Lies, Damned Lies, and Healthcare Statistics

U.S.A. ranks 26th in Life Expectancy, Behind Slovenia!

It’s hard to ignore this dramatic newspaper front page headline.
The Life Expectancy graph is prominently displayed below the headline to
emphasize this statistic and to question the quality of U.S. healthcare.
Because you know, if there’s a graph, it must be science. IMG_5458

Even Slovenia is ahead of the USA. Further proof that the United States lags far behind
so many other nations in our quality of healthcare.”
Nothing against Slovenia, a beautiful country in Central Europe, but that statistic was meant as derogatory to our healthcare system.

While the stat may be correct, the conclusion is a lie. A damned lie.

I’m just not in the mood these days to put up with folks
attacking my country or my profession.

It’s hunting season and our nation’s healthcare is the target. Take a shot.
No limits. Like shooting fish in a barrel, you can’t miss. Whack-a-Doc.
But as the song goes, “you don’t know what you’ve got till it’s gone.”

Statistics are often used to make a point. In a world of sound bits, headlines, and shortened news stories, the superficial takes on more meaning than it should.
USA healthcare is too expensive, yes. But poor quality? Don’t be ridiculous.

The message that our nation’s healthcare is dreadful, ranked 26th in the world based upon a life expectancy chart is misleading, and frankly, it’s offensive.

It’s like telling a person that their parents were not so great
because they passed away too young.
“I beg your pardon?”

Let’s take a look at those stats.
First, life expectancy is way, way up overall. Everywhere.
In the USA, you can expect to live about 8 years longer now than you could in the 1970’s.
Your average life expectancy is 40 years longer than you could have hoped for if you were born at the beginning of the 20th century! 40 years longer!
In fact, throughout the history of Mankind, the average life expectancy has been only around 40 years old… most people died before 40… until this last century.

Thanks, America!

IMG_5461Advances during the last hundred years have been largely driven by the efforts of the United States, through improvements in hygiene, waste disposal, water management, immunizations, pharmacological and surgical advances. Free market motivation, American innovation, and altruistic dedication.

Our entire world has benefitted from the advances made in the USA.
How quickly some people forget.

An American medical education remains the most respected in the world, with many countries reaching out to our healthcare leadership and experience to guide their own efforts. There are foreign physicians training in every major medical center in our country. They are the lucky ones to be able to train here and they will tell you so. We lead the world in success rates in almost every mode of treatment and procedure. For example, the USA has the highest breast cancer survival rates in the world. And more than three-quarters of American women are screened for cervical cancer, more than in any other country.
May God continue to bless our greatest national treasure, American women.

Here’s another point: Life expectancy is largely driven by genetics.
Any biologist can tell you that the great diversity of race that makes America strong also affects our nation’s life expectancy rates. When all other variables are filtered out, people tend to live about as long as genetic tendencies guide. So comparing these numbers in the USA with, let’s say, Japan, Sweden, or Switzerland, the gene pool plays a significant role.

There are other factors in the life expectancy calculations.
For example: Violence and Auto Accidents.
U.S. Centers for Disease Control and Prevention reported in 2013:
More Americans die each year from suicide, around 40,000/year,
than die from motor vehicle accidents, around 35,000/year.

Our leading causes of death, heart disease and cancer, are more dramatically influenced
by a person’s lifestyle choices than healthcare intervention. Diet, exercise, smoking, and hope can affect these diseases far greater than acts of medicine.

We have access to more options of healthcare diversity than any country in the world. Our freedom to choose our own personal path to better healthcare is astounding.
Alternative, Chiropractic, Homeopathy, Spiritual, Naturalistic, Evidence-Based, Academic.
Take your pick. Blend them all if you choose. America’s healthcare remains the best in the World. It’s just up to you to use it wisely. Accountability, that’s the best option.

My final point.
IMG_5162When did the length of life become the measure of healthcare quality?

Healthcare is better measured by our vibrance, passion, and joy.
Our bodies are meant to be used, our minds tested, our muscles strengthened.
Run, walk, eat well, breath, study, pray, laugh, age.
Fill your years, however many years you may have, with love and curiosity.
There is no greater place than America to do so.
Ignore the naysayers and statisticians, let them be buried in Slovenia.

