November 17, 2011 #hchlitss tweetchat

“Nationwide physician shortages are expected to balloon to 62,900 doctors in five years and 91,500 by 2020, according to the Association of American Medical Colleges work force projections," American Medical News reports. "That's up more than 50% from previous estimates. AAMC officials attribute the widening gap to increased demands from the aging baby boomer generation and expansion of coverage by 2019 to 32 million uninsured Americans under the health system reform law. … To counter shortages, the AAMC is urging federal officials to lift limits on Medicare funding for residency positions, which have been capped at 100,000 slots since 1997" (Krupa, 10/11). http://www.kaiserhealthnews.org/daily-reports/2010/october/11/doctors-issues.aspx    

Thursday, November 17, 2011 #hchlitss tweetchat featured Kevin Bernstein, MD @BernieMD31.  He had just published a post called “Should we occupy medical schools to effectively occupy healthcare?”  at http://occupyhealthcare.net/2011/11/should-we-occupy-medical-schools-to-effectively-occupy-healthcare/ .  Kevin is presently doing his Family Medicine residency. The tweetchat was based on information provided in this blogpost.  @BernieMD invited Mark Ryan, MD, @RichmondDoc, a faculty member in Family Medicine at the Medical College of Virginia at Virginia Commonwealth University.

Topic 1:

Physicians in other specialties are said to denigrate those who choose family medicine.  Is this something that you have experienced? 

Both @BernieMD31 and @RichmondDoc shared having had this experience. 

·          Those who want to enter primary care go through “a  hazing process” during medical school . 

·         Entering primary care is called a “waste of talent.”

·         Many specialists denigrate Family Medicine.

·         Those interested in Family Medicine hear “if [they] want to be a "real doctor" …should be  [fill in the blank]”

·         There is a perception that becoming a specialist means that you are smarter 

Both physicians refute the belittling of their profession.

·         Family Medicine is not a bunch of algorithms – it’s an art.

·          “I can see anyone, and at least start evaluation on anyone... and I can often complete the evaluation and treatment plan. Without a specialist.”  

·         I went into Family Medicine because I want to be able to care for any patient in my office. It is valuable in rural and international settings. 

·         “Why go to school and residency for so long only to focus on one body system” when you can treat the whole person.

·         It's those on the fence about primary care that follow the money.  For those who are undecided, money and lifestyle equals prestige.

Topic 2:

How do we get the rest of medicine to value patient-centered preventive care so that more medical school graduates go into Family Medicine?

·         Change the way Family Medicine and Specialities are paid.

·         In the military, a family doctor  and orthopedic doctor with same number of years experience, same rank, same number of family members  have only a $30,000 difference in pay.  This is in contrast to the civilian setting where there is a difference of $300,000.

·         Set up “medical homes” for primary care.  “Medical homes is not about physicians making “house calls” as the name may imply.  It is about revising the health care experience by making it patient-centered, integrating care, reducing cost, having more “accessible” care, having electronic medical records (EMR) and improving outcomes.

·         The American Medical Association established a committee called the Resource Based Relative Value Scale Update Committee, known as RUC, in the early 1990s.  Unfortunately, this committee has had the ear of those who make the decisions on Medicare and Medicaid pay for physicians.

·         The RUC is predominantly made up of Specialists.  Those in Family Medicine believe that this group has kept the pay differential in place between Specialists and Primary Care Physicians

·         Family Medicine is not asking for a pay raise.  They are interested in having physicians paid less for procedures that don’t benefit morbidity or mortality.

·         Enhancing Family Medicine interest is occurring in different medical schools like VCU.  http://t.co/XrOoAN6g #fmSTAT

Topic 3: 

Would increasing the length of family medicine/primary medicine residencies increase prestige within the medical setting? 

Neither @RichmondDoc nor @BernieMD31 believed that this would be an effective way to change the problem. 

·         Since specialists predominate the hospital settings and medical staff for schools, students see the specialist as the “measure of success.”  Interestingly in Canada, residency is only two years.

·         A change in the gap in pay between primary care physicians and specialist will do the most to change the prestige situation.  Reference was made to the COGME 20^th Report.  This report indicates that the relative difference in pay between these specialists and primary care needs to be changed, not by increasing the pay of primary care physicians but by paying the specialists less.

The Canadian system single payer system was touted as an example of reducing the administrative burden on US physicians.  Canadian administrative costs average 1/4 of the US.  “US Physician Practices  versus Canadians:  Spending Nearly Four Times As Much Money Interacting With Payers” http://t.co/7yLP3upC

Canadian system:

·         Family medicine physicians are treated with more respect

·         Have a much lower pay gap

·         In the US recent experience, when there was less financial disparity between primary care and specialists, more students when into primary care. Altarum and COGME

 

Topic 4: 

Can you tell us about  the occupy medical school movement? Why is it important? How to get involved? 

Medical schools are advertising that they are producing primary care physicians but they are not.  Even US News and World Reports are giving high ranking for schools lowest at production true primary care physicians.

