Primary Care Pay For Primary Care Work

At our medical staff mid-year meeting we discussed in depth how primary care is so necessary to manage chronic illness, provide preventive services and keep health care costs down. One study showed that the more primary care doctors are available in an area, the lower the disease burden and mortality in that area.

The major barrier to providing good primary care to a group of people is that there just aren’t enough of us. Let’s face it, doctors are really smart people. If we’re smart enough to get into medical school, we’re definitely smart enough to figure out that going $300,000 into debt to pay for our education requires careful thought about our specialty choice after school.

Primary care compensation is at the bottom of the barrel as far as medical specialties go. The three medical specialties with the lowest compensation are, in order, family medicine, general pediatrics and general internal medicine. (Yes! I’m number one!!)

I’m an assistant professor in Case Western Reserve University School of Medicine’s Department of Family Medicine and Community Health. I work with students regularly and one of my goals is to show them why they should consider primary care. It’s definitely never boring!

I also tell them I completely understand why primary care is hard to sell to students who are paying $46,000 per year for their education. So how can we get more medical students to choose primary care?

The bottom line is that we need to pay primary care doctors more. We need to pay primary care doctors more, and specialty doctors less. And we need to insist that primary care level of care is provided by primary care doctors, NOT specialists.

What do I mean by that? I mean that care that CAN be provided by primary care doctors SHOULD be provided by primary care doctors. There is absolutely no reason for a patient to see a gynecologist for a routine Pap tests. I can’t get my patients in to see a gynecologist when they have an abnormal Pap test, fertility concern, excessive bleeding or pelvic pain because they are too busy doing routine Pap tests.

Endocrinologists are not needed to manage routine hypothyroidism. Patients think if they have high cholesterol they need a cardiologist, if they have migraines they need a neurologist, and if they’re depressed they need a psychiatrist.

These people ONLY need a primary care doctor. We manage ALL of this, quickly and in many cases better and in a more cost-efficient manner than the specialists.

So this is my suggestion for controlling health care costs and incentivizing medical students to see primary care as a more desirable option. First we need to increase payments to primary care doctors for the work they do. Then we can offset that spending by either refusing to pay specialists to do primary care work, or by paying them what primary care doctors make to do the same work.

If an endocrinologist gets paid what a family doctor receives to manage routine hypothyroidism, that will save money because, believe me, the endocrinologist gets paid more than I do to do that same job. If that causes endocrinologists to tell patients their family doctor can manage their thyroid, so much the better. Maybe then it won’t take me 3 months to get someone who needs a hormone workup for an unusual problem in to see the doctor they need.

With the current furor about the pay gap between women and men and between white workers and minorities, I would suggest the pay gap between primary care doctors and specialists is just as shameful. It is time for Medicare, Medicaid and private insurers to pay primary care doctors properly for the work we do. And if specialists choose to provide primary care services, they should get paid what we get paid for that.

QUESTION: Did you know there is a pay gap between primary care and specialty doctors?

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Glucosamine And Joint Pain

Ellie is an older lady I see for high blood pressure and high cholesterol.  She is a sweetheart who until recently worked in a day care.  A few years ago she came to me worried that she might have to stop working because her joints were hurting her too much to keep up with her toddlers.

Changing diapers, tying shoes and bending and lifting were really taking their toll.  She was interested in ANYTHING that would help her feel better and able to keep doing what she loved.  We talked about trying glucosamine because she had used anti-inflammatories and they bothered her stomach.  She also was worried about her heart risk with NSAIDs.

A significant proportion of adults use glucosamine for joint pain.  One survey of over 10,000 American women reported 15% take glucosamine.  What is the evidence that glucosamine is helpful for joint pain?

First of all what is glucosamine?  Glucosamine is a sugar-protein hybrid molecule that is used by the body to make and repair cartilage and produce fluid to lubricate joints.  Tendons and ligaments which support joints also contain glucosamine.

Most people are familiar with using anti-inflammatories like Aleve and ibuprofen for joint pain.  They are effective for short-term relief of pain but they have significant side effects.  They are hard on the GI tract and increase the risk of stomach ulcers.  They block the effect of aspirin in heart disease patients (if you take aspirin for your heart do NOT take over-the-counter NSAIDs without talking to your doctor).  And they do not prevent the progression of osteoarthritis, which is the slow progressive loss of cartilage in the joints.