We have the greatest healthcare system in the world.

Guy L Culpepper, MD


There are No Ordinary Moments

And There are No Routine Office Visits

“Oh, and one more thing Dr. Culpepper…”

IMG_2379I hear those words frequently, just as we’re leaving the exam room.
It’s often the most important part of an office visit. That moment when both the physician and the patient have let their guard down. It’s a safe moment. And sometimes it’s the
real reason a person came to see me.

“My father loved you.”
I looked at the middle aged mom putting her over-stuffed purse back on her shoulder. Claire hasn’t changed much in twenty years. Her kids have worn her out a little, but she still grins the same way that she did as a college student. I remember her dad. Funny thing is that while I can hardly remember where I put my car keys this morning, I can still remember most of my patients quite clearly. Her dad was tough. An oil man.
He didn’t grin so much.

“How long’s it been?”
“Two years.” She stood with the heavy purse hanging on her shoulder. Obviously she’d grown accustomed to its weight.
“He was a good man,” I said. Not much more to say, so I gave her a doctorly pat on the back. Sometimes being quiet is the best medicine.

Claire had come to see me for a “routine” visit. CPT code 99213.
A level 3 office visit, defined as the evaluation and management of an established patient with a problem of minimal complexity.
The most common code used in primary care billing.
It doesn’t pay much, but it’s the foundation of our industry.
The truth is that there’s absolutely nothing routine about it.

I thought our visit was done. And as you might guess, I was behind. I’m often behind.
“He said you saved his life.”
That comment surprised me. After all, we were just acknowledging his passing.
Not much life saving there.
I must have looked confused because she clarified. “You changed his life.”

Now I’ve been doing this long enough not to take credit for the big stuff.
That’s in other hands. Much bigger hands. But it is polite to say “thank you” and listen. Besides, I really like compliments. So I kept listening.

“Mom said that he came home after a visit with you, I think it was for a blood pressure check…” She paused as if I would fill in the blank, but HIPAA held my tongue.
“He said he’d been waiting for a doctor to tell him when it was time to quit drinking.
He emptied out the cabinet and didn’t touch a drop in last three years of his life.”

“I’m glad he took my advice.”

IMG_2592“It was a wonderful three years. Mom had her husband back,
my son got to know his grandfather…” She adjusted the heavy purse and moved it away from her shoulder. I was a little bit afraid that she’d sit back down. My nurse is used to apologizing to our patients about their wait. So I put my hand on the doorknob to silently steer the situation.

Mom’s are smart. She read my body language.
“I know you’ve got to go, Dr. Culpepper,”
she said, “you always have so many people waiting. But I just wanted you to know that by taking that extra moment, by stopping on the way out,
you gave my father much more than a minute of your time.”

“Thank you,” I said. Her words made me feel warm. In that moment, the rushing and the stress of primary care was far away. The kind of moment that keeps family doctors doing what we do. A reminder that no office visit is ever routine.
Then I remembered… this was her office visit.IMG_2586

I took my hand off the doorknob and placed it firmly on her shoulder, to the spot where her heavy purse had tugged just moments before.
“Claire, you know the real reason he changed? Because he loved you.”

There are no ordinary moments.

Guy L. Culpepper, MD

Obamacare: Prognosis Terminal

Health Insurance Exchange Fails its Physical

Politics and science work together about as well as politics and religion.
What about politics and education… energy… economics… ?
Come to think of it, politics doesn’t get along with anyone.
So it’s no surprise that problems arose when politicians got involved in healthcare.IMG_3979

This blog is not about politics. You’ve had enough of that.
I’m writing about access to primary care.

I’m a family doctor explaining why I won’t be a part of Obamacare.
And it’s not because of politics.
In fact, most primary care physicians are opting out.
Because we simply can’t afford to participate. I’ll explain why.

IMG_4122Primary care costs less than your cell phone. And more Americans have a cell phone than have a family doctor.  Obama gave away phones during his campaign.
Now, some politicians want to give away family doctors.
But we don’t take too kindly to being given away.

