The Primary Care Conundrum

Ask any health care wonk and they’ll tell you that within the larger health care crisis is a primary care crisis. There is more and more demand for primary care physicians – the person you probably call your “family doctor” – but America’s medical schools are producing fewer of them.

Why? Well in a word, money.

It’s not actually medical school that’s the problem. It’s what happens next. A newly graduated physician, carrying a big chunk of debt used to pay for medical school tuition, gets to chose their residency and, as such, decides what type of doctor to become.

In the U.S. we let medical students choose what to do. Not being dummies, most of them notice that diagnostic radiologists and orthopedic surgeons make three times what primary care doctors make, and choose their career path accordingly. Why the vast difference in compensation? Doing something to a patient – fixing a broken hip, reading an x-ray – has always been better rewarded more than talking to them about their high blood pressure or their son’s excema.

And while the taxpayer has subsidised teaching hospital residency slots to the tune of a more than $100 billion over the last two decades, the government doesn’t limit the number of those slots by specialty type. Most sensible countries do because they know that the more specialists there are the more specialty care gets done. And specialty care is very expensive. Which is the main reason we spend so much more on health care here than in other countries. In 1965, primary care doctors made up 50 percent of physcians; the other half were specialists. Today, about 70 per cent of America’s doctors have become specialists. Most other countries have the reverse ratio.

There were two major attempts to redress the imbalance in the 1990s. First, managed care plans like HMOs started paying primary care physicians a global fee to provide all care to their patients. In some cases this meant that primary care groups started acting as general contractors and ended up reducing the specialty and hospital care their patients received — and keeping more money into the bargain. In some markets, notably southern California, specialists saw their incomes drop dramatically. Politically this resulted in the ‘managed care backlash’. Patients and specialists complained, politicians and judges threatened, and insurers and employers who were paying for the HMOs backed off. Worse the insurers started cutting payments to the primary care groups and many doctors ended up bankrupt — having taken on insurance-type risks that they couldn’t manage: getting paid to treat a group with a range of illnesses and problems and incomes rather than one or two not-so-sick people with fat wallets.

The other attempt to improve the lot of the primary care doctor was the introduction of a physician payment scheme by Medicare called the Resource-based Relative Value Scale (RBRVS). The name underlined the intention. Payments to doctors were meant to be based on the relative value of resources used. So a unit of time spent managing patients and talking to them about exercise for high blood pressure, for instance, would be close in value to a unit of time cutting them open.

Unfortunately, America’s specialty societies hijacked the process and they now control the somewhat secretive RBRVS Update Committee, which advises Medicare on those payments. So specialty care and procedures remain much much better rewarded than primary care. In the nearly three decades after this problem was first recognized, it’s becoming harder and harder to find primary care doctors. It’s going to get worse; last year the number of medical students opting for primary care fell to an all time low.

So what’s the likely outcome? Medicare clearly will take a hack at redressing the imbalance in payments as part of whatever reform happens in 2009. But unless the specialists and the hospitals that live in symbiosis with them are ready to significantly and voluntarily cut their incomes and reallocate that money to primary care, there will not be enough money for primary care to solve the current shortfall. And the U.S. is not seriously going to tackle – let along address – this problem as a matter of public policy until the whole system breaks so severely that more people demand massive reform. Such a time is still at least a decade or so away.

In the meantime, the market will have a go at addressing the primary care shortage. but it won’t do it in ways that primary care doctors will like. You’ll continue to see an expansion in nurse practitioners in retail clinics in supermarkets and drugstores. And more and more people will become frustrated by the lack of availability of primary care docs in their neighborhood and will go online where they’ll find plenty of entrepreneurial companies offering Internet consults. Of course if an online consult is good enough – and it probably is in many if not most cases – why does that doctor need to be in the same town, or even the same country? Or if it’s a diagnosis that requires extensive medical knowledge, why can’t a computer do it as well? Why not indeed? You’ll see all this happening in the next few years as well.

In fact, the result of the primary care crisis may not be inspired reform. it may instead just end up causing globalization and technology outsourcing to come into physicians’ lives. Just like it has to auto workers, steel workers and call center clerks.

Milan’s Mobile Mosque

Milan city officials are grappling with a mosque so overgrown that hundreds of Muslims kneel on sidewalks to pray. The solution is igniting a game of NIMBY hot-potato as neighborhoods and politicians move services from one spot to another.