How does glucosamine compare to NSAIDs in improving joint comfort in arthritis?  Studies have shown that glucosamine is as good as celecoxib (brand name Celebrex) and significantly better than placebo at improving both joint pain and joint function.  As mentioned above, celecoxib (an NSAID) caused stomach upset and glucosamine did not.

What else can be done to improve arthritis?  In one study comparing glucosamine and exercise, both treatments significantly improved joint pain.  However, exercise was also effective at improving the thickness of the cartilage cushion.  So if you have arthritis, get moving!  Exercise helps the joints heal in addition to improving pain.

About a month after starting Shaklee’s Joint Health Complex, Ellie reported she felt significantly better, but what happened a few months later really made my day.  I caught up with her to see how she was feeling and she said she’d been meaning to call me.

“Guess what happened?” she said.  “I took a basket of laundry up the stairs.”

Puzzled, I said “That’s great,” thinking “okaaaaay…”

“No, you don’t understand,” she replied.  “I normally have to stand at the bottom of the stairs and get ready to go up, knowing it’s going to hurt my knees.  I just found myself at the top of the stairs one day, and my knees were OK.  Sore (because they’re always sore), but OK.”

I got it.  Not only was she not hurting as much, she wasn’t AFRAID of hurting.  She wasn’t limiting herself anymore out of fear of joint pain.  She was just going about her life and getting done what needed done.  And that’s the best result of all!

Are you limiting yourself?  Are you afraid to do things because of joint pain?  Why not try Shaklee’s Joint Health Complex?  After all, if it doesn’t help there’s no risk.  As always, Shaklee’s products have a money-back guarantee.

We have special pricing for Joint Health Complex this month because it’s Men’s Health Month.  Until June 30th, Joint Health Complex is 15% off – so don’t wait to order!

Don’t miss out on any more bike rides, long walks and games of Frisbee or bocce with your family.  Click here to order Shaklee’s Joint Health Complex today!  Reach out to me at drjen@jenniferwurstmd.com for more information.

QUESTION: Do you suffer with joint pain?  Have you found anything that helps?

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Drug Prices In TV Advertising

You’ve surely seen them. You can’t watch a prime time news or entertainment program on television without seeing ads for new medications. Now in addition to the litany of side effects tacked on to the end of the ad, drug companies will be required to include their drug prices in TV advertising.

Why would this be needed? The Department of Health and Human services is using publicity to draw awareness to drug prices. If you hadn’t noticed, drug prices are skyrocketing particularly for new brand-name drugs.

From the time a new medication is first developed and patented, no other company is allowed to use or sell the medication for 20 years. Now that doesn’t mean they get 20 full years of patent protection while the medication is being sold. However, while that drug is under patent protection the company can sell it for whatever the market will bear. There is no competition to drive down prices, especially if it is the first drug in the class.

In order for a new medication to be approved, it has to prove not only that it is safe and effective for the condition it treats, but also that it is different from and better than all the other medications in the class that have already been approved. Usually that means the side effects are less or there is a targeted group of patients for which a new medication works better or is safer. For instance, Byetta (a diabetes medication) can’t be used in patients with advanced kidney disease, but Victoza and Ozempic (newer medications in the same class) are safe.

Recently patient advocacy groups have been pushing the government to help rein in runaway drug prices. Especially when American patients pay 2-3 times what patients in other countries pay for their medication, they definitely have a point. While drug price fixing or control rubs me the wrong way (contrary to my libertarian leanings and the market freedoms that make America different from other countries) I am all for public disclosure of prices. I love the website GoodRx.com which provides retail drug prices at different pharmacies so patients can choose where to go to get their medications if they have to pay out of pocket.

When patients can’t choose for themselves what medication to take, direct-to-consumer marketing has never made any sense to me. Pharmaceutical companies spend almost $6 billion dollars annually on advertising, and 3/4 of that money is spent on TV ads. Every penny of that cost is passed on to patients.

