On the town

I woke up early on Wednesday to see as much of the city as I could before I flew out that evening. I headed down to the National Mall to meet another friend there for breakfast. Not surprisingly, there were a ton of runners down there at 7am. I’d catch fragments of conversations as small groups of them ran past my bench. Somehow, things like “youth civic engagement” and “my junior year at Penn State” didn’t seem odd coming from people in shorts and spandex. This really is a unique town.

After a greasy spoon breakfast at Lincoln’s (across from the similarly-linked Ford’s theater), I headed to the National Museum of Natural History.

Holy crap, this place is cool.

Say, friend, did you know that the original mammal that--after millions of years--became the primates that became the humans looked remarkably similar to a house mouse?

Or do you know what a monotreme is? I didn’t either. It’s a mammal that reproduces and defecates out of the same whole. There are only two species known (platypuses and something called the echidna), and that’s probably a good thing.

The pygmy marmoset (far left) is too small to digest complex foods, so it sinks its front fangs into trees a sucks out the sap. (These are preserved animals, but the National Zoo has the real deal.)

And apparently, panthers have two-way mirrors in the front of their eyes that let light in, and keep reflecting in back into their retinas to dramatically improve their night vision.  Amazing.

Of course, what visit to the Natural History Museum would be complete without dinosaurs!

By the way, this museum also houses the Hope diamond. The Hope diamond is a giant diamond now worth about $3,000,000.  It was likely mined from India in the 1500s.  It has a long and storied history, and was once part of the French crown jewels.  Rumor (and wikipedia) has it that Louis XIV granted a noble title to the lucky trader that sold him the diamond.

It was recently set into that (semi-tacky, but who the hell am I to say) necklace.

After a great couple of hours in the Natural History Museum, I walked across the mall to the National Air and Space Museum. I want to live there. Seriously.

I knew that I was going to have a great time as soon as I saw the two Cold War missiles in the lobby.

They looked like they were leftovers from a James Bond movie set. I think everyone would have felt better if they knew that the rockets were never intended to fly. They were apparently designed for the sole purpose of looking bad ass. Seriously, Soviet Union, did you really need all of those letters on the side of your rocket?

And speaking of bad ass, my next move was to look up.

Keep in mind that this was all happening within the first 30 seconds of me being in the museum. It’s the happiest place on earth.

The museum is broken up into different sections, each representing important sectors or themes in the aviation industry. The civil aviation room chronicles the history of commercial flight, and has amazing exhibits from Eastern Air, TWA, and Boeing, amongst many others.

And this little gem was in the WWI room.

If that’s a computer, then I overpaid for mine.

One of the most jaw-dropping exhibits is the actual Wright Brothers plane. The actual one, not a mock-up, not a replica, but the actual first-ever airplane.

I could have easily written it off as a replica if I didn’t notice the armed guard at the exhibit entrance. This thing is priceless.

There were also great exhibits on spaceflight and military aircraft, but I’ll save that theme for the next post. It’s a good one.

M

These hallowed halls

I promised that there would be poop jokes in this post, and I’m sorry to say that I don’t have any at the moment. But I do have a lot more travel photos.

Impressive, isn’t it? Seeing this in person should be required for all Americans that can afford the trip. And we should all kick in to pay for the people that can’t afford it. Both the structure--and what it represents--is an amazing sight.

The actual Capital building is just used for meetings of the House, Senate, and certain committees. Most of the action actually happens in the five or six office buildings that surround it. These house the offices of the Senators and Representatives, and are where they spend most of their time.

Some are traditional, and some are modern, but they all have an amazing feel to them. Forty year old lobbyists walking past twenty year old staffers, while the sixty year old Congress people hide away in their back offices. People are moving and things are happening!

This is the main lobby of one of the older office buildings.  It's where both parties hold a lot of their impromptu press conferences, and you can see a TV camera set up in the top left corner.

This is one of the many hallways coming out from the lobby above.  The two doorways with flags in front of them lead to Senators' offices.

This is one of the newer, but equally impressive office buildings.  This one houses the offices of Harry Reid, Jon Kyl, and Al Franken, amongst many others.