Last Friday, the ‘mobile mosque’ was around the corner from my house. On my way to a lunchtime piadina, a young man on a bike stopped to ask politely in a heavy foreign accent: “Scusi, signora (argh) how do I get to Vigorelli stadium from here?”

A few seconds later, I remembered the city had given worshipers use for prayer services — just for one week — there. After lunch, I went to check it out. The last time I’d been to the stadium, a Fascist-era bike racing track, Fiat had sponsored a faux-ski run in it. The venue is never particularly busy, it’s an odd size and not well served by public transport.

Continue reading

Review: Spanish Road Trip

I first fell in love with Spanish food while attending a programming trade show in Washington, DC. Some friends and I had dinner At Jaleo’s, a tapas bar. Prior to that I’d had Americanized paella, which my mother occasionally made when I was growing up, but that was the extent of my experience with Spanish food. Then in 1997 two weeks with my family in a villa on the Costa del Sol confirmed my passion for this simple cuisine.

Consequently when I was recently offered a review copy of Spain: A Culinary Road Trip, I jumped at it. This is a companion volume to a PBS series in which chef Mario Batali, food writer Mark Bittman, actress Gwyneth Paltrow, and Spanish actress Claudia Bassols tour Spain exploring it’s art, culture, and food.

Because Batali is a chef and Bittman a food writer I assumed the book would essentially be a cookbook with some narrative related to the TV show woven through it. But it’s not. There are indeed about 70 recipes in it of which some are traditional Spanish fare, others more modern dishes, and some are recipes invented by the four participants. But as the dust jacket notes, it’s more like a scrapbook.

In the introduction Batali writes: “I must say that my truest roots in the world of food are still deep in the heart of Castile where my family traveled simply but comfortably with a constant eye on the best place for a tortilla Espanola or a pincho moruno.” It turns out he lived with his family in Spain while he was growing up. It also turns out he owns two Spanish restaurants in New York, something I didn’t know having thought he was purely an Italian chef.

The book is organized by the routes they took through Spain so, for instance, the first section is named “From Madrid to Toledo.” The section then consists of short descriptions of Madrid and Toledo, photographs of hanging hams and Batali and Paltrow in a restaurant, a description of the restaurant and it’s owner, assorted chunks of dialog and random thoughts, a few recipes, and a description of a birthday dinner. In short, each section is a diverse hodgepodge of elements related to each other primarily by geographic proximity.

The problem with the book is that if you don’t care that Batali is a celebrity chef and Paltrow is a famous actress then a lot of the material isn’t particularly interesting. A photograph of Paltrow and Bittman standing over a paella pan is less interesting than the same photo would be if the people were native Spanish herders. And a quote by a restaurant owner – “Everyone has eaten here but the Pope, he’s too busy.” – is more amusing than a silly exchange between Bittman and Bassols.

I did try a few recipes. The recipe for escabeche is good as is the one for pisto manchego but the empanada recipe doesn’t even look good and using puff pastry is just wrong.

All in all, I’m disappointed in the book. As I mentioned, my expectation was that it would be a collection of recipes for one of my favorite foods with some narrative to knit the food together. But despite the recipes it really isn’t a cookbook and the narrative is more like a collection of random elements probably better conveyed in the television series. It is handsome in its way and would look nice on a coffee table but I’m glad I didn’t pay for it.

Pisto Manchego

Adapted from Spain: A Culinary Road Trip

4 ripe plum tomatoes
2 sm Japanese eggplants
4 red bell peppers
2 sm red onions – not peeled
2 tablespoons plus 1/4 cup olive oil
Kosher salt and freshly ground black pepper

Heat oven to 375F.

Coat tomatoes, eggplants, and peppers with 2 tablespoons of oil and arrange on a baking sheet with onions. Roast for 45 minutes to an hour until onions are tender. Cool until you can handle the vegetables.

Remove skins from tomatoes and seed and core peppers. Cut the eggplants in half and scoop out the flesh. Peel, trim, and cut up the onions then coarsely chop vegetables with remaining oil in a food processor. Taste and adjust salt and pepper.

Serve on toasted coarse bread.

An Expert Dilemma

I want to ask your help. I have to make a financial decision regarding my health insurance and given the confusion of the system – one I’m supposedly expert in – I need advice.

Now realistically you’re not likely to be much good to me. Why do I say this? Well, the data says you’re dummies.

Last week Trizetto, a private tech company, put out a survey that said as much. While 80% of consumers surveyed were concerned about health care costs, less than a third knew how much their family spent.

