February 2009  |  Welcome to Finding Balance eNews

Upcoming Events
I want to thank you for the great response to my program in Hawaii, which now has a waiting list for enrollment. I remind you that I will be delivering the same program August 31–September 4th, 2009 at the Omega Institute in upstate N.Y.

I will also be delivering a weekend program, March 27-29, 2009 in Petaluma, CA.

Please see the Calendar on my web site for additional listings.

The Future of Primary Care
I have not yet used this newsletter to present an “editorial” opinion, but since our health and well-being personally is clearly related to our sense of work stability, I would like to address this issue here. This represents my personal opinion from the view point of a consultant to many major medical groups and health systems. I have no intention of being comprehensive as it would take up too much space and too much of your time. My intention is to plant some thoughts and stimulate discussion.

Our current health system is non-sustainable. A recent survey from the Physicians’ Foundation shows disturbing results:

• An overwhelming majority of physicians – 78% – believe there is a shortage of primary care doctors in the United States today.
• 49% of physicians – more than 150,000 doctors nationwide – said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
• 94% said the time they devote to non-clinical paperwork in the last three years has increased, and 63% said that the same paperwork has caused them to spend less time per patient.
• 82% of doctors said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement were made.
• 60% of doctors would not recommend medicine as a career to young people.

In addition we have the most expensive health care delivery system in the world with outcomes ranking us between 25 and 30th on the list. With this in mind, let’s take a brief look at the future of primary care in the U.S. I will focus on some possibilities by examining what works.

Problem – The overwhelmed Primary
Few primary care docs view the 10–15 minute office visit as a sustainable model, especially with patients who have multiple health issues. The need for this is indicative of a shortage of physicians; a simple supply/demand mismatch. Potential solutions are as follows:

• Train more physicians – This can be accomplished by developing more medical schools, a slow process.
• Enhancing interest in primary care – The two main aversions to primary care today are financial and lifestyle issues. Simplistically, we need to consider paying for medical school in exchange for primary care participation in a national health system (I’ll get there soon). Once we have enough docs, lifestyle becomes less of an issue.
• Pay physicians for their time and outcomes as other professionals are paid.
• Increase the use of nurses, NPs, MAs, PA’s, health coaches and dietitians. We can’t do it all and should learn to be comfortable with that fact. There are good models for this in the U.S. already; fully integrated health systems, like Kaiser-Permanente.

Problem – Lack of insurance coverage
A significant percentage of the U.S. population has no health care coverage. This number is likely to increase in the next year with the worsening economy. We already have governmental health care coverage in a non-uniform fashion: Medicare, Medicaid as well as state and local forms of coverage. Ideally, we will move in the direction of a unified coverage plan for the poor and elderly, streamlining the existing system. While this is a complex process, I truly believe it needs to begin now.

One model to examine is the U.K.’s National Health Service (NHS). While there are good and bad aspects to this model, we can learn from England’s mistakes and build a hybrid system of public and private health care.

• U.K. primary care physicians now have average earnings of $220,000 (in U.S. dollars), which is more than many specialists earn in the U.S.
• The payment system is a mixture of risk-adjusted capitation and 25% additional pay for performance.
• Because of the uniform nature of the system, the U.K. government has been able to introduce nationwide quality-improvement initiatives, ranging from annual performance reviews of all physicians by local peers and national standards for the care of major diseases.
• U.K. physicians work in teams with other health professionals. This is the standard of care
• EMR is uniform, and care continuity is maintained for the most part.

These aspects make a national health service attractive to young physicians just out of training.

Problem – No public delivery system
Is this true? We have community clinics, VA hospitals, and a large variety of free clinical services. What if these were to be networked and in doing so, the overhead of care delivery could be reduced? I would say that we have a public delivery system that is too variable and insufficient to cover the currently uninsured. Building a functional system may take sometime, but appears to be worthwhile. We could use Kaiser as an intermediate step in this direction, through appropriate contracting with the government. This could be the beginning of a national delivery system. If done in a fully integrated model that offers young primary care physicians stable employment, this could be an ideal model for our future. In time, new clinics and hospitals will need to be developed or obtained to flesh out this system.

While I can easily be described as an idealist, I do believe it is time to revamp our health care system, as does our new administration. I hope that I have helped to elucidate some core issues for you. Again, these are just a few thoughts on the topic. For an excellent review of some key issues, I refer you to the New England Journal, Volume 359, November 13, 2008.

Just for fun
Being a Jersey guy in my youth and having seen Bruce Springsteen more times than I can remember, I need to come to the defense of his new CD, Working on a Dream. The reviews have been mixed indeed. Any artist will be compared to his past success. It is hard to beat Born to Run, Greetings from Asbury Park, and Born in the USA. With a catalog like Bruce has, he can’t win! So let’s look at the new album as if it were a new piece of work by an artist that you had never heard before. Here’s my track by track run down:

1. “Outlaw Pete” – The music is anthemic and rocking, the problem is that the subject matter would make a better acoustic track – Not my favorite and not a great first track. This would have made a better rootsy last track.
2. “My Lucky Day” – Fun rocking and playful. Should have been track one. Great driving tune.
3. “Working on a Dream” – Classic Bruce, from the vocal mix to the lyrics. Great backing vocals by Patty and the gang – a la the Beach boys.
4. “Queen of the Supermarket” – Bruce does longing so well. I am not sure that the supermarket is my image of a place of longing (except when I am really hungry), but I suspect that this song will grow on me. Great mix as well.
5. “What Love Can Do” – Catchy song, reminds me of the Byrds or certainly later Roger McGuinn. I would swear it was McGuinn on backing vocals. I really like this song. Great guitar playing and a wonderful deep sound.
6. “This Life” – A Beach Boys tune if I ever heard one: Brian Wilson style production with a great late 60’s feel, minor chords and harmonies. The lyrics are classic Bruce – This is a keeper. Listen to this one as if it were a new artist, not Bruce. You will love it.
7. “Good Eye” – Good roots blues. I probably would have done it simply with acoustic guitar and harmonica. Sounds like they worked too hard on this one.
8. “Tomorrow Never Knows” – Starts like Credence and ends like Bruce. A good catchy tune. Sounds like Bruce, doing Steve Earle doing Bruce.
9. “Life Itself” – OK – so someone in the studio is either Roger McGuinn or a huge fan of his. Great 12 string dissonance in the background. This is also one of those songs that really doesn’t sound like classic Bruce, but works well.
10. “Our Kingdom of Days” – A solid tune on first listen. I am not sure it will sustain itself over time.
11. “Surprise, Surprise” – Fun light pop from Bruce: happy and bouncy! The refrain is great late 60’s tunesmithing. Not everything in life needs to be serious. And there’s that 12 string again. Bruce doing McGuinn doing Bruce – I am confused, but happy.
12. “The Last Carnival” – This song feels like part of a long stream of songs that started with Wild Bill’s Circus Story oh so many years ago. Trains, America and the average man.
13. “The Wrestler” – The song from the movie. Simple raw Bruce. Gotta love it.

Have I gone on way too long? Pardon my verbosity, but health care systems don’t get revamped often and Springsteen releases only happen every few years! I will be shorter next time – that only matter for those of you who are still reading. The rest will never know.

Be well, play well!