Here’s the thing. While educated and powerful people debate the failure of a website, the nuances of a law, and the moral obligation of a country to provide healthcare, most of them have overlooked the obvious. We are just flat out of primary care physicians.
Kaput. Empty. No room at the Inn.

Let me spell it out for you.

1) There aren’t enough primary care physicians to care for Americans.
Obamacare doesn’t help that. There is nothing in the Affordable Care Act to enhance primary care. Nothing to motivate more physicians to choose a career in primary care. No incentive to keep established PCPs in practice. Nothing to expand our offices or reward the wonderful people that work in them. No increased pay, no less paperwork, no fewer regulations. In fact, the opposite is true. We have more laws and taxes, confusing rules, and increased overhead.

2) Policies being sold by the Insurance Exchanges have very high deductibles.IMG_4111
Most Americans with insurance know that a deductible means that they will have to pay for the first $5000 of their healthcare. But the patients who can’t afford insurance, even if their plan is subsidized by the ACA, still can’t afford to pay their deductible. The ACA was to help those 30 million people who couldn’t afford insurance. But even if the insurance premium is tax subsidized, how will these patients be able to afford their deductible? By the way, that deductible happens in the PCP office. So who doesn’t get paid? The primary care physician.

3) Most hospitals are not even in the Insurance Exchange networks.
Once a deductible has been met, which is usually within the first few hours of a hospitalization, the hospital can anticipate getting paid. Even knowing that, most hospitals have opted out of over 2/3’s of the Exchange’s insurance plans. There are few things harder for a primary care physician than trying to find a hospital bed for a seriously ill “out of network” patient. It would be better for the patient to have gone directly to the hospital ER instead of to their PCP’s office. If a patient is already in the ER, the rules requiring a hospital to keep a sick patient could help. But doesn’t going to the ER first raise cost?

4) The preventive care coverage is very limited as to which services are covered.
All non-covered services will go to the deductible. Meaning the patients who couldn’t afford insurance must still pay for their illness care. Patients are confused by this and get angry at the PCP because they expected a “free physical”. When told that “your physical is covered”, patients bring long laundry lists of their medical problems that have been neglected. These need significant attention. Disease care is not covered as part of a screening preventive exam. The lab tests, and the physician’s time to evaluate these problems, are not “preventive care”. There is no provision for PCPs to be paid for this care. It goes to a deductible and primary care doesn’t get paid.

IMG_37485) If a patient doesn’t pay their insurance premium, the PCP must refund the insurance company. The Insurance Exchange policies have a 90 day grace period. A patient can sign up for insurance, see a physician between days 30 and 90, then chose not to pay their insurance premium. The PCP that cared for that patient will be notified by the insurance plan that the patient didn’t pay for the insurance, the policy is cancelled, and the PCP must refund to the insurance company all fees paid. If the PCP doesn’t refund the insurance company, the funds will be subtracted from the next payment. The insurance company is protected. The PCP bears the risk and takes the loss.

6) The earliest enrollees will be the sickest.
The young, healthy people that were “forced” to buy insurance are not signing up. The healthy seem to prefer paying the $95/year penalty instead of paying hundreds of dollars each month for a high deductible plan. Without the healthy enrollees, the price will soon go up. Meanwhile, overworked PCPs that participate in the Exchange plans will be assuming care for those patients who were sick enough to fight through the enrollment process. These are the patients that need the most care, or have neglected the most serious medical conditions. These patients have put off their care because they couldn’t pay for it. When the PCP delivers comprehensive care and expensive tests, those charges will go to the deductible. You see the pattern here. The PCP bears the cost once again.

7) Your PCP is already providing charity care every day.IMG_3828
Primary care physicians quietly provide free care in their offices every single day. We can’t advertise our charity because we would be overwhelmed. Everyone has a friend or a family member that needs free care. And unlike non-profit hospitals, no one subsidizes our charity. We can’t afford to market our giving, and we’re not very good at saying “no”. So like the thousand points of light that make our country brighter, we quietly tell a patient “no charge today” or “pay me when you’re able”. Warm handshakes aren’t taxable.

