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.

IMG_2590
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