Union Behavior Might Be Obstacles in Transforming American Healthcare

Some interesting articles in USA Today regarding union positions about the H1N1 vaccine which suggest that transforming American medicine so that it is higher quality, improved access, and even more affordable will be extremely difficult if not impossible.

Some hospitals, healthcare organizations, and the state of New York attempted to have staff required to get the seasonal and H1N1 vaccines. Even though, Infectious Diseases Society of America recommended all healthcare workers get flu shots, the Service Employees International Union (SEIU) opposed this and won.

Although patients are lining up demanding flu shots, doctors and the Centers for Disease Control want those at risk, SEIU indicates that the issue is education, rather than attaining compliance by fiat. To be completely fair, too many doctors don't get vaccinated either which is equally as disturbing. In healthcare, we make too many exceptions rather than require that the right thing gets done at all times.

While I was troubled by the behavior of SEIU, I can understand while disagree with their opposition to mandatory vaccination. It seems more of a political decision rather than scientific.

Yet, later that week SEIU was again in the news. This time upset about the distribution of flu vaccine to companies that have employed in-house doctors and clinics. Specifically, the union had a problem with companies like Goldman Sachs which received vaccinations from the City of New York in a equitable system where only those at highest risk (chronic illnesses or pregnancy) were to be immunized and the original distribution was reserved for pediatricians and obstetricians who requested vaccine. Sadly only about half of the pediatricians in New York City wanted it. As a result, the city moved on to give vaccines to those doctors caring for adults, which included the physicians working at Goldman Sachs as well as the Federal Reserve Bank, Columbia hospital, and Time. From the article:

"Wall Street banks have already taken so much from us. They've taken trillions of our tax dollars. They've taken away people's homes who are struggling to pay the bills," union official John VanDeventer wrote on the Service Employees International Union website. "But they should not be allowed to take away our health and well-being."

The union has about 2 million members, including health care workers.

Um, so wait. Healthcare workers are considered a high-risk group as defined by CDC. Naturally healthcare workers should be among the first in line to get the vaccine. If you had agreed to a mandatory vaccination program for those in the union who are healthcare workers, wouldn't that mean those in your union therefore are vaccinated and kept healthy? Getting the vaccine, which is in short supply wouldn't be a take away, but a benefit!

Having mandatory vaccinations in really only a small issue in a much larger problem. How can employers and unions get together and transform American healthcare?

To be clear, I'm not opposed to unions. One of the most successful organizations ever is Southwest Airlines, which to the surprise of many who don't know, is among the most unionized airline in the country.

I'm troubled because companies like General Motors failed because unions and employers were unable to see eye to eye. As a result, it failed because it was unable to compete with foreign competitors. Unlike the auto business, there foreign national healthcare organizations wishing to take over the US marketplace.

What it does mean, however, that making healthcare better and cheaper won't happen. Result? Government takeover or increasingly more Americans uninsured, worsening healthcare quality, and increased costs.

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All

A fascinating article and equally disturbing is a fantastic article from Wired magazine. An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All is an objective look at the two different camps regarding vaccinations and the concern whether they are the cause of autism.

Both camps want to keep children safe. Both have very different ideas on what that means. For doctors and the medical profession, the science has been drowned out by a very effective media savvy campaign which has resulted in significant decreases in immunization rates resulting in the return of previously contained childhood illnesses like measles and pertussis.

As the internet connects more of us and removes obstacles for acquiring knowledge, it has instead reinforced and caused polarization not only in politics, but even more so in medicine.

Find out the truth on how to stay healthy and well by asking questions, listening to opposing points of view, and then making your own decision. I learn from patients. Patients learn from me.

As the article rightly notes, choosing not to have a child vaccinated isn't risk free, but rather a different set of risks occur. While I may disagree with patient's decisions, I do respect them as long as I feel they are informed about the pros and cons. I only hope that they choose based on rational thinking rather than emotional fear.