·         Yet they are getting federal funding for producing primary care physicians

·         Occupy Medical School asks where is all the tuition money going.  Why are medical students having $200,000 to $300,000 debt burden

·         Medical school is so expensive that many of the disadvantaged cannot afford to go to school

·         There is a suggestion that medical school conduct research on only  1% of our population

·         Nurses and physicians don’t stay in primary care because of lifestyle and money.

At one point in the tweetchat, the discussion diverged to include the role of nursing, especially Advanced Practice Registered Nurse Practitioners.  The Institutes of Medicine’s recommendation to expand the Medicare and Medicaid programs to include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered.

Topic 5:

What is the difference between primary care physician and nurse practitioners educations?

               

According to family medicine physician, nurse practitioners are key team members, but their training differs markedly.  Robert Bowman's http://t.co/jczLdykm  research  clearly shows primary care years for Family Medicine MD far exceeds that of Nurse Practioners.  There is a table which shows the  number of standard primary care years by various training paths http://t.co/i1qYmtU1.

 

Topic 6: 

What do you foresee as the future of  primary medical care?  How can we help?  How can we help Nurse Practioners to be respected, Primary Care Physician numbers increase and help change the system? 

·         We are at a tipping point. Medical students that are not going into Primary Care now are making big mistake.

·         Keep up with the Occupy healthcare blog and sign up for google plus Occupy healthcare group http://t.co/MvbrbQGq

·         Follow #FMRevolution, future of family medicine blog and @drmikesevilla for nonstop family med fun!

#Hclitss chat November 6, 2010 Summary and Transcript

November 10, 2011 #hchlitss chat followed up on Occupy Healthcare #occupyhealthcare of Sunday November 6, 2011.  Our guest was @NateOsit, one of the moderators of #occupyhealthcare.

The chat began with a sharing of information/links to:

·         the blog for #occupyhealthcare http://t.co/XMzL55qZ

·         the google group http://t.co/K5CKkWSt

·         the CrowdMap http://t.co/EzqFWnEW

·         the Action plan http://t.co/7HLUOBVt

·         Single-Payer National Health Insurance | Physicians for a National Health Program: http://t.co/pO9eKVfa

Followed by the questions:

                 Does the #occupyhealthcare movement make sense to you?

Participants listed a number of reasons why it does make sense. 

·         there are billions worldwide without access to affordable healthcare,

·         healthcare has a devolved into a system of perverse profit incentives where profit is more important than  people

·         there are staggering inequities in health

·         there is a disconnect with people being cared for and their health care providers

·         people are being bankrupt by medical costs

·         unemployed are going w/out heath insurance or paying high premium through COBRA

·         works only for those who can pay.  Our health care system is very uneven.  It is good for some and that is one reason why many don't "see" its faults

·         the health insurance many have is “faux” insurance.  When something happens they find out that it doesn’t cover their medical expenses

·         doesn't address health disparities

·         leaving people without health care it increases stress and other factors that influence health

·         the healthcare system is set up to profit from treatment, not prevention or curing

·         political power is in the hands of the medical –industrial complex

At one point in this part of the discussion, Nata Osit pointed out that something has to be broken when “I worked in a major hospital for 2 years without access to affordable healthcare.” 

Clearly there is a problem when the cost of  health insurance increased 30% from 2001-2005 yet income from 2001-05 increased only 3% (Robert Wood Johnson Foundation).

How does Occupy Healthcare Connect with Occupy Wall Street #OWS movement? 

·         Where we connect with the  #OWS is that we need to have a political process not dominated by who has the most money in the game

What are some tangible actions that patients, providers, health educators and social scientists can do to change the system of health care?

·         Healthcare renaissance will require a cultural renaissance that includes willingness to shared sacrifice and a drive for sustainability

·         Encourage prevention got to make it a national priority  http://t.co/f9E8rY7g

·         mobilize 10 people a day to join at bit.ly/rv8Mar

One of the problems in other countries is there is universal care and also a private component.  How can we avoid this?  There is also a complaint of long waits.

·         A Canadian stated that she dreamed of marrying best things from the Canadian system and the US health systems

·         Triage is an important part of healthcare. Private systems bypass that.   If you have more  money you get better, faster care

                The US has a disproportionate number of specialists

·         We have to acknowledge the huge demographic shift that our specialist-heavy system is NOT prepared for.  More primary care physicians are needed

·         Specialities offer increased income

·         Specialist see fewer patients, are more expensive and less likely to recommend noninvasive/cost effective care

·         Primary care physicians need to be paid better

·         Primary care physicians need more respect within their profession

·         There are incentives for increased primary care physicians in the ACA but they do not go nearly far enough for the change in demographics  

·         Primary care physicians need to have longer residencies to improve their knowledge and respect in the profession

·         Medicare reimbursement committee needs to have fewer specialists, more open, not privately run  http://t.co/YRdKpMrV

A distribution of care is important.

·      Distribution of “great care” that great care...like endocrinologists...are at academic centers

·          We need the access for all who need those specialists.  How do we do this?

•  If we don't concentrate specialists in academic centers where research happens- where do we put them—

Occupy Health Care

The chat #OccupyHealthcare occurred on Sunday November 6, 2011 at 9pm ET.

