We should be ashamed. We should be angry.

What kind of a country do we want to be?

For some time now, we have been learning about the steady decline in the welfare of children in the United States.  20% of children now live in poverty, schools are often failing them, health care has been difficult to access, immunizations are down, families are stressed,  and now we are informed in an extensive new study that the newborn death rate in the United States is now higher than in 40 other countries including Malaysia, Cuba and Poland. Our previous ranking was 29.

The great tragedy here is that many of these deaths can be prevented, with improved access to appropriate medical care, leadership for effective public health education, prenatal care and parental education and support.

Access to basic health care for all needs to begin first with our children. And it is the responsibility of all of us to step in, when parents are unable to. Yes, this is a moral issue, but also in our general self interest. The well being of today's children determines our future. 

Our society is pursuing a self destructive course by failing to provide all of our children with access to good health, education and a nurturing environment to grow up in, while at the same time we indebt them by failing to pay our bills. We should be ashamed. We should be angry. This is why we need health care for all in this country. This is not the rich against the poor. All of us in these United States of America must compete against the world. There is no valid reason why our children should be handicapped in their start in life compared to those in Malaysia, Cuba and Poland. There is no  good way to spin this.

WE'RE NUMBER 41! WE'RE NUMBER 41! Does that sound right to you? And we pay more than anywhere else.

These are the countries where a baby has a better chance of living in the first critical months of life:

Luxembourg
San Marino
Iceland
Japan
Singapore
Slovenia
Sweden
Andorra
Cyprus
Czech Republic
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Monaco
Norway
Spain
Australia
Austria
Belgium
Estonia
Israel
Netherlands
New Zealand
Portugal
Switzerland
Brunei Darussalam
Canada
Croatia
Cuba
Hungary
Lithuania
Poland
Republic of Korea
United Kingdom
Malaysia
Malta
Serbia
Slovakia
Chile
Latvia
Montenegro

Report from a Town Hall Meeting, Mt. Vernon, Washington

The news had been full of reports of angry crowds with rude and obnoxious behavior, harassing members of Congress who were attempting to discuss health care reform with constituents, so it was with a little trepidation that I set out for the 2nd of 3 meetings hosted by Congressman Rick Larsen for Washington's 2nd Congressional District. Could the normally respectful and open minded people I live and work with behave this way? Turns out, I need not have worried!

So many people came to the meeting that the large auditorium was completely filled, and a crowd of thousands spilled over into the outside lawn. Speakers were set up so that all could hear, and Larsen made a point of coming out on to the lawn area to take questions. Congressman Larsen treated everyone with patience and respect. Oh, to be sure, there were some who seemed bent on stoking ill will, such as the guy who had a picture of the President defaced to look like Hitler. These folks were far outnumbered by those who came to listen and have true dialog, and when the Congressman singled out the picture of President Obama as Hitler, to say it was not reflective of true and honest criticism and debate, there was a loud and prolonged applause from 90% of those in attendance. To those who complained that the house bill was rushed through by people who did not understand it, he made it clear that he had read the entire bill, and had a copy with him to refer to if there were specific questions. And the questions did come!

One of the most interesting things I learned at this meeting is how confused and misinformed some worried people are about the truth contained in the recent bill passed by the House of Representatives. For example, one woman thought that payment for care would be limited to $5,000. The Congressman explained that no, this figure was a cap on expenses for her to be responsible for, and not a limit on benefits. Another thought that illegal aliens would be covered, and was told that they are explicitly not covered by this bill. There were many other examples.

Larsen made it clear that he is not approaching reform as an ideolog, but rather, he wants to accomplish practical change by keeping the following principles in mind:

• Ban discrimination for pre-existing conditions, age and gender;
• Don't try to fix what isn't broken. If people have insurance and doctors they like, they should be able to keep them;
• Eliminate fraud, waste and abuse in government health programs;
• Invest in prevention and pay for quality of care, not quantity of tests;
• And get reform that works for Washington State.

He particularly took pains to explain that Washington state currently is penalized for providing higher-quality, lower-cost care by Medicare because reimbursement rates are so low that many local doctors do not accept Medicare patients. Under the original health care reform bill introduced in the House, this problem was not fixed, and was expanded, so that the same unfair, wasteful reimbursement policies would have been expanded from Medicare to the public insurance option. As he said, "What good is an insurance card if you can't find a doctor who will treat you?" That was his reason for opposing the "public plan" option as presented. To improve this situation, Larsen has worked with colleagues from Washington and other states with the same problem to secure an agreement with House leadership to agree to reform Medicare payments, reward high-quality, cost-efficient care and remedy geographic disparities that hurt access to care for local patients.