Can Doctors Provide Rational Care or Cave In? H1N1 Experience with Public Health Indicates Latter

As the country discusses providing everyone with health insurance, an even more important conversation is how to slow the rise of healthcare costs. Many studies and research point to the ability of doctors to remove waste by not performing unnecessary tests or procedures and not prescribing the latest medications which are proven to be no better than generic versions. There is a belief that much of this additional cost is due to the fee for service reimbursement system where doctors get paid more to do more.

For example, spending 30 minutes on nutritional counseling, weight loss, and exercise for one patient with hypertension doesn't pay as much as prescribing blood pressure medication for three patients in 10 minutes. In the fee for service environment, volume is key, not necessarily providing the right care or the most rational care. A recent Newsweek opinion piece by an emergency doctor showed how he evaluated a patient appropriately for a recent head injury, discussed the plan with the family, and arranged follow-up with the pediatrician all without getting a CT scan of the head. Result? Patient did fine. No radiation exposure to the brain. No additional cost to the healthcare system, insurer, or family. Everyone benefited.

While the example isn't rare, it also isn't common. Some 30 percent of tests or procedures performed in this country have been suggested to be unnecessary and added no value to improving patients' quality of life or outcomes.

In other words, if we removed the fee for service reimbursement system, then doctors would prescribe only the right care. Not too much or too little, but just right.

Or would they?

Recent articles should make us think twice. The H1N1 virus which has been demonstrated to affect those under age 25 years old and pregnant women disproportionately than the general population now has a vaccine available, albeit in short supply. This limited supply has been given to individuals not deemed at high-risk for adverse outcomes by CDC.

While the issue might be that some public county clinics received more vaccine than others (a systems or distribution problem), the bigger question is whether public county officials and doctors are willing to have honest and frank discussions about a person's need for the vaccine. Unlike doctors in the fee for service environment, these providers don't get paid more to do more. Since compensation isn't an issue, then can they talk through the fear that people have and provide the appropriate care?

Answer? Unfortunately no. Public health officials don't want to be the police and determine who should justifiably get the vaccine and who should be turned away.

In other words, if people want it, then they will get it. If public health officials can't say no appropriately, then can we expect much better for doctors in the future? Even if the fee for service reimbursement structure is removed, unclear if that will ever happen, will doctors provide rational care and advice or cave in when patients demand prescriptions based on television ads or care recommended by celebrities?

As I received my vaccine at a flu clinic, there were nurses asking each individual in line what vaccine did they want. The nurses appropriately advised those not in the high-risk groups that they would only receive the seasonal flu vaccine and not the H1N1 vaccine. There were no fights, outbursts, or fear. Patients understood that they were getting the right care. Not too much and not too little, but just right.

If America is going to solve the affordability issue of healthcare, then doctors will need to lead the way.

Based on the public clinic officials' performance, I'm even less optimistic about the medical profession's ability as a whole. While I have great confidence in my fellow medical school alumni from the University of Connecticut School of Medicine, the colleagues I work with at the Permanente Medical Group as well as the many medical bloggers I've encountered (many who follow me via Facebook or Twitter - thanks everyone!) , I have real concern about many doctors nationwide and specifically on their ability to provide rational care and not to cave in and take the easy way out when making decisions about medical care.

What does this ultimately mean? Without doctors leading the way, the only choice left is government run healthcare. If doctors can't say no based on scientific and medical evidence, then Uncle Sam will say no. Don't say I didn't warn you.

Why I Chose to Get the H1N1 Vaccine

As a practicing primary care doctor and as the only doctor in my family, I take my job very seriously. Particularly now with so much information available literally at anyone's fingertips via the internet that separating the truth from hype can be impossible for patients. The public often gravitates towards those with media publicity and exposure rather than expertise. This was reinforced by a recent Newsweek article which found Suzanne Somers recent book about nutritional cures for cancer treatment as questionable.

So certainly the amount of exposure regarding the H1N1 vaccine and who should get it and why has been getting plenty of airtime, bandwidth, and newsprint.

