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.