, his boss covered the ambulance and other bills.)

“That’s definitely the concern: what happens if I have to pay for this?” he said. “And the answer, I guess, is credit cards. Hopefully it won’t happen until I find a job that actually gives me insurance, which probably won’t happen anytime in the near future, given the way the economy works.”

Most family insurance policies cut off dependents when they turn 19 or finish college, and many young adults start out in New York cobbling together part-time or freelance work with no benefits. To qualify for Medicaid, a single adult can earn no more than $706 a month — less than what a full-time minimum-wage earner makes. Yet the average insurance premium for a single adult is $900 a month, according to a spokesman for the State Insurance Department.

“At this point, I can’t really justify it monetarily,” said Ian McElroy, a musician who moved to Bushwick, Brooklyn, from Omaha, last year. “It’s not like I think I’m invincible, I’m 29, the world can’t touch me. It’s the very opposite of that. I’ve got to make rent and eat.”

With insurance out of reach, Mr. McElroy has taken to playing doctor, using online resources like WebMD, which offers medical news, descriptions of various diseases and drugs, and discussion groups. As he spoke, Mr. McElroy was icing his feet, which, one day in January, had become cripplingly painful; he was unable to walk.

“I think I have plantar fasciitis,” he said. “I’ve been laid out for two weeks.”

(Even if the Paterson proposal passes, Mr. McElroy, like Mr. Voris and Ms. Polec and her roommate, would not qualify because their parents live out of state.)

Internet diagnoses, self-medicating and trading prescriptions, of course, come with potentially dangerous side effects. Dr. Barbie Gatton, who has worked in emergency rooms throughout the city since 2002, said she often sees young people who have taken the wrong antibiotics borrowed from friends.

“We see people with urinary tract infections taking meds better suited for ear infections or pneumonia — the problem is, they haven’t really treated their illness, and they’re breeding resistance,” she explained. “Or they take pain medicine that masks the symptoms. And this allows the underlying problem to get worse and worse.”

There are clinics throughout the city that provide the young and uninsured free or cheap snippets of medical help, like the Community Healthcare Network mobile unit, which was parked in the East Village one snowy night. Lindsay Bellinger, 26, who does administrative work through a temp agency and lives in Astoria, Queens, said she relied on the mobile unit for pap smears and tests for sexually transmitted diseases.

“This takes care of gynecological work,” Ms. Bellinger said. “And I get a visit to the dentist from my parents as a Christmas gift.”

Levon Aaron, who has asthma and works as a bouncer at a West Village bar, has not had insurance since he was 19. Mr. Aaron, now 23, said that his asthma attacks had been less frequent since he began playing handball and working out, but they had not gone away. He tries to use his inhalers sparingly, but four times in the past year he has found himself out of medicine during a severe attack and landed in the emergency room.

In the hospital, he gets a prescription for a new inhaler, which costs about $30 to fill. But his outstanding bills total about $3,000, he said, an amount he cannot fathom paying.

Mr. Aaron was one of several young adults who said living without insurance meant trying to take better care of themselves.

“I’ve stopped eating fast food,” said Santiago Betancour, who is 19 and lives in Rosedale, Queens. “I’m eating rice, vegetables and fruits. And when I get sick, I exercise to sweat it off.”

Of course, there are those who do feel invincible, like Eric Williams, who is 24, unemployed and currently in the middle of a six-week snowboarding adventure in Wyoming, Montana, Colorado, Utah, British Columbia and California. Mr. Williams said by cellphone near Bozeman, Mont., that he looked into buying health insurance before he left, but abandoned the idea after being unable to find anything for less than $400 a month. Instead, he is just trying to be careful, though not always with success.

“I’ve hit a couple of trees,” Mr. Williams said. “But I’m trying not to.”

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