So, why did I chose to get the H1N1 vaccine?

Because it is the right thing to do for myself, my wife, and my children.

Here's the scenario. A new novel flu virus that targets those 25 years and younger and who are twenty six more times likely to come down with it than those 65 years and older appears out of the blue in April 2009. Healthy children, young adults, and pregnant women are disproportionately affected. Many die. The world's best scientists and researchers, using the latest in medical research, identify and sequence the virus in record time. The blueprint is handed off to pharmaceutical companies in a herculean effort to produce enough vaccine for a world fearful that another 1918 pandemic is among us where millions of young and healthy individuals died before their time.

The 2009 summer continued to see significant cases of H1N1 flu. In late October, 46 states report widespread H1N1 virus activity. Doctor visits related to influenza like illnesses stand at 7 percent with no end in sight.

Based on the latest monitoring, the overwhelming virus type is H1N1. From CDC of the nearly 5,000 specimens that tested positive for influenza, 99.8% where influenza A and nearly 70% were confirmed to be 2009 H1N1. Of the remaining 30% that weren't initially subtyped, those that were submitted to CDC for further analysis ultimately were H1N1. From CDC:

No. of specimens tested 12,943

No. of positive specimens (%) 4,855 (37.5%)
Positive specimens by type/subtype
Influenza A 4,844 (99.8%)
A (2009 H1N1) 3,378 (69.7%)
A (subtyping not performed) 1,436 (29.6%)
A (unable to subtype) 30 (0.6%)
A (H3) 0 (0.0%)
A (H1) 0 (0.0%)
Influenza B 11 (0.2%)

During week 41, influenza B viruses co-circulated at low levels with 2009 influenza A (H1N1) viruses. All subtyped influenza A viruses reported to CDC this week were 2009 influenza A (H1N1) viruses.

Finally, American medicine develops a designer vaccine that is specific for exactly the virus that is the predominate strain this flu season. The vaccine only has one virus type and not the typical cocktail of multiple viruses used in the seasonal flu vaccine. The flu season is caused by one type of virus, which the vaccine provides protection. In addition, this designer vaccine is produced using proven production techniques and given via a delivery system (injection form) used for years. Side effects are very mild and have been documented with previous vaccines.

That's the story. Here's the irony. Public response? 38 percent of parents when offered refused the H1N1 vaccine for their children.

Perhaps it is how we get our information and news. Our society is focused on 30 second soundbites. The general public lends weight to individuals with celebrity status and often equates their media exposure to scientific and medical expertise. Viruses don't care if you are Republican, Democratic, or Independent. When public figures like Bill Maher and Glenn Beck talk about their opinion, they need to state that their opinion is for entertainment only and in no way is a substitute for medical expertise (you would think that would be obvious to listeners).

As a practicing primary care doctor, I continue to worry about how the public gets its important health care information and its ability to separate hype from the truth.

Get educated. Get informed. If you refuse, then that is ok as long as it is informed refusal. If you refuse because of ignorance, then I hope you or your loved one never gets ill and dies from this preventable illness. A lifelong feeling of regret when something could have been done, but wasn't isn't a burden I wish on anyone.

Quick summary.
Novel potentially deadly virus preying on the young and healthy as well as pregnant women? Identified and sequenced.
Possible vaccination? Developed using proven techniques.
Side effects? Well known and mild.
Public response? Fear, apathy, and inaction.

My worry? That the flu season isn't as bad as what the President's Council of Advisors on Science and Technology forecast as one scenario of a 30% prevalence of H1N1 resulting in 90 million ill, nearly 2 million hospitalized, and at least 30,000 dead.

The best part so far with the H1N1 vaccine? The side effects of the shot are actually much better than the seasonal vaccine, which we all received last month. Children didn't have any fever. My arm wasn't sore at all.

I'm ready for this flu season as one of the front line primary care doctors.

Are you?

