ObamaCare & Medicaid . . . On the Road to the Great Depression

Robert Lewis Stevenson said, "Don't judge each day by the harvest you reap but by the seeds that you plant." So . . . I'm going to plant a seed.
The Arizona Osteopathic Medical Association has been asked to contribute Political Action Funds (PAC) to those congressional members supporting Arizona’s Medicaid expansion.  I seem to find myself in the physician minority as to my point of view on this subject. Do others not see the economic damage that the Affordable Care Act has caused and will cause in the future?  Does no-one see the sadness and depression on the faces of patient’s in the exam rooms? Does no-one put two and two together to see the effect that federal and state regulations imposed upon the small businesses of America have upon the average American family?  

I respect their points of view, however, I am very discouraged by the progressive position and mindset of many physicians around me.  Maybe I'm missing something? Maybe they see the world with a different set of spectacles? This kept me awake last night as I pondered the reasons. 

I recognize that the practice of medicine is, to say the least, life encompassing.  Often, it is all you can do just to keep up with the many demands upon the physician each day.  Understanding how the economy effects your practice is the last thing that many physicians want to do.  But I see it as one of the most important, especially as a physician who owns his own practice. 

Maybe this lack of interest is due to the declining physician ownership of practices. According to Becker’s Hospital Review, only 37% of physicians in 2013 have any ownership interest in their practice, down by almost 8% this year from last year.  This statistic, just over a third of physicians, seems in line with the number of physician that are opposed to expansion of Medicaid in Arizona and the Affordable Care Act or “Obamacare” in general.  

“Obamacare” and the employer mandate has made it nearly impossible to expand my practice, and the Medicaid expansion may make it worse.

How is Medicaid expansion bad?  Wayne Allen Root explains it better than I can: “Forget the 7.3 percent unemployment rate that is reported by the government. That’s pure fraud and propaganda. That figure goes down only because hundreds of thousands of Americans drop out of the workforce. In other words, if you stop looking for work, and go on food stamps and welfare, [our White House Administration] says the unemployment number just got better!

 “The only truth about unemployment is found in the Labor Force Participation Rate of 63 percent. That’s the lowest in four decades. For men it’s the lowest since record-keeping began in the 1940’s. What this means is 37 percent of the able-bodied, working age adults in America are not only not working, they’ve given up looking for work.

“Even worse, an unimaginable percentage of those who are employed have only part-time jobs. Seventy-seven percent of the new jobs created since January 1st are part-time jobs. That’s not good folks. Studies show 1-in-4 part-time workers live in poverty, while only 1-in-20 full-time workers live in poverty. So millions of Americans under Obama who show up as “employed” are merely working their way towards poverty. And millions of others who have full-time jobs are working at McDonalds, or working as waiters, or bartenders, or janitors.”  The American middle class is being moved to the intensive care unit.

“Here are the two most ironic points about this slow-motion train wreck called the Obama economy: “Obamacare” is the number one culprit destroying real jobs. Business owners are done. No smart business owner in all of America will lift a finger to create a full-time, high-paying job with benefits. It just makes no economic sense anymore. So Obama’s signature achievement has not only created a part-time economy, but all those people in part-time jobs don’t have health insurance. This should be a Saturday Night Live skit. The man has created nationalized health care so that everyone loses their jobs and no one has health care.” 

This is pure insanity . . . unless your goal is to create an entire nation dependent on government welfare.

Mr. Root continues, “Secondly, here’s the really sad, tragic, and ironic fact of the Obama economy . . .Obama’s policies are destroying the very people who elected and believed in him. It’s almost as if Obama is out to destroy his own voters. Let’s take a look at who is suffering the most from this Obama Great Depression.

“Obama won the 2012 election with a razor thin 51 percent of the vote. His biggest supporters were blacks (93 percent voted for Obama), Hispanics (71 percent), single women (67 percent), young people (60 percent), and those without a high school diploma (64 percent). This is the loyal foundation of Barack Hussein Obama. This is who made him President, without a single qualification, except being a community organizer.

“Now let’s look at how Obama repays his loyal fans. New research out just last week proves that since 2009 income for black heads of households dropped by 10.9 percent. For Hispanic heads of households it dropped by 4.5 percent. For single women head of households it dropped by 7 percent. For young people (under age 25) it dropped by 9.6 percent. For those with a high school diploma or less, income dropped by 8 percent.

“In dollar terms the numbers are even worse. Female incomes are down by $2,300 per year under Obama; black incomes are down over $4,000 per year; Hispanic incomes are down by $2,000 per year.