All in all, I was very impressed. Congressman Larsen should be commended for working hard on our behalf, with clear principles of reform. He is obviously very knowledgeable and energized about this issue. Residents of our area should be commended for their attention and respectfulness of the town hall process. I was glad that I went.

One disappointment I do have is with our local newspaper, The Bellingham Herald. I could not find a report of our local meeting, but there were 2 articles with old news about how meetings are being disrupted. What a missed opportunity by our media to set the record straight!

What's In It for Me? What are our obligations to each other?

As what passes for a health care debate rages all around us, I have come to realize that between the polarized extremes there exists a very important group of people who are the key to what will happen this fall, and that is the large group of Americans who have health insurance and who are worried they may lose advantages in any reform. All of the noise in our media is an attempt to reach this group, who are likely asking, "What's in it for me"?

I believe that those who currently have health insurance and good access to medical care would be well advised to support proposed health care reform for the following reasons:

• They may lose their insurance coverage! Right now, 14,000 insured people lose their coverage every day when they lose their job or the employer cannot continue to afford benefits, and that number is expected to increase greatly with current trends.
• Business can't afford the increasing costs! Under the current system, costs are expected to double during the next 10 years.
• Young people are priced out of the system! Those looking for work at the beginning of their careers are most likely to get jobs without benefits, leaving them uncovered and raising the cost for all others.
• Insurance often does not work when you need it, even if you have it! The for profit system is full of people who work hard to "ration your care" by figuring out how not to pay for things.
• The payment system must be reformed! Our current mess of a non system is caused by the payment incentive and lack of incentives we now have.
• Quality is often lacking! A sad and poorly understood fact is that even people with good insurance get the recommended care they should have only about 1/4 of the time. The care is not organized in a way that allows most doctors to manage their patients the best way possible.
• They may lose their doctor! Very few medical students are going in to the primary care disciplines, due primarily to the fact that they cannot afford to. Retiring family doctors are not being replaced. Reform which supports primary care is crucial to attracting the best and brightest into primary care.

When all is said and done, however, thinking just about ourselves misses one of the most important reasons for reform. Perhaps the most important thing to consider is, what are our obligations to each other? Our entire American society is engaged in global competition with all the countries on earth for the innovations, jobs, products and benefits of the world to come. We must have a society with well educated, healthy and productive citizens to secure the benefits of the future. Our companies need a level playing field that does not saddle them with the unequal and exorbitant costs of a failed system.

If the the future is scary to you, it is really not because of the risk of changing, but because we might not change. Don't be fooled.

How Does The Patient-Centered Medical Home Transform Health Care Delivery?

Can Patient-Centered Medical Homes Transform Health Care Delivery? The answer is clearly yes, and that is a point I have tried to emphasize, but I often get asked by those less familiar with the subject, how does this really make a difference?

The basic idea in a nutshell is that in order to be effective and add value, health reform must deliver a new delivery system built on a solid foundation of primary care. There are two barriers to this happening:

• We are losing primary care providers, and very few new doctors are in the pipeline to replace them
• The way primary care doctors are paid is inadequate and dysfunctional, so that they are not paid for the work that patients truly need and want them to do.

The medical home is an approach to primary care organized around the relationship between the patient and their personal physician. It is is primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” It has now been endorsed by important, independent health care think tanks, such as the Commonwealth Fund.

In 2007, four primary care specialty societies, representing more than 300,000 primary care specialists, issued a joint description of the Principles of the Patient-Centered Medical Home:

• A personal physician;
• A whole-person orientation;
• Safe and high-quality care (e.g., evidence-based medicine, appropriate use of health information technology);
• Enhanced access to care; (e.g., phone visits, secure web visits, group visits with appropriate use of health information technology);
• payment that recognizes the added value provided to patients and insurers who have a patient-centered medical home.

Today, few Americans say they have a source of care with these features, but I am proud to say that my medical group, Family Care Network, has made wonderful progress to become a full fledged Patient-Centered Medical Home for our patients. We now know what works. There is no excuse to delay. If we do not move forward in this effort, we will continue to reap the whirlwind of spiraling costs and plummeting value. Primary Care will disappear. Now is the time.

The need has never been greater

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".