It gets worse. Around 60% of Americans, including the vast majority of those under 65, get their insurance from their employer. How much are employers paying each year? Well according to Joe Public, not that much. Most don’t know or think it’s less than $5,000 per family. In reality it’s around $9,000.

But I’m not one of the blissfully ignorant who gets his insurance at the company trough. Well, not quite. And hence my cry for help.

As a solo consultant I buy my insurance in the gong-show that is the individual insurance market. It’s an convoluted process in which you attempt to persuade an insurance company that you are healthy and worthy of their lowest premium rate. About four years ago I succeeded in this endeavor and Healthnet issued me a high deductible policy at the low price of $99 a month. I’m paying nearly $200 a month now because of premium increases, but that’s still way less than I would have paid if HealthNet had decided that I wasn’t a good risk.

Now California, where I live, doesn’t do much to protect individuals entering the insurance market but once you’ve bought an individual policy, the insurer can only increase the rates with everyone in your age group. But if you let the policy lapse and then try to buy another — usually because you went back into the corporate world and then left again — they’ll re-examine your medical history. If anything has gone wrong – surgery, illness, funny blood work – you might see your rates increase by a factor of 4 or 5. More likely, you won’t get insurance at all.

That’s not currently my problem. This is: I got married.

My wife has a job and health care benefits. She put me on her company plan for an extra $50 a month.

This year my individual premium is heading to $250 a month. Now most of you are saying, why is he continuing to pay $250 a month when his wife is paying $50 to cover him on her plan? The obvious thing is to cancel my HealthNet plan.

But what happens if my wife comes to her senses and stops being my wife? If that happens I’d be better off keeping my plan at $3,000 a year because if I have to buy insurance again in a year or two, and they decide I’m not a good risk, it might cost me $12,000 a year!

It gets more complicated. If my wife stops working, we could buy into her company’s plan under something called COBRA for another three years. But if we decide not to do that we might have to re-apply in in the individual market as a family which means being underwritten again – and running the risk of being a bad risk. So, perhaps we wouldn’t be able to buy insurance, and we’d both be in deep trouble!

And like the rest of the dummies in the survey I don’t know how much my wife’s employer plan actually costs. When you pay for COBRA you pay the whole fee: the employer does not chip in. So I need to find out, and work out the possible future costs. And if you figure into that the relative chance of my not being married and therefore not being able to buy into my wife’s plan my $3,000 in “extra” insurance starts to make a kind of odd sense.

But this all begs a question: Why? The current health insurance system has so many complex wrinkles that an alleged expert (me!) is not sure what to do. There aren’t any good choices, and the decision analysis requires PhD-level economic forecasting. Which makes Republican nominee John McCain’s plan to force these decisions on more people, by giving tax incentives for people to drop their employer’s plan, a mite puzzling.

If this keeps going long enough, the political revolt may create a stable universal insurance plan that will cover me. OK now I’m really kidding.

So can someone tell this dummy what to do?

Exercise Time

MCM: You must be referring to a new exercise program that has been quite heavily publicized recently. It is indeed for a game console called, not pee-pee, but named apparently after that very same bodily function.

Continue reading

Literary Tapas: A Chef’s Selection

When I started writing about food I immediately started reading what other people wrote about food – primarily as a way to learn how to write about food myself. One of the first books I picked up was Best Food Writing 2001 and I was amazed at how many different ways there are to write about food, how many different ways there are to think about food, and how food can be such an easily conveyed metaphor for thinking about the rest of our lives. I’ve been studying the masters ever since.

At the moment I’m half-way through Best Food-Writing 2008 edited by Holly Hughes and with the lazy days of summer on the way, it seems to me that now is as good a time as any to contemplate those who contemplate food, cooking and everything else that goes on in a proper kitchen.

I’ve long been a fan of John Thorne, author of Serious Pig, Pot on the Fire, and Simple Cooking. This is great food writing with much the same sensibility as the best food blogs – focused on food and cooking and yet much more than that. He writes with marvelous evocativeness and a certain dourness – for this Southerner, anyway – that’s reflective of his New England heritage. Best of all, I’ve learned a great deal about my cooking style and attitudes from reading about his and his focus on simplicity. A perfect clam chowder is about less rather than more.

I’ve been meaning to read America’s first great food writer, M.F.K. Fisher for years. Last winter I finally began. Since January I’ve read The Gastronomical Me and How to Cook a Wolf. She really does deserve her reputation. In How to Cook a Wolf, Fisher’s book on cooking – and living – well with very little, she writes: “There are many ways to love a vegetable. The most sensible way is to love it well-treated. Then you can eat it with the comfortable knowledge that you will be a better man for it, in your spirit and in your body too, and will ever have to worry about your own love being a vegetable”.