Let’s talk about a specific example. A newer medication I have seen advertised recently is Trulicity. This is an injected once-weekly diabetes medication. According to GoodRx.com, 4 doses of this medication costs $863 at CVS. It’s more complicated than that, because this is not what the pharmaceutical company charges. There is a retail markup, and besides, almost no one pays retail cost for any of their medication. Between insurance and pharmaceutical discount cards there are many ways to reduce the cost of medications.

Part of me wants the government to ban direct-to-consumer TV advertising for pharmaceuticals altogether, like they did with tobacco advertising on TV. Requiring advertisers to disclose their prices is a great first step. Pharmaceutical companies are suing the government to block this rule. If health care providers have to provide transparency on the cost of testing (like CT scans and MRIs) then pharmaceutical companies should have to provide transparency on their charges too.

In addition, this will also shine light on just how much the retail pharmacies and pharmacy benefit managers (like Caremark and Optum Rx) are marking up prices to increase THEIR profits. Drug prices are complicated. Price control at the federal level is not the answer. Transparency and forcing the major players in the industry to justify THEIR piece of the pie? That just may be the answer we need.

QUESTION: Do you think companies should include their drug prices in their ads?

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Chronic Headaches: What Can I Do?

I’ve had a theme lately!  I’ve been seeing a LOT of patients with chronic headaches.  I thought I’d review a little about headache for you.  I know many people suffer with headaches without understanding much about them.headache-clip-art

First of all, chronic daily headache is defined as having a headache on 3 or more days per week.  That’s a lot of headache days!  By the time people come in to see me, often it has progressed to a constant headache.  Usually the patient has tried just about every over-the-counter medication available, with no relief.  Some people have taken so much ibuprofen that they are also suffering with heartburn and upper abdominal pain from ulcers and reflux.

There are three “types” of headache and all three can progress to chronic daily headache.  By the time the headache is chronic it can be tough to sort out which type started it all, and honestly it doesn’t really matter in the chronic setting.

The most common type of headache is tension-type.  It generally is described as “tight” or “band-like.”  This type also often affects the neck and upper back with tight, sore muscles.  It is usually associated with stress.

Another type of headache is migraine-type.  This type almost always starts in teens and young adults although children can suffer migraine too.  In women it may be tied to the menstrual cycle (so-called “menstrual migraine”).  Usually it is on one side of the head, centered around the eye, and pounding or throbbing in quality.  Bright lights and loud sounds can make the headache worse.  It may be accompanied by nausea and vomiting.  Usually going to sleep in a dark, quiet room helps these headaches.

The third major headache type is sinus headache.  Anybody who has had a horrible cold with sinus pain and pressure knows what this feels like.  People who suffer with chronic allergies or who have a cold or sinus infection are the ones who usually get this type of headache.  It generally is located in the forehead or upper cheeks, is associated with a stuffy and/or runny nose, and is relieved by decongestants.

So now that we know the different types of headache, what makes a tension headache turn into a chronic headache?  Nobody really knows for sure.  We do know that stress and sleep problems predispose to headache.  We also know that headaches (migraine in particular) run in families.  There is also evidence that nutritional deficiencies predispose to chronic headaches.

There is a gene mutation that seems to make people need more B vitamins.  It was first diagnosed in people who have early heart disease and a problem called hyperhomocysteinemia (yep, not only can I say it, I can spell it too LOL!).  It’s interesting to find that not only do these folks tend to have high blood homocysteine which accelerates heart disease, they also often suffer chronic headaches.  Giving them high-dose B vitamins, especially folic acid, helps their headaches as well as brings their homocysteine levels down.

I read a really cool study where they checked chronic headache sufferers for the gene and treated them with high-dose B vitamins to see if the headaches responded, and they did.  But they also treated the headache sufferers that did NOT have the gene and found that they got better too!

So what do I do for somebody who has been suffering with chronic headaches?  After I make sure they don’t have a brain tumor (!) I give them a couple of pieces of advice.  First they need to make sure they’re getting enough sleep at night.  Stress management is also helpful (check here for more info).