Primary care physicians have been caring for the uninsured and the underinsured for much longer than Obamacare. Primary Care is the greatest value in healthcare.
Now, more than ever, it’s time to remind our nation,
“We’ve been here for you, we’re still here for you. Let’s keep the politics out of it.”

Guy L. Culpepper, MD

You Make Me Better

Our Team is Our Strength

My wife and I just returned from Wyoming for our anniversary trip.IMG_5416
27 years of marriage.
She tells me it feels like 27 minutes… underwater.
Who am I to argue?

Marriage is much like Primary Care.
It can be suffocating and elating, tearful and joyful.
Sometimes all in one day.

We left together and we returned together. Which is one answer to the question,
“How do you stay together for so long?”
Hang on and keep moving. Together.
The passion for marriage, much like for medicine, ebbs and flows.
So it is with tides, careers, hormones, and opinions.
Of course, the love is always there.
But at times, it’s less about love and more about holding on.
Primary care physicians are like my remarkable wife. They are very good at holding on.

Here’s another key:
(and you can forget everything else, if you just remember this)
Know that your partner makes you better.

When times are tough, when you’re tired, sad, or forgetful, turn to the ones around you.
Your team is your strength.IMG_5245

Some of the greatest people that I’ve ever known are physicians.
But this post is not about physicians.
It’s about the team that makes physicians better.

As our country struggles with ways to improve primary care,
we must be certain that our team is also rewarded.
We could not do what we do, as well as we do it, without these wonderful people.

IMG_5354Many of my patients are willing to put up with me because of the pleasant greetings that they receive from my front office staff.
My receptionist’s smile can make you feel better.

When my medical assistant reminded me about your drug allergy, she added it to your record. I looked like an attentive physician. I was attentive because she was.
It was my medical assistant that saved your life.

I am better because of my team.

I can remove your mole. Expertly. But you’ll want my assistant to draw your blood.
She has a gift. You’ll hardly feel it. She also gives much better shots than I ever could.

My nurse knew the moment she brought your husband into the exam room that he was really sick. I was with another patient, but she had the foresight to check his oxygen level. She’s very good at knowing when someone’s in trouble. She called the ambulance.
I gave her the flowers that you sent.

Oh… and about remembering the school that your son attends, which pharmacy you use, and the last time your mother in law visited you… yes, my medical assistant reminded me.

I am surrounded by dedicated and caring people. They make me better.

Our office is clean because of the delightful people that come in around 10 PM every night to clean it. Yes, I’m often here to see them. That’s a different post. You would notice if they didn’t show up. Doctors and nurses can be very messy.

Then there’s the business side of what we do. It’s called managing an office.
Somehow, a thousand times a day, our office manager does the impossible.
Orchestrating the moods and needs, complaints and requests, credits and debits
of a business wound tighter than a worn out pocket watch.
Every now and then someone says, “Thank you.”

Improving and rewarding primary care

improving and rewarding the people around us.

Independent primary care physiciansIMG_5374
must be rewarded for providing the
foundation of our nation’s healthcare.

And that reward must be sufficient
to share with our entire team.
Our partners make us better.

By the way, when my wife comes
up to gather air for another 27 years,
I’ll be telling her “thanks” too.
There’s nobody I’d rather be underwater with.

Guy L. Culpepper, MD

Wellness. Seriously?

There is no “I” in Wellness

Look up “Wellness”.meditation
Bam. 270,000,000 results.

Enough for all 114,000,000 United States households.
Plenty of wellness is available.

Wellness must be very important. Every healthcare provider in America, from cardiologists to chiropractors, emphasize it on their website. And every insurance company sells a program for it. You’ve seen the ads. That much caring could make a person cry.
In fact, you should be downright ashamed if you’re not promoting wellness. Right?
If not, you must be one of those people that promote sickness. What? That’s silly.

What is Wellness?

The National Wellness Institute defines wellness:meditation nat geo
an active process of becoming aware of and
making choices toward a more successful existence.

Now that’s deep. Boring, but deep. Like a well.
I get it… wellness is well… OK, I don’t get it.
Neither does anyone.

When you google “Wellness Programs”, you will get 57,600,000 results.
That’s about 57,600,000 more results than the actual wellness programs get.

