A guest post by Val Jones, MD.

On the eve of our second presidential debate, I had the chance to interview Dr. Ken Thorpe, Executive Director of the Partnership to Fight Chronic Disease (PFCD), about America’s healthcare crisis. Here’s what he had to say (click here to listen to the podcast):

1. I was part of a press conference call with you and former Secretary of HHS, Tommy Thompson last week. I learned that the economic burden of chronic disease is the rough equivalent of two Wall Street bailouts a year. Can you describe the scope of the crisis to our listeners?

About 75% of what we spend on healthcare is associated with chronically ill patients. That’s about 1.6 trillion dollars per year. Chronic disease accounts for the biggest source of spending in the healthcare economy, and it’s also the fastest growing – as more and more people are living with chronic illnesses. If we’re really serious about getting to the bottom of the healthcare affordability crisis, we’ll have to first address the chronic disease issue.

2. We're starting to hear that healthcare is an economic security issue, do you agree, and if so, what is the link between healthcare and economic security?

There’s no question that healthcare is a major part of the economic security issue for several reasons. First of all, from an employer standpoint, they’re seeing health insurance premiums becoming a growing share of their cost of doing business. And it’s an area that they can’t control very well. For workers, insurance is crowding out increases in wages and eats up a rising share of a family’s income. At the federal level, healthcare costs (through Medicare and Medicaid) are on a trajectory to consume an ever increasing share of our economy unless we do something to curb the chronic disease burden.

3. During the presidential debate tomorrow, I'm hoping that Senators Obama and McCain discuss their views on our healthcare crisis - and that we get beyond the "who's going to pay" issue. What are you hoping they'll address?

I agree. I think the public is interested in hearing from the candidates on healthcare and economic issues, but they want specifics. They don’t want double-talk or finger pointing about who’s right and who’s wrong. They just want to understand what the candidates are proposing and what it means for them. How are they going to keep high quality healthcare and also afford it?

4. It seems that when the politicians in Washington talk about health care reform, they focus on the issue of the uninsured. Yet, when you look at the polls (including the most recent Kaiser Health08 Poll), voters want to hear candidates talk more about affordability or cost. Why the disconnect?

I think the politicians have been a little slow on the uptake on this issue until recently. The flip side of the uninsured issue is that 250 million Americans (85% of us) have health insurance and 96% of voters have health insurance. For them, the main issue is affordability. I think both candidates are aware of this, and it would be really helpful for the public to hear exactly what they’re proposing.

5. Do you think Americans understand the role of chronic disease in driving healthcare costs?

I don’t. The polling we’ve done suggests that only 15% of the American public understands the dominant role that chronic diseases play in terms of health status (morbidity) and healthcare spending. What we’ve tried to do at PFCD is help people to understand that if we’re going to reduce healthcare spending, we have to find new, innovative ways to reduce the share of Americans with chronic diseases and do a better job of managing them.

6. Can you give me a few examples of policies that would help to advance the notion of turning our "sick" care system into a true "health" care system?

We have to focus on primary prevention and finding ways to decrease smoking rates, improve nutrition, and start to bend the curve on the obesity epidemic in this country. Obesity rates have doubled since 1985 – so that 35% of Americans are now clinically obese. I think reversing this trend must begin in schools, followed closely by community-based interventions, with assistance from employers and productivity management initiatives.

7. Can you be more specific about initiatives that have worked?

Large employers like Citibank, Bank of America, and Johnson and Johnson have begun initiatives where employees are encouraged to get a health risk appraisal (so they understand their health risks) and then they’re offered a personalized list of activities that could help them reduce or maintain their current risk levels. Financial incentives, a culture of health in the employment setting, and having resources (like nurse practitioners) available at work sites can cut costs. Programs like this save $1.50 to $5.00 for every dollar spent.

Another good example is Hannaford Brothers grocery stores in the northeast. They’ve provided heart-healthy labeling on their food items. The higher the number of stars on the label, the healthier they are to eat. Primary care physicians in the community have pitched in to encourage patients with diabetes and other chronic diseases to purchase food with higher star values. Interestingly, the grocery stores have lost money on the no-star products, but have made up for the losses with lower healthcare costs for their employees.

