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Thursday, June 21, 2012

Two Conversations About Health Care

Last weekend I was struck by two conversations that I had with acquaintances about recent experiences that they had had with their primary care physicians.  The first occurred at my local pool. A fellow swimmer asked me if I took new Medicare patients.  She bemoaned that she was abandoned--her beloved physician of over 20 years had sent out a letter announcing that she would no longer accept Medicare patients. My friend had recently gone on Medicare.  She speculated about her physician’s  motives, but felt personally rejected, or “fired.”   After she explained her situation, I affirmed, “I do take new Medicare patients,” but qualified my response with a description of my concierge model primary care practice, which requires an annual retainer fee from members in exchange for improved access to me and other amenities, including my guaranteed smaller patient panel size. 

I started a retainer fee primary care practice after having been in a traditional fee for service practice for 12 years and then after taking a year’s leave of absence from clinical medicine. Many of my old patients sought me out, though currently most patients enrolling in my practice are new patients looking for a better primary care experience.  My swimming friend nodded that she understood and that her mother had a concierge physician--she was familiar with the concept and could see its value, though was going to have to decided whether she could afford it. 

My second conversation was at a friend’s 59th birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with one of the hosts, a self-employed professional, he asked what kind of medicine I practiced. I explained that I was an internist, or a primary care physician for adults, and that I was in solo practice in Atlanta after practicing at the Emory Clinic for 12 years.  As I spoke he announced that he was in need of a new primary care physician. He went on to explain that his physician, who he was very fond of, had converted his practice last year to a concierge model practice—requiring patients to pay a membership fee in order to remain in his care.  He had made the decision not to enroll in the new practice model, in part because he was already paying a high deductible for care under his insurance and he was unsure how the annual fee would impact his out of pocket cost.  Before the host of the party said more (not wanting him to feel awkward with me), I explained that my practice was a similar model. He and I spoke for about twenty minutes about the problems in primary care and the reasons that primary care doctors were seeking out new practice models.  The man with whom I chatted pulled over his partner, who had been cared for by the same physician.  His partner reacted to our discussion—“but this is not a solution for our country’s health care problems.” I agreed, and we talked about cost and discussed new models of health care, including the Medical Home and Accountable Care Organizations, both of which have yet to materialize as answers for doctors like me.  He went on to assert that he felt that one solution to the problems in medicine would be to produce more doctors, while at the same time to lower the cost of educating them.  Personally, I doubt that producing more doctors in general, will improve primary care, nor will it reduce cost; though, better incentivizing primary care career choices would be helpful.

These conversations illustrate that for the American populous the main problems in health care today are access and affordability.   For primary care physicians the problem is not so simple.  The "system" has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine.

Most Americans equate spending money on health insurance with spending money on their physicians. Primary care physicians see relatively little of the money that consumers put toward their health insurance premiums. Our fees and reimbursement rates are relatively low in comparison to the exorbitant fees for tests, procedures, E.R. visits, and hospitals stays. As our overhead expense has increased, in part because of the administrative hassle involved in getting money from health insurance companies, we have responded by increasing the number of patients seen per day and our panel sizes to the point where many (including myself) feel that quality of care and the patient-physician relationship is compromised.

“Concierge medicine” and the abandonment of Medicaid, and now Medicare, by primary care practices are a reaction to these pressures, which have changed the nature of general practice and offer solutions to protect the personal aspects of the physician-patient relationship.  However, clearly these motives remain poorly understood by the average American consumer, who is faced with rising out of pocket medical costs to pay for health insurance, and increasingly feels burdened with excessive health care expense.

The disconnect leaves doctors like me in a conundrum. Do we continue to work within the confines of a system that has failed to protect primary care as an honored specialty? Do we compromise the care that we deliver in order to preserve access?  Or, do we jump ship and force change by creating new models of care—models of care that patients are increasingly seeking out as they recognize their value? It can be a difficult position to be in.

Thursday, June 7, 2012

"How can I raise my HDL?"

"How can I raise my HDL?" I have often been asked this question during my years of practice.  Lifestyle strategies include smoking cessation, exercise, and alcohol in moderation. However, evidence is mounting that perhaps this is not the salient question.
Three recent studies suggest that raising HDL levels may not be helpful in terms of reducing one’s risk of cardiovascular disease.
1)    The AIM-HIGH study compared niacin, which raises HDL, lowers LDL and lowers triglycerides, to placebo in patients at high risk for cardiovascular disease events (death, myocardial infarction and stroke).  The study was stopped because an interim analysis showed that patients taking niacin experienced no benefit from the drug with regard to preventing cardiovascular events.
2)    Dal-OUTCOMES was a study in which dalcetrapib, a new drug which causes circulating HDL levels to increase by a mechanism different from niacin (CETP inhibition),  was compared to placebo in patients at high risk for cardiovascular events . This study was also stopped early after an interim analysis showed that patients taking the dalcetrapib did not have fewer events than those given placebo.  Some years ago, another CETP inhibitor, torceptrapib, was found to actually increase cardiovascular events (though this was blamed on torcetrapib’s  side effects of increasing aldosterone levels and slightly raising blood pressure; dalcetrapib has no such side effects to blame).
3)    A recent study looked at people with genetic variations in cholesterol levels—one group with low LDL levels, and another with high HDL levels. People with genetically low LDL levels had fewer cardiovascular events than those with genetically higher LDL levels, reinforcing the concept that lowering LDL prevents cardiovascular disease. However, patients with genes that resulted in high HDL levels had similar rates of cardiovascular events to those who have genes resulting in lower HDL levels.

Epidemiological data has linked higher HDL levels to an increased risk of cardiovascular disease.  However the results of these recent studies call into question the utility of trying to raise HDL as a means to prevent cardiovascular disease.

In a separate study conducted by senior author Frank Sachs it was found that not all HDL is created equally. This study, published in April 2012 in the Journal of the American Heart Association, found that HDL molecules that contained apoprotein C-III actually were associated with increased risk of heart disease, compared with HDL that did not contain this “pro-inflammatory" protein.  

Practically, what does this mean? Those with low HDL should continue to pay attention to this as a marker that is known to be associated with higher cardiovascular risk.  However for now it remains uncertain whether HDL is actually causally related to higher cardiovascular risk.
In the words of Sekar Kathiresan (as reported in the New York Times) , Director of preventive cardiology at Massachusetts General Hospital, a geneticist at the Broad Institute of M.I.T, and investigator in the recent genetic study:
“The number of factors that track with low HDL is a mile long:  obesity, being sedentary, smoking, insulin resistance, having small LDL particles, having increased cholesterol in remnant particles, and having increased amounts of coagulation factors in the blood.  Our hypothesis is that much of the association may be due to these other factors.”

For now a person with low HDL has less reason to focus on using available HDL-raising treatments and drugs, and more reason to do everything else to reduce his/her risk of heart disease—including getting LDL cholesterol down to recommended levels, or even lower.

Guest Co-author: Kreton Mavromatis, MD, FACC, Assistant Professor of Medicine, Division of Cardiology, Emory University, Director of the Cardiac Catheterization Laboratory, Atlanta VA Medical Center and Juliet Mavromatis, MD, FACP, Adjunct Clinical Assistant Professor of Medicine, Emory University