“How about actual unemployment figures for Obama’s fans? We see the same results. Reported unemployment (a bogus figure) is 7.3 percent. But among blacks (who voted 93 percent for Obama) it is an unimaginable 13.3 percent. Among Hispanics it’s 9.4 percent. Among black youth it’s 20.9 percent. Among teens it’s 23.7 percent.

“The black middle class is being destroyed. Black home ownership has slipped to the lowest level in decades.

“But perhaps the worst statistic of all is the unemployment plus under-employment rate for college graduates under age 25: 18.3 percent. That means new college graduates (also big supporters of Obama) not only can’t find a decent full-time job in the Obama economy, at the same time they are saddled with the highest student debt in history. That could be why we have the highest student loan default rates in history.”

The Medicaid Expansion in Arizona will just speed up the process already occurring across the country.  Our “lemming-like” acceptance of this expansion as physicians is leading to the further destruction of Arizona’s and America’s economy. Contributing PAC funds is like putting the proverbial nail in my businesses coffin. For the reasons above, I cannot in good conscience support the expansion of Medicaid in Arizona.  

Family Physician Burnout . . .

A national survey published in the Archives of Family Medicine in 2012 reported that US physicians suffer more burnout than other American workers.[1] Some 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.
Medscape conducted a survey and family physicians were given the same criteria. The response was discouraging: 43% responded that they were burned out. The 2 specialties with the highest percentage of burnout were those that dealt with severely ill patients: emergency medicine and critical care. Family physicians were in third place.



What is causing the burnout? Following table lists the causes found in the study.



In the Archives article,[1] the authors sum up the very challenging problem of physician burnout: "Collectively, the findings...indicate that (1) the prevalence of burnout among US physicians is at an alarming level, (2) physicians in specialties at the front line of care access (emergency medicine, general Family Medicine, and family medicine) are at greatest risk, (3) physicians work longer hours and have greater struggles with work-life integration than other US workers, and (4) after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk. These results suggest that the experience of burnout among physicians does not simply mirror larger societal trends."

What to do? The finding suggest that physicians should participate in and advocate for changes in work that give them more control over there ability to help and interact with patients. They should become involved in advocating for health reforms that will return a greater level of control to physicians and their patients. These would include payment for value and greater patient participation in decision-making about care. Reorganizing primary care practices to allow more time for complex patients and recognition by insurers that excessive hassle is bad for patients and physician are also vital. These changes should lead to more satisfied patients and physicians and less burnout,[3] .

References:
1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physician relative to the general US population. Arch Intern Med. 2012;172:1377-1385. http://archinte.jamanetwork.com/article.aspx?articleid=1351351 Accessed February 7, 2013.
2.http://www.medscape.com/features/slideshow/lifestyle/2013/family-medicine?src=wnl_edit_specol#2
3. Centor RM, Morrow RW, Poses RM, et al. Doc burnout -- worse than other workers'. Medscape Roundtable in Primary Care. November 13, 2012. http://www.medscape.com/viewarticle/774013 Accessed February 20, 2013.

Policy & Politics

I read a thought provoking post from Dr. Vartabedian over at 33 Charts.  Should your doctor be involved in politics?  It is a very good question.
Stepping into the quagmire of political discourse often leaves an oratory odor.  I, too, am guilty of this.  However, in a time when transparency is important, being genuine and true to our values is essential.
Through social media and daily office interactions, I come in contact with many physician's and patent's viewpoints and compare them with my own. One thing that I find interesting is that many don't differentiate or understand the difference between policy and politics.  There is a difference.
It is very important, from the perspective of voice, to make a distinction between policy and politics when we interact.  Policy is a course of action based upon principles or values.  Politics are inter-relationships or activities that we engage into move policy in a desired direction. Don't confuse the two.
When listening to the talking heads and political pundits, it is essential that we see the difference.  Just spewing rhetoric without understanding our position on a policy seems to be what fuels the cesspool like arena of politics. It is often what turns us away from important and productive political conversation about policy.

Medicine and Fast Food

No, the practice of medicine is not like fast food.

We live in a society of fast cars, fast food, instant messages, and instant pictures.  We want it our way and we want it now.  This is evident by the fact that the average American household has $16,000.00 in credit card debt (2011 Household Statistics).  We want it now and well worry about payment or consequence later. This is also evident by the successes of instant messaging services, cell phones and fast food restaurants.

As a family practitioner, I feel pressured by both patients and insurance companies to serve up a diagnosis and a low cost generic pill with the same speed.  No, the practice of medicine is not like fast food. If it were, then I would install a drive up window next to my office desk, and place a large marquee with a clown wearing a stethoscope at my front door.