8. As a physician, I'm very concerned about our dwindling primary care base and I think that prevention begins with a strong doctor-patient relationship. Unfortunately financial incentives reward procedures rather than patient education. In your view, are politicians sufficiently aware of this problem?

I think that politicians are aware that there’s a growing mismatch between the clinical needs of chronically ill patients and where our healthcare dollars are invested. Two things are likely to happen. First of all, MedPAC (which is the congressional advisory group that makes non-partisan recommendations to the congress on Medicare policy) will continue to call for ways to rebalance payments to primary care physicians versus specialists.

Second, we also have to build healthcare delivery models where we have the primary care physicians coordinating care, but we also have nurses and nurse practitioners executing on aspects of that care in order to extend the capacity of our physician base in the near term. We need more financial incentives for doctors to select primary care residency positions, and we need to have dieticians, mental health professionals, behavior modification specialists, nurses, and others helping the primary care physicians to influence their patients for the better.

9. What is the main message that the Partnership to Fight Chronic Disease is trying to get across to the American people?

Americans need to appreciate the dominant role that chronic diseases play in driving healthcare costs and impairing the health status of the population. They also need to know that there are things that we can do about this politically. We have a 110 member, bi-partisan organization that includes everyone from the Chamber of Commerce to the Labor Unions. No matter who’s in office, there’s an opportunity for us to encourage major health reform to improve the quality and affordability of care.

To listen to the podcast, click here.

Despite the potentially tough environment, there are some advantages to being a prison physician. Salary for a board-certified physician starts at almost $250,000 a year. Furthermore, there are some other perks that you may not have thought of:

There are no hassles with third-party payers, patients will always show up for their appointments, there is plenty of security, and there's no need for malpractice insurance.

The California Department of Corrections is hiring.

While watching the stock market dives 500 points today, Richard Reece gives an interesting take. Maybe the economic turmoil will force another look at rampant health care spending.

There will be an epiphany that no other solution exists except for the re-emergence of primary care. Perhaps it takes a catastrophic economic calamity to force our leaders to take the appropriate measures to save primary care, since it's the only answer to rein in health care costs.

Electronic records are a recent theme here. #1 Dinosaur give his take in a Medscape piece (registration required), calling the current crop of EMRs nor ready for widespread use:

The EMRs promise of a "paperless" office is as distant as ever. It's much easier to keep my efficient, time-tested paper charts than lay out thousands of dollars for hardware and software that aren't going to save time or money, or make a single substantive difference in the care that I deliver.

It's not that this dinosaur doesn't appreciate the advantages of living in a computerized world. However, after a careful evaluation of the present-day pros and cons of EMRs, I still say, "Make mine paper."

Doctors are not technology-adverse. But going digital has to be done with the right programs, and the current generation of EMRs aren't quite there yet.

For good reason. Both Shadowfax and ER Stories write about the addictive potential of this narcotic, and how there is really no positive indication for its use.

It seems like they all get work done, which is no surprise given the media attention.

Joe Biden's probable botox treatment is next to be analyzed by this plastic surgeon.

Dr. Wes alludes to his legal ordeal with anonymous comments. I applaud his stand not to take the offending comment or the post down. It's more than I would have done.

However, he did pay a price in terms of a hefty legal expense and three visits to court.

Comments are moderated here, and because of the legal uncertainty surrounding this issue, I am more aggressive filtering out questionable comments.

So I apologize in advance if I accidentally deleted a legitimate comment.

Massachusetts' emergency departments are overflowing with newly-insured patients. Don't want to say I told you so but I can't help it:

Doctors and counselors working the front lines of emergency care say a major reason patients still flock to their doors for routine care is that there are too few primary care physicians in Massachusetts. Some newly insured patients are waiting months for their first visits.

When you promise coverage without addressing physician access, this result is entirely predictable.

Why the Presidential candidates are not addressing poor physician access nationwide is a mystery to me. Those focusing on covering the uninsured will simply project the disaster happening in Massachusetts across the country.

Doctors are at odds with administrators in this California hospital. The administrators simply calls the physicians "whiners", and are ignoring the reasons behind the exodus of physicians.