Still confused? Find out of the vaccination or the nasal spray is best for your children. Why people fear the H1N1 vaccine. Fast facts about H1N1 - although for the latest information go to Flu.gov or CDC.

How Effective Are Generic Drugs?

A brief ABC News video titled How Effective Are Generic Drugs? provides the truth about generic drugs. For the vast majority of individuals they are equally effective and less expensive. If you truly need a brand name drug, then obviously you'll pay more.

For many however, generic is perfectly fine.

How to make your health insurance count as if your life depended on it

Five years ago, I penned an opinion piece which appeared in the San Francisco Chronicle titled, "How to make your health insurance count as if your life depended on it".

The most disturbing and troubling aspect of the piece is that if it was published today it would still be completely accurate. Healthcare quality still varies dramatically over the past decade despite the Institute of Medicine's 1999 landmark report "To Err is Human".

Even as many expect President Obama to have healthcare insurance reform bill requiring universal coverage signed by the end of this year, the reality is that it will still be a full decade before meaningful improvements in the healthcare system will be seen. That's optimistic to say the least.

What should you do? Make sure you make the right choices today so you will be around for years to come because it isn't clear even five years later after my opinion piece that the healthcare system is in any hurry to fix itself soon.

Who pays for this inertia? You do. But with some education (and even the critical insider tips from my book), you can get the best healthcare American medicine has to offer without overspending).

The op-ed piece follows.

How to make your health insurance count as if your life depended on it

It's that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the "perfect" Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention. But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimates that this year, 79, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely -- not because of hospital errors, misdiagnoses or negligence, but because they chose the wrong insurance plan. Had they selected a high- quality program, the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association would have been reached and their lives prolonged.

When NCQA compared the performance of the top 10 percent of health plans with the national average on certain measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, it discovered variability among plans exceeding 20 percent. If one used similar criteria to compare the safety performance of the top 10 percent of airline carriers with the national average, the quality gap was far less than 1 percent. The same applied for banking and manufacturing. How safe would you feel about flying if among the various airlines there was a quality variance of more than 20 percent? Yet, when it comes to health care, consumers don't appear to be concerned.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . This means you have an increased chance of not knowing whether you're choosing a poor-quality health plan this year.
As if that weren't enough, during this enrollment period, the term "consumer-driven health plans" is the new catchphrase for cost containment. In an effort to save money, employers are less likely to provide comprehensive coverage, but rather directly give you the dollars to manage and spend on health care. Now you, not the health-insurance plan, will decide what tests, treatments and procedures you can afford. For your nagging sciatica, should you pay for an MRI of the spine or a CT scan to rule out a herniated lumbar disc? For your sake, with the burden of financial responsibility and the lack of consistency among health plans, you'd better hope you never ever get ill.

So what can you do? Although there is no national urgency to fix the problem, you aren't completely powerless. First, check out the NCQA Web site (http://www.ncqa.org/) and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It's your money. Don't you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. How do I know? I am employed by one of the health plans highly rated by NCQA. My hope is that with hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.

The Truth About H1N1 Vaccinations - Shot, Nasal Spray, or Neither? Parents Uncertain.

A recent Associated Press-GfK Poll found that one-third of parents will not have their children vaccinated with the H1N1 flu vaccine. While 59 percent of parents were willing to give permission to schools to administer the H1N1 vaccine to their children when available, 38 percent refused.

Sounds like a lot, doesn't it?

But it's not. News reports failed to highlight another fact in the same survey. Two-thirds of parents (66 percent) planned on having their children vaccinated against the traditional seasonal flu and one-third (32 percent) did not.

In other words, the number of parents opposing the H1N1 vaccine is about the same as the seasonal flu vaccine. As a whole, a significant number of parents oppose flu vaccinations whether for the seasonal or H1N1 virus, which was commonly referred as the swine flu in the spring.