Employers spend over 2 billion dollars each year on wellness programs, not counting the money spent on in-house policies, rewards, and initiatives. Money that could be used to facilitate primary care. That’s enough to pay for one office visit for each of the 25 million uninsured that we’ve turned our economy upside down trying to help.
It’s enough money to raise the income of every practicing primary care physician in our country by $10,000 a year.
Primary care… you know… those people that provide the real preventive care for our country. The ones that are getting harder to find.

Primary care physicians, in contrast to wellness programs, have been shown to improve healthcare and to lower costs. Real data. Real science.
But wellness programs market more effectively. They’re out there selling their stuff.wellness catfood

Our country seems determined to buy wellness.
As if the more money we spend, the more well we can be.
The bleeding edge of wellness.
The most wellness you can buy.
You need the latest version of wellness.”
“You don’t want last year’s wellness.”

Businesses feel obligated to purchase some type of comprehensive implementation of wellness protocols, with onsite biometric analysis and real time maternalistic nurturing feedback. If a company cares about its employees, it will invest in wellness. It’s right there in the brochures. There are actual contests to see who has the biggest wellness program. Spending more equals caring more. Right, parents? Oh? That explains a lot.

There is no consistent evidence that wellness programs work.
Sure, lots of companies sell these programs by quoting data of $3 returned for every $1 spent on wellness. But this data compares the worker’s who participate with those who don’t. Motivation is what made the difference, not a specific program. And even the data on those engaged has not yet shown statistically significant healthcare cost reduction.

Motivation drives outcomes. It also skews results.
Science calls that bad research. Salesmen call it marketing.

Physicians are expected to practice “evidence based medicine.”
Wellness programs, well, not so much.

The Rand Corporation research in 2013 reported that “statistical analyses suggests that participation in a wellness program over five years is associated with a trend toward lower healthcare costs… but the change is not statistically significant.”

The health promotion movement didn’t start with Forrest Gump running.
Dr. Kenneth Cooper published his life changing book, 
Aerobics in 1968.
We’ve known for a while what we need to do. Let’s review it.

Exercise more. Eat less. Drink less. No smoking. Any questions?

Has anyone noticed that obesity is more prevalent now than ever?
Despite four decades of wellness programs.
According to the CDC:
2000:    0 states had an obesity prevalence of 30%
2010:  12 states had an obesity prevalence of 30%
Americans are getting fatter.
Still smoking, drinking, and making bad choices toward a more successful existence.

If only they had primary care physicians. Evidence has proven that PCPs help.

But don’t worry, your neighborhood corporate insurance giant has got a program for it.
A Wellness Program. Just buy it. We can talk about obesity at today’s lunch meeting with our new wellness coach. And they have cookies.

Jefferson1Thomas Jefferson said in 1785:
“Give about two hours everyday to exercise:
for health must not be sacrificed to learning.”

2013 translation: “Just move it. Don’t over-think it.

Picking up his walking stick and curiously lifting his eyebrows,Thomas Jefferson might be heard adding, “Wellness. Seriously?”

Guy Culpepper, MD

No Replacement for Primary Care

“The primary care shortage may be averted if non-physicians
are allowed to deliver primary care.”

This phrase has been repeated so often that some people may be starting to believe it.

empty doctor

Washington think tanks, policy makers, and special interest groups have increasingly popularized the idea that much of primary care is easily replaced. Instead of improving reimbursement or reducing hassles, just replace PCPs with other types of providers.
Here is the logic:
“After all, most sore throats, diarrhea, and coughs can be treated by a nurse.”

NewsFlash: Most of those illnesses will get better on their own anyway.
This is not the barometer by which to measure the value of primary care physicians.
In the examples used, it’s not that a non-physician could have done just as well,
because the patients with those illnesses were getting well anyway.
It is the ability to use those opportunities to look beyond the minor illnesses,
to identify other risks, and to establish a foundation for total healthcare.
It is when an illness seems minor, but is not. That is primary care.
The treatment of minor illness is not difficult. Typically it requires no treatment.
                                 Minor illness is… dare I say it… minor.