I'm sure this scenario is being played out nationwide:

In our quarterly staff meetings, the number of doctor resignations outnumbers new medical staff. The morale among Memorial Hospital's medical staff is at an all-time low. The patented reply of Santa Rosa Memorial Hospital is that these doctors left due to circumstances beyond its control such as low Medicare reimbursement rates, high cost of doing business in California and high cost of living. But one factor that I never see reported is the hospital itself. The problems health care professionals encounter in day-to-day care at this hospital could fill pages. The focus is more on cost-cutting than on patient care. Physician and hospital administration communication is one-sided.

A recent editorial comments on Medicare's never-event policy.

There is no question that hospitals and doctors shouldn't be paid for catastrophic mistakes, like wrong-site surgery. However, the editorial seems to support the widespread expansion of the initiative:

In the long run, as the list of conditions is expanded and more insurers follow Medicare’s lead, the savings could be substantial.

Medicare is already proposing partially preventable conditions to be added to the list, like hospital-acquired infections and delirium. No guidelines exist to prevent these complications 100 percent. Bob Wachter, among others, has discussed this in detail.

Blaming doctors for complications that cannot be totally prevented will only disincline them from treating high-risk patients, like the elderly and those with chronic diseases.

The Times' editorial board should be careful what they wish for before trotting out their traditional anti-physician stance.

A technologist notes some of the pitfalls obstructing widespread EMR adoption. One important point is that those behind the systems don't know how doctors work, or what makes their lives easier.

Until they do, and can come up with systems that improve physician's lives, resistance will continue:

A large percentage of technology professionals are about the machine. They're about the what and the how. They're not about the who. It's easy to fall into the view that the system was working perfectly before people got to it. Technology is 90% people. What are they doing? What is the real need? Can we do this without adding a gadget? These are hard questions to ask, and the broken and cynical among us won't ask them. Sometimes they're right that no one will listen anyway.

A positive experience from this Houston internist.

Tellingly, one of the biggest problems is finding primary care physicians for patients who did not want to follow him into a retainer practice. As we know, those that take Medicare are becoming rare.

Most concierge practices are staffed by doctors fed up with the current system. But more newly graduated doctors are seeing the light, and going straight into these type of practices.

Off until Monday. Enjoy the weekend.

Raise their salaries 50 percent. Voila, problem solved.

These numbers are truly frightening (emphasis mine):

U.S. medical schools would produce 1850 graduates who would become primary care doctors engaged in direct patient care.

Let’s put that number in context. In 2002, in a landmark Health Affairs article . . . estimated the U.S. would be 50,000 physicians short by 2010 and 200,000 by 2020.

That's just nasty.

CNN's Sanjay Gupta gets altitude sickness while on assignment in Peru. (via Clinical Cases)

Cash-only cosmetic procedures are taking a hit in this difficult economy, with anecdotal reports of a 30 percent decline in demand.

Alexander Sterner writes in an op-ed that no young doctor is entering primary care Internal Medicine. The numbers are this residency program are emblematic of the nationwide trend:

Last year, Rush Presbyterian St. Lukes and Loyola University graduated more than 40 physicians trained in Internal Medicine. None will work as traditional primary care doctors. All but 6 chose to complete several more years of training as cardiologists, gastroenterologists, oncologists or nephrologists.

Of the six who will practice Internal Medicine, three chose to be "Hospitalists," who deliver care only to hospitalized patients. Three joined "boutique" practices, where they are highly paid to be on 24-hour call for entitled individuals, but do not accept Medicare or private insurance.

This is the first I've read where graduating residents are starting to go directly into boutique practices. Normally, established physicians are the ones who make the transition to concierge care. It's a disturbing that significant money is spent to train these doctors only for them to go to cash-only practices.

Dr. Sterner also takes a jab at universal health coverage:

"Universal Health care" threatens to cause "Universally unavailable Health care" by adding people to the mix, creating competition for appointments, increasing waiting times and shortening visits. Soon, an aged adult will have difficulty getting an appointment with his or her physician of choice.

He predicts a future where mid-levels will take over direct patient care, with doctors only in a supervisory role.

Many physicians don't accept Medicaid because of poor payments. Those that do often lose money.

As hospitals focus on the bottom line, benevolent physicians who dedicate their practice to treating the poor are finding themselves on the firing line.

Stories like this won't help any more doctors open their doors to Medicaid patients.

Thanks everyone for your comments on my piece on EMRs earlier this week.