You read Fisher, not so much for recipes, as for philosophies. You read a chapter, or a page, or a sentence, and then put the book down to ponder a moment. Sometimes to ponder what she wrote, and other times to ponder what might be fun or interesting or surprising to do with that last bit of hard salami in the refrigerator.

But when my head became too full of darkly ambitious thoughts about food and cooking, I turned to Jeffrey Steingarten, food writer for Vogue.

Why a magazine like Vogue needs a food writer, and how it ended up choosing a lawyer to do the writing baffles me. But Steingarten is tremendous fun to read. He combines passion for food and cooking with what I can only describe as a lawyerly sense of humor. His rants about things like food allergies and raves about things like blood sausage leave your jaws aching with a grin. The Man Who Ate Everything and It Must’ve Been Something I Ate are a perfect antidote to Fisher’s more serious reflections.

Along the way I’ve read Jaques Pepin’s The Apprentice. A genuine likeability shines through this famous chef’s autobiography and leaves you very much wanting to have a meal and a glass of wine with him. And currently I’m reading Calvin Trillin’s Feeding a Yen with The Tummy Trilogy yet to go. I’ve long been a fan of Trillin’s wry and often acerbic political wit, but somehow I had never read his food musings which are more self-deprecating than passionate, mostly when it comes to his own tastes: “One morning, late in the week, I held out until almost eleven before I bought my first helping of macaroni pie, and found myself boasting to Alice about my willpower.”

I first turned to these books to learn how the writing should be done. But since then I’ve grown to love the collections of essays. They stimulate far more than your appetite, although many of them do that as well, and they’re perfect for reading in short bursts – say, at the beach.

The Face of Foreclosure

The lawyer sits across from us, trying his best to look concerned and caring, but clearly he is in a hurry. He has a waiting room full of people just like us and, he tells us, a month’s backlog.

We are there to file for bankruptcy and, while he respects the paperwork we’ve brought along, to facilitate things he’s prepared a packet that we should fill out at home and return along with his fee. He asks us about the two properties we have just lost in foreclosure: one we were supposed to sell to offset the cost of the other which, up until two days ago, we’d lived in.

Continue reading

The Real Deal

Of course, our focus on authenticity in our popular culture is flawed. Gangsta rap and punk are supposed to be authentic, but bubble gum pop and teeny boppers are fake. There are music fans that don’t care, listening to whatever strikes their fancy, and I suppose you could charge that they are lacking in artistic values. But you could just as easily charge certain discriminating hipsters and intellectuals as being snobs.

Continue reading

If Dogs Have a Heaven, There’s One Thing I Know

Any Dog Person will tell you there is That One Dog that got them started, usually one from childhood. In my case that dog was Shep.

In my family, we hear a celestial choir singing when you utter “Shep,” (click this link if you dare and have plenty of tissues). His name is sacred and conjures the image of obedience, loyalty and adoration that is everything a dog should be. Every dog we’ve had since then has had to endure the disgusted look of my brother and, “You’re no Shep,” usually delivered when the dog has failed to roll over without being taught.

I was 13 years old when we got Shep. We had had other dogs before this, but Shep was mine, acquired at the age when a teenager is looking for someone or something to love unconditionally.

He was half German Shepherd Dog, half who-knows-what; he looked sort of like a Briard – more like a German Shepherd Dog-sized Yorkshire Terrier. The women at the veterinarian’s office called him The Disney Dog.

Shep lopes through my memory as everyone’s ideal pet. He never once messed in the house and did his business in one four-by-four-foot square area in the backyard. His paws never ventured any further than the boundaries of our suburban yard unless I invited him to walk with me. You could parade other dogs, cats, and even bitches in heat in front of him and he would not leave my side (bitches in heat coming into our yard, however, were. . . ahem . . . fair game, this in the age before spaying and neutering became the norm).

When I think back, his obedience led me to take chances that I wouldn’t think to take with my dogs now. I would go into a grocery store to do the week’s shopping and leave him in the car with the windows rolled down completely. He never jumped out. We’d go on picnics and it never occurred to us to tie him up and it never occurred to him to leave our site.