One of the classic jokes in medicine also happens to be a truth:
“The patient got here just in time…
another day and the illness might have cured itself.”

The trick is in knowing what is minor.
And the magic is in seeing beyond the complaints.

Ask an obstetrician. Often a delivery is just “catch the baby”. At those times, the only hard part is “don’t drop it”. Most deliveries are just guiding chaos. Birthing a baby has happened for millennia without physicians. Like coughs and fevers, the majority turn out fine.  But there’s a reason why an obstetrician studies so hard for so many years. To be prepared for the one delivery that doesn’t go right. And for the ability to anticipate when that problem might occur. That is primary care.

The sweat, sacrifice, and years of attention to detail in medical education have no substitute. The demands are high, the training is long,
and not everyone can do it.

Primary care physicians have met the requirements and are uniquely qualified.

Primary care physicians see patients everyday with chest pain. Most are not cardiac.
Everyday a cough is treated. Most are not cancer. Fevers, rashes, belly pains, and bumps on the head. Sore throats and diarrhea. How does one know which is minor?

And then there’s sadness, worry, fear, divorce and desperation.
Loss of job, loss of family, loss of faith. Patients share these pains.
Are any of these ever minor? That is primary care.

Primary care physicians treat all of these everyday.
Now pay attention to this part…
It’s by having seen that patient for their “minor illness” that allows primary care physicians to provide better care when it’s serious. It’s the early diagnosis, the evolving symptom pattern, sometimes even the “gut” feeling of an experienced primary care physician that comes from years of training and the demands of our educational requirements…
that makes the difference in care.

Pharmacists, chiropractors, and nurses are important members of the healthcare team.
The non-physician members of our team are needed, respected, and cherished.
But not one of them is a replacement.
Only a primary care physician is a Primary Care Physician.

Guy L. Culpepper, MD

“Oh, You’re Just a Family Doctor.”

The Healing of America

Our nation’s healthcare has been getting a lot of attention lately.
It’s very ill.

flag stetho

Everyone has an opinion as to the diagnosis.
The bedside is surrounded.

Too much spending… too little spending.
We must insure more people… we’re too dependent on insurance.
Too few options… we need a single payer.
Do more… do less.

Consultants enter the room, one after the other, with arms full of studies and charts and various probes. Our nation looks worried. The consultant’s faces reflect the grim nature of our situation. The crowded room is loud and smells of confusion. Opinions collide.
Not one of the experts look toward the bed. No one talks to the nation.

“A cure may be possible, but this will be a long and painful process,” says one, “and it is going to be very expensive.”
“Oh, yes,” the other consultants nod. “Very expensive.”

In the corner, blocking the window, a large man in a suit says, “Did we mention painful?”
“We told her that,” says a woman in white, “The consent forms are signed.”
“Many of these tests have never been done before, some were tried, but always fail.”

“We even passed legislation to perform some of the more dangerous tests. You would not be able to do this without government assistance. It may take several generations to pay for all of it.” A man in a finely tailored suit placed his briefcase beside the bed. “Some of it will never be paid.” He has an odd smile.

A technician squeezed in next to the computer and was gleefully pounding away at buttons. “I have no idea what some of these do, but we must get this for everyone.”

Our country stirred, rising up to look around the room.

“You lay back down,” said an expert. “We have everything under control. There is nothing you can do to help yourself.” He looks over at the administrator and winks.

Our nation finds the strength to speak. “I want a second opinion.”

A hush falls across the room.  The crowd near the door shuffles and a woman enters. She wears a simple cotton dress and a white coat. There is a scuffed stethoscope draped over her shoulder. She looks a little tired.

“I’m so glad you came,” says our country.

The consultants pull back their shoulders and turn their heads. “Who are you?”
Mumbles erupt, “We don’t need her.” “What does she know?” “Show us your data.”
“You’re just a family doctor.”

The woman moves quickly to the bedside and places her hand upon our country.
“OK. Let’s start with some fresh air,” she says, “Everyone out.”

Light cascades across the room, illuminating our nation. “With a little hard work, you are going to be just fine,” says the family physician. “I’ll be here to help you.”

“I feel better already.”