Medicine is an art.  A picture is painted of the patient by what is seen, heard, felt and understood through the eyes of the practitioner.  This can't be done over the phone or through a drive-through window. It requires a patient who is willing to place his or her history, symptoms, feelings, private concerns and trust upon the examination table It requires the astute observer to see all the reflections of light and shadows and all the highlights.  It requires the observer, the doctor, to recognized that many times this is difficult for the patient.  That trust is built through a relationship that occurs over a period of minutes and a period of years.  The beauty of the art occurs when the practitioner and the patient understand one another and application of healing can begin.

The art of medicine paints a different picture every time. That's why art isn't sold under the golden arches, or at the corner pharmacy.  No, the practice of medicine is not like fast food.

Vitamin D Effect on Weight

Vitamin D plays an interesting role in may aspects of human health. It plays a role in disease prevention including osteoporosis, some cancers, autoimmune disorders, hypertension, diabetes and has recently been found to effect weight loss.
What is Vitamin D?  It is an oil-soluble (fat-soluble) vitamin that helps in the absorption of calcium and phosphorus in the intestine and suppresses parathyroid hormone (PTH), the hormone that stimulates bone resorption (breakdown). Vitamin D also plays a role in muscle function and in the immune system, but our understanding in these roles are still limited. (1)
Vitamin D can be found in fatty fish, cod-liver oil and eggs. In the United States, cow's milk is supplemented with Vitamin D and this is often the source from which most people obtain it. Deficiency in Vitamin D often occurs from lack of sun exposure, inadequate intake, surgery to or damage of the intestines ability to absorb, or from kidney or liver damage resulting in problems processing Vitamin D. Recent studies reveal that obesity is a major factor in altering the way the body uses Vitamin D and stimulates PTH.

I find that about 30-40% of my patients are Vitamin D deficient.  Many researches claim this is due to poor sun exposure or the use of sun screens, however, I live in Arizona.  Sun over exposure is usually the problem here, yet I still find that 30-40% of my patients are deficient.  My patients should be able to get enough sunlight walking from their cars to the grocery store entrance.  I disagree that "lack of sun exposure is the cause."  Although our current labs claim vitamin D levels should be above 20 ng/dl, I find people do not get the needed effect until 25 Hydroxy-Vitamin D levels should are greater than 32 ng/dl.
Poor Vitamin D intake is usually the problem.  Our bodies convert 25 Hydroxy-Vitamin D into the active molecule 1,25 Dihydroxy-Vitamin D.  Recent studies reveal that higher Body Mass Index (BMI) leads to lower conversion of 25 Hydroxy-Vitamin D to 1,25 Dihydroxy-Vitamin D. (2,3)  Simply adding 25 Hydroxy-Vitamin D as a supplament frequently helps with weight management in many of my patients. Supplementation with 1000-2000 IU is often adequate.  Higher doses should be discussed with your doctor.

References:

1. C P Earthman, L M Beckman, K Masodkar and S D Sibley. The link between obesity and low circulating 25-hydroxyvitamin D concentrations: considerations and implications.International Journal of Obesity (2012) 36, 387–396; doi:10.1038/ijo.2011.119; published online 21 June 2011.

2. Frost M, Abrahamsen B, Nielsen TL, Hagen C, Andersen M, Brixen K. Vitamin D status and PTH in young men: a cross-sectional study on associations with bone mineral density, body composition and glucose metabolism. Clin Endocrinol (Oxf) 2010; 73: 573–580.

3. Konradsen S, Ag H, Lindberg F, Hexeberg S, Jorde R. Serum 1,25-dihydroxy vitamin D is inversely associated with body mass index. Eur J Nutr 2008;47: 87–91.

Cholesterol Drugs Increase Risk for Diabetes?

A recent article in the January 9th edition of the Archives of Internal Medicine (1) found that post menopausal women had a 48% increased risk of getting diabetes if they used any of the STATIN type cholesterol medications. The Women's Health Initiative, an observational study of over 153,000 post menopausal women found this increased risk. This is a significant finding and a worrisome claim.

In a time when STATIN medications like Crestor, Lipitor, Zocor, and Pravachol are being used more frequently to decrease risk of coronary heart and vascular disease, this poses a significant risk and raises a number of questions.  Is the increased risk actually due to the cholesterol lowering medication, or is the progression to diabetes a component of the patient's heart disease risk due to other genetic factors?  Is the mechanism of action in these cholesterol medications contributing to diabetes risk or are these patients already in the progression to diabetes and cardiovascular changes were identified and treated prior to progression to diabetes.
What should you and I make of this data?  Well, first, don't stop your cholesterol medication. Talk to your doctor about this study and your risk of diabetes.  Second, realize that cardiovascular changes and elevation in cholesterol starts up to 20 years before diabetes is diagnosed in many patients with insulin resistance and metabolic syndrome. Third, further evaluation and research needs to be done and we shouldn't base our decisions on just one observational study.
More to come on this subject I'm sure . . .