It's interesting to follow the ensuing discussion around the blogosphere, and there were a few comments that caught my eye. Like this one:

Most of these computerized record systems are not ready for prime time! They have major faults - it can often take significantly more time to complete an electronic record than to dictate the same visit, dictated records often contain more nuanced information and explanations, and it is often harder to find information, at least in the system I am forced to use.

They are not as user friendly as the claim to be. Doctors are being forced to do jobs they were not trained to do, such as being the transcriptionist and billing and procedure coder.

Doctors are salaried; we are not paid by the hour. Pay us by the hour and either they will eliminate electronic records because of the extra time we need to complete them or they will be forced to invent more user friendly systems. I WANT MY PAPER CHARTS BACK!!!!

It takes a good year or two for doctors to be comfortable with an electronic record system. During that time, it takes significantly longer per patient visit.

When doctors are paid per encounter, that affects both their salary and the clinic's revenue stream.

I wonder indeed if doctors were paid by hour, would they be more accepting of the technology? I suspect so.

As it stands, today's EMRs are nowhere near ready for widespread use. Those wanting nationwide adoption need to realize doctors need a more polished, user-friendly product first.

There is no question that morale is at an all-time low in the medical profession.

I think it comes from an "us against the world" mentality, where physicians are increasingly alone against the forces of administrators, insurance companies, dissatisfied patients, major media, health policy experts and the government.

Many workplaces fail to acknowledge low morale, and this anesthesiologist talks about how it affects her.

We've talked earlier about the demise of the doctor's lounge.

But here's an example of the power of Twitter, a popular microblogging service. Imaging if doctors were connected here, and able to converse and curbside akin to a "virtual" lounge?

Take a look at this example, held within a span of 12 minutes.

Speaking of which, feel free to subscribe to this blog's Twitter feed.

Buckeye Surgeon recalls a time when he was stuck by a needle, and talks about the emotional turmoil that accompanies it:

Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable. Whether it's lump in the breast or a heart attack at age 47 or a sudden stroke or a car that runs a red light. Eventually, there's a needle stick that gets us all. And I think it hurts, initially, no matter how old you are when it happens.

Despite the very small chance of HIV transmission from a needle stick, it does little to lesson to worry.

Claudia Henschke is a staunch supporter of CT scans for lung cancer screening. As a radiologist, this is understandable and she stands to benefit financially if CT scans were widely accepted and covered by insurance companies.

Her zealotry has colored her research, as studies in the NEJM and The Oncologist have been called into question. In this editorial in the latter journal (via MedPage Today), an audit of her work is called for:

We have previously called for an audit and now more than ever, it is in the interests of all concerned, including the authors, the sponsors (i.e., National Cancer Institute, American Cancer Society, as well as an independent foundation that derived its major support from a tobacco company) that an impartial audit be conducted expeditiously.

Who is this rare breed?

Shadowfax gives the best, most convincing, case I've read supporting universal health care:

No, Health Care is not a right. When advocates of universal health care misuse the language of universal rights to push for health care for all, we fall into the trap of over-reaching and provoke a justified pushback, even from some who might be inclined to agree with us. Universal health care is, however, a moral obligation for an industrialized society, and will not result in the apocalyptic consequences promised by the jeremiads.

The eloquence brought a tear to my eye, and I strongly encourage you to read the whole thing.

A great perspective piece in the NEJM (via the WSJ Health Blog), saying that executive physicians symbolizes all that is wrong with the mindset of the American patient.

The central tenet that "more is better" is thoroughly debunked, as it should be:

Executive physicals also reinforce a related misperception — that costlier is better, that a $3,000 examination must be worth more than one that costs 1/10 of that amount. This is an indefensible idea that should not be promoted by the health care industry. Even as individual hospitals sell these services for exorbitant fees, gratuitously overusing our health care resources, our system as a whole is appropriately straining in precisely the opposite direction, toward cost-effectiveness, transparency, competition, and accountability. With its outrageous cost and unproven efficacy, the executive physical is almost a parody of the high-cost, low-return procedures that prudent companies rightly want clinicians to eliminate for other employees.

When it comes to health care, "more", "costly", and "new" are not necessarily better for the patient.

Everyone needs to understand that if there is hope to control health care spending.

BusinessWeek stirs the pot asking whether doctors deserve respect owed to benevolent professionals.