The first “pills” I put chronic headache sufferers on are a high-quality B complex and a multivitamin.  And it works!  Only very rarely do I need to progress to any prescription medications.  Patients are very happy with such a safe and natural treatment 🙂

Since I work closely with the Shaklee Corporation (check here for the reasons why) I always recommend their products.  I have found that many people coming in to talk about headaches are already taking a store-brand multivitamin, but when they make the switch they feel better.  Will a better brand of vitamin make a difference for you?  Try it and see!  Follow this link to choose the products that are best for you, or fill out a free HealthPrint assessment to get suggestions.

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Essential Fatty Acid Testing

Have you ever been told to take fish oil?  Well, as many times as you’ve heard that advice, I’ve probably told ten times that many people to take it.  How much should you take?  Well, I went over some rough guidelines in my blog about fish oil some time ago.

I was doing some reading some time ago and came across an article about doing blood tests to guide fish oil therapy.  Hey!  I didn’t even know blood tests were available to determine how much fish oil a person needed to take!  On I read…

Turns out, just like treating other problems of the blood chemistry (like electrolyte disturbances, low magnesium, high cholesterol and vitamin D deficiency) fish oil therapy can be guided by blood testing.  However, more information can be gotten from those blood tests than just how much fish oil a person should be taking.

Blood fatty acid testing can give an overall “wellness score” for the body.  It’s known that omega-3 fatty acids (like those found in fatty fish, flaxseed oil, borage seed oil and walnuts) are very good for you and are generally deficient in the Western diet.  On the other hand, omega-6 fatty acids (found in olive oil, corn oil and many other oils used in cooking and baking) are very prevalent in our diet.

In the body, a healthy ratio of omega-3 to omega-6 fatty acids is about 1:1.  In other words, your polyunsaturated fatty acids (PUFA) should be balanced between omega-3 and omega-6.  The more heavily skewed your blood PUFA levels are towards omega-6 fatty acids, the less healthy you are, in general.

A very brief scan of the literature revealed LOTS of evidence of positive health effects of a high omega-3/omega-6 ratio. For instance, higher ratios were protective against progression of prostate cancer, cognitive decline in the elderly, neurologic deterioration after acute stroke, and progression of coronary plaque after heart attacks (even when patients were taking a statin drug!).  Asthma patients with higher ratios have better outcomes and fewer symptoms.  Higher levels of omega-3 fatty acids were also associated with lower blood pressure.

There are two other fatty acids that can be measured, that give a lot of information about inflammation in the body.  Those fatty acid are arachidonic acid (AA) and eicosapentaenoic acid (EPA).  The ratio of AA to EPA is increased in inflammatory states.  The lower it is, the better.

So how can we use this research to help influence your health?  First you need to get tested.  If you have a cholesterol problem, high blood pressure, diabetes, obesity, or any other inflammatory condition, ask your doctor to order these tests:

  • Total omega-3 fatty acids
  • Total omega-6 fatty acids
  • Total polyunsaturated fatty acids
  • Arachidonic acid (AA)
  • Eicosapentaenoic acid (EPA)

The first measure to understand is the omega-3 fatty acid/total polyunsaturated fatty acid ratio.  Ideal would be about 50%.  To alter the ratio, you would eat more omega-3 fatty acids and less omega-6 fatty acids.  This would translate to eating more fatty fish like salmon, mackerel, anchovy, sardine and herring (SMASH is the acronym for fish with high omega-3 levels) and taking more fish oil supplements.  Using less cooking oils and eating less processed foods (which have added oils in them) is helpful too.

The second measure to calculate is the AA/EPA ratio.  The higher this ratio is, the more inflammation is present in your body.  A low level would be under 3, moderate is 3-6, elevated is 7-15, and high is >15.  If you have a high ratio, your best approach is to adopt a Mediterranean-type diet with lots of fresh colorful vegetables and fruit, fatty fish, lean meats in moderation, nuts and seeds.  Limit sugar, added oils and white starches.  Avoid food additives, especially partially-hydrogenated vegetable oils, like the plague.

These tests can be repeated to gauge progress.  If you make changes in your diet and add fish oil supplements, a repeat test can help to see if you’re moving in the right direction.

Don’t guess!  Test!  Then you’ll know whether your diet is helping nourish your body or if you’re causing inflammation and increasing your risk of a whole host of medical problems down the line.

QUESTION:  Do you think essential fatty acid testing would be helpful for you?  Why, or why not?

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