Reference:
1. Culver AL, Ockene IS, Balasubramanian R, et al. Statin use and risk of diabetes mellitus in postmenopausal women in the Women's Health Initiative. Arch Intern Med. Published online 2012 Jan 9. doi:10.1001/archinternmed.2011.625

Shadows of the Gallows

(Post taken in entirety from Musings of a Distractible Mind by Dr. Rob.  It was just too good not to, as this is exactly how I feel.  Thanks Dr. Rob for putting in prose my feelings for the last year. . . )

“It will never happen.”
“They know better than to do it.”
“They realize the disaster it would be if they let it pass.”
That’s what I hear.  I hear that the upcoming SGR adjustment, the one that will cut Medicare reimbursement by 23%, won’t go through.  In case you missed it, the SGR is a formula coming from the Balanced Budget Act of 1997 that does automatic cuts to Medicare reimbursement.  This year we witnessed a legislative game of chicken in congress, with both sides agreeing that it was a bad idea to screw physicians in a time that they are trying to fix healthcare.  Here’s what happened:

On March 3, 2010, Congress delayed the enforcement of the conversion factor until April 1, 2010.^[5][6] On April 15, 2010, Congress voted to again delay the implementation and extended the 2009 rate to June 1, 2010.^[7] On June 25, 2010, President Obama signed legislation that not only delayed implementation of the conversion factor until December 1, 2010 but also increased reimbursements by 2.2%.^[4] The 2.2% increase is retroactive to June 1, 2010, and will expire on November 30, 2010. Barring any further congressional legislation, this will result in a 23.5% decrease in Medicare reimbursements on December 1, 2010. (Wikipedia)

So we are t minus 65 days until we face another congressional battle.  The thing that makes it scary: November 2.  On November 2, our current congress changes its members, making the current congress lame-ducks.  Lame duck, impotent, worthless.  They are the ones who are supposed to fix this once and for all?  They are the ones who aren’t going to play political sabotage on the other side?
I was talking with some of my colleagues last week, and the “it won’t happen” line didn’t work.  They were all depressed, and all making plans to deal with a systemic melt-down.  They talked like men living in the shadow of the gallows.  Plan for the future?  The only way to do that is to stop accepting Medicare, which will be hard to do when 40% of the practice is Medicare patients.  There were a lot of downcast eyes, a lot of frustration.  There was not much comfort to give when the dark clouds are gathering.
Things are about to get worse.
Oh wait!  I forgot!  It will never happen.
Now I feel happy.

Disconnect Between Private Medical Practice & Medical Education

It fascinates me that there is such a disconnect between the economic view of those in private medical practice and those in Medical Education or University Based Practices.  Recently read an interesting post by Bryan Vartabedian, MD, at 33 charts discussing the future and inevitable changes in medical practice.
It is my opinion that medicine is changing and the practice of medicine will probably be unrecognizable in the next 10-20 years.
Yes, technology is making the evidence of practice guidelines better and more effective, but that is part of the way medicine is changing.
Daily, I am barraged with "practice protocols and guidelines" from every specialty group and every expert committee (a full ream of paper is mailed to me daily from all these expert groups).  Insurance companies then accept these guidelines as the "gospel truth" and if I'm not following them to the letter, my paycheck is reduced.  The "art of medicine" is disappearing with the overlay of the flowchart and practice protocol or practice guideline.  But to earn my living, I have to either demonstrate I followed the protocol, or write an additional paragraph as to why the protocol is not appropriate for that patient.  It is impossible to do that 35 times per day even with the most efficient electronic medical record available (I know 'cause I have one).
But the educational system still appears to be teaching the students that the current evolution is the "best."  The student cry "foul" and question the experience of those who have been in the trenches and claim that the error is on the part of private industry.  This progressive view of medicine is killing the "art."  And it is in the "art of medicine" where the caring and compassion is found.
Medicine as we know it will change into an efficient, cold, assembly line of diagnosis and treatment dispensing, unless we collectively change it.  The enjoyment of medicine is found in its art.  Once that is gone, you will loose the great physicians.  You will have an industry of cookbook, cookie cutter practitioners dispensing the latest medial equivalent of the GM Volt. The government is driving this.  In my practice, 50% of my patients care is driven by Medicare in some capacity.  When you put the government in control of medicine your going to get more bureaucracy and less art.
What is the answer?  Time.  Only time will tell. Until then, we practice medicine the best we can with the tools we have and apply the art of that practice to each individual.