Participants in First #OccupyHealthcare Chat

People from around the world, but primarily from the United States, answered questions.  There were 1,187 tweets during this chat.  To analyze the content a systematic process has been used to identify themes and perspectives.  The following is a preliminary report on the chat. 

            Questions were asked by four moderators timed to occur at regular intervals over the course of an hour.  The first question asked:

 Why do we need to Occupy Healthcare? What are the problems, what are the reasons we need to act, and why now?   Is there a need to Occupy Healthcare? Is there any urgency? 

 Themes noted in the discussion included:

: 

1.       Everyone deserves access to a health care

a)     Need a healthcare systems that values humanity and individuality of patient and provider

b)     Healthcare system needs to have patients at the center

2.       Healthcare in US costs too much

a)     Most bankruptcies are health related

b)     People have to choose between healthcare or groceries

c)      People are losing their homes to pay for healthcare

d)     Cutting the safety net while enacting reforms not good

3.       Healthcare system should support and promote health

a)     Prevention is not emphasized

b)     Social determinants are not addressed

4.       System is fragmented requiring patients to coordinate care

5.       System of payment is inappropriate

a)     For-profit model does not work

b)     Emphasis is on volume of patients seen, not value of the experience

c)      Physicians and hospitals are paid to provide unnecessary care

d)     Providers and vendors make money on the number of transactions and not patient support

e)     Treating patients is more profitable than finding cures or prevention

6.       Money in the system is poorly managed

a)     Health care executives are making multimillion dollar salaries and benefits

b)     Malpractice insurance raises costs of providing services

c)      Fear of litigation increases likelihood of excessive testing and services

7.       Health insurance

a)     Health insurance is not insurance 

b)     Health insurance, no matter the carrier, is expensive and doesn’t cover costs of healthcare

c)      Health insurance should not be for-profit in design

d)     Since health insurance is expensive, many are uninsured or underinsured

e)     Health insurance reform is not healthcare reform

f)       Coverage should not be based on employment status

g)     Coverage should not be based on immigration status

8.       Medical industry is the voice lobbying in politics and government.  Patient and providers need to take it back

9.       Charity and compassion for others is part of the rent one pays for being on earth

The second questions asked participants to come up with goals for a movement to change healthcare system. 

Patterns in the responses included:

1.       Change from the present  “illness for profit” corporate system

2.       Insure that all have fair and equal access to care

3.       Build alliances among people who are driven to build better healthcare system

4.       Give scholarships for primary care physicians

5.       Increase communication in healthcare setting

6.       Silos of excellence with brilliant caring physicians and researchers need to be generalized so that all can receive quality care

7.       Increase patient and provider influence:  Make them the voice lobbying in politics and government

8.       Legislators receive same healthcare experience as constituents

9.       Define quality healthcare metrics:  What is  “good healthcare” in the  primary care setting

10.   Educate public that providers, physicians, nurses etc. are exhausted and feel demoralized by the system as well  For example:

a)     “#occupyhealthcare do you think you can make me think? Make me work? Make me your slave...AND then keep you healthy? Good luck.”

b)     “I was overwhelmed, trying to coordinate care, treatments, bills, insurance, etc. we must improve!”

The third question asked participants to provide some practical steps to achieve the goals.

1.       Change Medical education

a)     Medical school tuition must be lowered to give those who are disadvantaged a better chance to become doctors 

b)     Embed community engagement in primary care residency programs to train physicians to advocate for social determinants 

c)      Teach person-centered care

d)     Integrate mental health education and public health education into primary care teaching

2.       Join already created coalitions who have been “fighting the fight” for years

3.       Inform patients of their choices and help them advocate for themselves

a)     Utilize proper analytics to assist and grow health literacy

b)     Promote data-informed health decision

c)      Educate patient, family and physicians of the need for end of life discussion before this time, since 50% of healthcare money is spent in the last 6 months of life

4.       Physicians need to take a lead in their organizations and need to be willing to initiate culture change

a)     Inform physicians of the need to reduce industry influence and propose responsible change

5.       Meet with legislators. Meet with corporate executives.  Make noise.  Get involved in the process

a)     Identify policies and forces beyond healthcare that impact health

b)     Social disparities affect health—work on policies that affect food, housing, social inequality.

c)      Remind corporate executives who run the hospitals they won’t run without health care providers (physicians, nurses, etc)

d)     Get academics out of the centers and into Town Hall meetings in communities

e)     Help patients register to vote 

f)       Fight for Patient Protection and Affordable Care Act to be enacted

g)     Become active in policy discussions with students, peers and friends.   Point out injustice when seen

6.       Reform payment structures for health care, primary care, wellness, and mental health care

7.       Assure access to experimental and ancillary care for those with rare or extreme illnesses such as cancer

8.       Move the dietary guidelines from the USDA to the CDC or IOM

9.       Establish  outpatient clinics near every hospital funded by the Federal government to serve indigent populations

10.   Reduce direct-to-consumer advertising by pharmaceutical industry

11.   Reduce the paperwork

Tonight we are going to continue the conversation.  Please join us at #hchlitss on Thursday, November 10, 2011 at 8pm ET.