Of course, my closeness with Shep was partially due to my age and circumstance. I was an insecure teenager in a family going through the turmoil of illnesses and financial stress. I was easily lost in the crowd of well-meaning or needy relatives that were a constant flow in and out of our house. My trivial teenage dilemmas, while monumental to me, were dismissed by everyone else. Shep became my confidant; he noticed me; he remembered when I should be somewhere and fretted when I wasn’t. If it wasn’t for Shep, I’d still be standing outside the Silverton School of the Performing Arts waiting for my mother to come pick me up.

Shep remains perfect in my memory and since he was my dog through my mother’s death has probably assured I’ll never remember anything negative about him. Death brings out the dysfunction in the best of families and there is no such thing as a “peaceful passing” in mine. After one particularly dizzying blow-up among my father, brother, my grandmother and The Aunts, I fled on foot, not even realizing I’d walked out with a dog and without a leash. It wasn’t until I was a good three miles away from home, along a busy New Jersey highway at 9 o’clock at night, that I realized, that Shep was next to me in as perfect a heel position as I could ask and have never again achieved with my show dogs.

Lots of dogs have bounded in and out of my life since Shep. I like to think of him as the leader in a long line of familiars: From Bridgett the rescue Labrador Retriever who had me actually screaming out the back door, “Put down that deer head and come in the house!” to Quigley, the rescue Bichon Frise who was only truly happy driving in a car; to Dundee, our first Australian Shepherd, also a rescue, who thought of himself as Heir 1’s little brother and Heir 2’s nanny; to my pack of six now that my brothers refer to as “Jeanne’s Posse.”

When people look at me incredulously and ask, “How can you live with so many dogs?” I can only look back, equally dumbfounded. But I don’t bother to ask how they can live without. They’d have to have known Shep.

Book Review: Bananas

“Yes we have no bananas,
Yes we have no bananas today.” – 1923 novelty song

Many years ago, as a teenager, I ate lunch in an Indonesian household on most Fridays. The meal always featured a huge platter of what I thought at the time were fried potatoes. They were highly spiced and slightly sweet and I adored them. But as a callow youth I didn’t think to ask anything more about them. Some 20 years later I was reading an article on plantains and realized that’s what I had been eating. I ran out to the grocery store, bought a plantain, sliced it into rounds, doused them with curry powder and a touch of sugar, and fried them. Yep, that was it.

I was reminded of my plantain experience when I first heard author Dan Koeppel interviewed on All Things Considered a couple of weeks ago. Koeppel has recently publish a book, Bananas: The Fate of the Fruit That Changed the World.

A few days after receiving the book, I started reading it. At 1:00 the next morning I forced myself to put it down and go to sleep having read half its 260 pages at a sitting. Koeppel weaves together a story that reminds me of a basket: A strand of science appears, and then disappears behind a strand of politics. It reappears then ducks behind a strand of history. Somehow Koeppel intertwines the strands creating a consistent, comprehensive, and highly readable whole.

What initially caught my attention in the NPR interview was Koeppel’s focus on monoculture. It’s topic I addressed in “Send in the Clones” and in other columns. It comes up a lot when you talk about bananas.

Edible bananas are all seedless, so they procreate asexually. That means the banana you ate last week was probably genetically identical to the banana you ate today and, in fact, most of the bananas you’ve eaten. This is monoculture – everything is the same. And because bananas are clones of each other they’re particularly vulnerable. Worse, because domestic (as opposed to wild) bananas are uniformly seedless they’re almost impossible to crossbreed in a search for disease resistance – and there are several diseases (Panama disease and Brushy Top being the worst) currently sweeping through the banana plantations around the world. In a practical sense the fate of the world’s most popular fruit may be extinction within the next 20 or so years. Seriously.

Koeppel focuses on this possible extinction, but delves into banana republics (at one time the modern Chiquita company owned 70 percent of the arable land in Guatemala), the spread of domestic bananas from Southeast Asia throughout the world, and it’s importance as a staple food in Asia and Africa – there are people who will starve to death without bananas.

I spoke to Koeppel and he describes himself as having the broadest knowledge of bananas of anyone in the world, but is quick to assert his knowledge is “only two inches deep.” He speaks of some of the banana researchers with great respect. Since the book was released he has been inundated with emails from banana researchers picking nits with his attempt to simplify and make understandable some highly complex issues. Just as he might object to some of the simplifications I’ve made here.

Koeppel set out to write a science book and was surprised to find food people (he was recently interviewed by Lynne Rossetto Kasper on Splendid Table) drawn to his book. But in addition to foodies and science geeks, political and anthropological buffs will also appreciate this extraordinarily well-written book.