Predictably, the lawyer rails on doctors saying that medicine has been turned into a business, with doctors being unduly influenced by economics.

The other side plays the knowledge card, contending that doctors deserve respect after undergoing such grueling training.

The lawyer is the one who is right.

Medicine is a business and medical students are indeed picking lucrative fields with money and lifestyle influencing their decisions.

But he makes the classic mistake of blaming the players, not the game.

Physicians have simply adapted to the rules given to them. Given a choice, many doctors would long for the old days where medicine was a far more benevolent profession.

The answer is clearly yes.

Medicine is more a business today than ever, and those who don't advertise out of ethical or moral concerns place themselves at a significant disadvantage in the marketplace.

That being said, I think that physician and hospital promotions have to be done tastefully, as there are limits to what kind of ads that are acceptable for patients.

Rather than spending money on expensive newspaper or billboard ads, simply optimizing your website for search engines is powerful and inexpensive.

More and more patients are searching for their doctors on Google, entering keywords like "Nashua primary care" or "Massachusetts primary care".

Having your name or website rank high is provides value and is quite effective in promoting your practice.

The "medical home" is often referred to as primary care's savior. Maggie Mahar writes a comprehensive piece saying this might be a tad optimistic.

She makes a point that, despite what I say, simply increasing primary care isn't enough. There has to be concurring coordination of care:

Most primary physicians don’t coordinate care by “collaborating with specialists to ensure both communication and collaborative decision making,” in large part because “our payment system fails to reward office-based physicians for managing disease and coordinating care.” As a result, PCPs don’t have the time to play phone tag with specialists, tease out a list of all of the medications their patient are taking, or organize the information in neatly cataloged electronic medical records.

As long as primary care continues to be incentivized by volume, coordination of care will fall by the wayside.

Another potential problem is the stringent definition of what a medical home should comprise. With the current definition, almost half of physicians in the country will fail to qualify. The initial, seemingly simple, step of implementing electronic records is already meeting significant resistance.

And finally, the carrot simply isn't big enough. The payment levels that are being discussed provide little incentive for doctors to fundamentally transform their practice:

A proposed payment scenario was recently reviewed in the June AMA News. It shows that Tier 3 (the highest, requiring the most extra services and reporting) would pay an extra $161,871 for a panel of 250 patients. That comes to $53.96/pt/mos which is barely enough to cover two or three extra phone calls.

In the current economic climate, it is unlikely that the money will be there to save primary care. Which means that the medical home concept will stay stuck in the planning stages for the forseeable future.

Offer them cash.

Sadly, it's probably the most effective way.

Interesting study showing a unique pregnancy risk profile for Asian-white couples. Apparently there is an increased risk of gestational diabetes, pre-term labor and low birth weight.

I don't think there is much data on interracial couples, which is a growing demographic.

Keep the primary care op-eds coming. Here's another one from the Denver Post - No doctor for old men:

Primary care — especially for the elderly — takes too much time, and it pays poorly. Medicare is constantly trying to cut payments to primary care doctors, while continuing to pay $1,000 for every MRI and $200 per month for non-life-saving drugs. The specialist may get paid several hundred dollars for only two office visits while the family doctor gets only $40 per visit. Why should the PCP work just as hard for less money?

Dr. Johnson brings up the point that the efforts for universal coverage will only exacerbate the problem, as there are not enough generalist physicians to take the influx of newly insured patients.

This will lead to more ED overcrowding, and strain the system further.

The focus should be on physician access, especially with the coming wave of new Medicare patients.

More fallout from the JAMA study on the media reporting of medical studies.

One reason is that reporters are not often versed on health care nuances. Matthew Mintz comes up with other reasons, such as the focus on negative headlines that tend to sell more papers, and the sheer volume of studies to interpret:

The public is inundated on a daily basis with medical information that is not always reported accurately, that often takes a negative spin . . . that leave the public and patients confused, and in many cases lead patients to distrust any product and even their own doctors.

This is one reason to read physician blogs, which can comment on the medical news from a more informed stance.

My latest USA Today op-ed was published this morning: Why doctors still balk at electronic medical records.

On a related note, I'm now a member of the USA Today's Board of Contributors. Expect to see my opinion pieces published every few months or so.

Thank you all for your continued readership and support.