Yet, reports from CDC show that the flu outbreak is widespread in 37 states with the vast majority being H1N1. The number of pediatric deaths for the 2008 to 2009 flu season (starting September 28, 2008) stands at 147 with 76 deaths due to the 2009 H1N1 virus. Twenty-nine of the H1N1 deaths occurred since August 30, 2009. What is concerning is that the number of pediatric deaths is higher than in years past. Since the H1N1 virus started in the spring, it is very possible the number of pediatric deaths will only increase for the 2009 to 2010 flu season.














The H1N1 virus is particularly harmful in children and young adults aged 25 years and younger. CDC reported in the spring that the number of H1N1 cases was 23 to 26 times higher in individuals 24 years and younger than people 65 years and older. The older cohort had some natural immunity while the younger group had none.

Given all of this information, why aren't parents acting?

Psychology may explain this. People tend to have more regret when they actively make a decision that results in a bad outcome than if they passively had it happen.

For example, some research suggests that changing answers on a test on average benefit the test taker. Yet, most of us are quite reluctant to do so even if it is in our best interest. Why? Feelings of regret are far more powerful if did something to result in a bad outcome than if the bad outcome occurred due to no action on our part. In the case of test takers, they felt better if they left a wrong answer (inaction) than if they actively changed an answer and then got it wrong (action). Even though having a wrong answer, the bad outcome, was the same in both cases the latter group felt far worse.

Actively scheduling and then taking a child to get the flu shot and potentially needing to deal with side effects are not very likely, but still a real possibility. Should the child suffer an adverse reaction, then naturally the parent would feel terribly responsible. If the child instead developed H1N1 and had not gotten vaccinated earlier, the parent would feel not feel as guilty.

Yet as for the threat of H1N1, I suspect many parents see what they want to see. If their child isn't ill and they don't know others who are ill, inaction is preferred.

This inaction is just a sign of a disturbing trend. Increasingly more parents are concerned about vaccinations in general than the illnesses they protect against because people don't have personal experience with individuals suffering from illnesses like polio, mumps, or measles. They don't recall the scare sixty years ago when polio outbreaks closed public pools, paralyzed otherwise healthy individuals, and prominently impacted the life of a sitting American president, FDR. Despite all of the medical advances in the 21st century, new cases of polio still occur throughout the world despite the availability of effective polio vaccines. Children still suffer from devastating life altering complications from polio because their parents refused get them immunized. Vaccinations work.

Given a choice between the inactivated flu shot, which uses a killed virus, versus a nasal spray vaccine, which uses a live but weakened flu virus, I would suggest parents who are concerned about safety to opt for the former. I feel better about receiving a dead virus to train the immune system rather than subjecting the body to a weakened one. I would note, however, that both vaccines are approved for usage.

Although the inactivated H1N1 flu shot must be given on two separate occasions for children 9 years old and younger (up to 6 months old), this is not different than when children get the seasonal flu vaccine for the first time. Read more about the inactivated H1N1 flu shot via the vaccination information statement. Research has shown that children 10 years old and up only need one H1N1 flu shot.

The nasal spray uses a live, but weakened virus which can only be administered to children ages 2 years and older. Therefore, children age 6 months to 2 years desiring a H1N1 immunization will need to get the shot. More about this nasal spray H1N1 vaccination via its vaccination information statement. It only needs to be given once.

In the end, I hope these parents that choose not to vaccinate their children against H1N1 are right. I hope their assessment of risk to their children is correct. I hope that they aren't wrong, because if they are wrong, they could be deadly wrong.

A vaccine exists and has the real potential to save lives. It's safe. Instead many parents are walking away partly due to psychology, some fear, and often due to lack of experience with formerly common debilitating illnesses. Often what troubles me as a doctor is knowing something could have been done to save lives, decrease suffering, and improve health, only to discover that the opportunity is missed and it never happens. I hope that the concerns parents have about H1N1 or the seasonal flu and their subsequent inaction do not become one of these tragic missed opportunities.

More information about the H1N1 vaccine can be found at the CDC website.