We met with the offices of Representative Flake (R-Phoenix), Senator McCain, and Senator Kyl. We didn’t get face time with any of them, since votes were happening during our appointment times, but we did meet with the health staffers for all three. And to be honest, that’s what we were hoping for. Things like payment formulas and residency funding are kind of wonky, and our elected representatives don’t have time to learn about all of them. So they have specialized staff members (health, finance, military, etc.) that are experts in these subjects. They meet with the various interest groups, and compile a summary for their bosses.

Not surprisingly, the health staffer for Rep. Flake could care less about what we were talking about (he’d rather talk about abolishing Medicare than about allocating a specific pool of money within it). But the health staffers for both Senators McCain and Kyl were remarkably receptive. They were well informed, and knew about the issues that we were trying to address. While we didn’t see eye to eye on all issues, we all agreed that the residency funds need to be more diversified. It was a very pleasant surprise to have their support on that issue.

After our three meetings, the rest of the Arizona delegation (a doctor and a resident) all struck off on our own to take advantage of our time in D.C. I spent the afternoon visiting a friend who served with Aimee in the Peace Corps. He has a very impressive job coordinating public relations for Senate Dems, and he reports to none other than Harry Reid. When he told me nonchalantly to just meet him in Harry Reid’s personal office, my eyes almost popped out of my head. I was actually kind of nervous walking over to meet him. “What if Senator Reid is there? Should I say hi? Should I talk about Medicare payment reform, or should I just say how nice the weather is?” But for better or worse, Senator Reid was in meetings all afternoon, so I didn’t have the chance to make an ass out of myself in front of the majority leader of the United States Senate.

But I had a great time meeting with my friend. He has an all access pass to the Capital building, and gave me a pretty incredible behind-the-scenes tour of the operation. I even got to see Al Franken reading the newspaper on the Senate podium. Apparently, whenever the Senate is in session, there needs to be a Senator presiding over it, even if nothing is going on. It’s clearly a pretty boring gig to sit on the podium (while all of your colleagues are off in meetings) so the junior Senators rotate through the job in two-hour shifts. And I had the luck of being there during Senator Franken’s turn. And for everyone who solely remembers him and Stuart Smalley and the guy that wore nothing more than a diaper on live television, he’s actually a remarkably astute policymaker. After all, you don’t have to be smart to be a Senator, but you do have to be smart to be funny. Seinfeld/O’Brien 2016. We could do worse.

Lobby Day!

Did you know that the Senate has its own barber?

I don’t know what to say about that, or even if anything needs to be said, but it was pretty cool.

Now, you might ask what I was doing in the basement of the Senate office building. I spent most of Tuesday lobbying on behalf of Family Medicine, and we had three major points to make:

The current equation that Medicare uses to pay physicians in flawed. It was passed in 1997 as one of Newt Gingrich’s signature bills, right after his party took over the house. The House Republicans weren’t happy with how much money Medicare was spending (nobody was, or is). They wanted to curb the expenses, so they went after doctor’s pay. As you know, I’m usually the first person to say that most doctors (particularly specialists) are paid far too much, but the problem with this bill is that physician pay is a very, very small component of total Medicare expenses, so cutting it would have a negligible effect on the overall expenses. But doctors are generally one of the more politically inept interest groups (silly us for focusing on our patients, and not politics), so we were an easy target. Congress is very, very weary of going after the insurance industry. 

But even that same Congress realized that this was a bad bill, so they passed a short-term “Pay fix” bill that pulls money from other pools of money to make up for the difference between what Medicare was supposed to pay doctors under Gingrich’s plan, and what it actually pays them (under the old formula).   The problem is that because of how Gingrich’s formula was written, the difference between real pay and “on the books” pay widens further every year, and it’s getting harder and harder to cook the books. In fact, last year, Congress couldn’t figure out how to pass the most recent pay fix, and the Gingrich rate kicked in. Overnight, doctors took a 30% cut in their Medicare pay, and it wasn’t resolved for two weeks.

Now, to balance out my Congress bashing, the Democrat Congress should have repealed the Gingrich pay rate as part of last year's healthcare reform law, but that would have obscured the benefits of that bill, since some of the cost savings would be negated by increasing the “on the books” pay rate for doctors.

What all physician groups are asking for (including the Academy of Family Physicians and the AMA) is that Congress pass a 5-year pay fix (instead of the current few months at a time), so that we can work with Medicare to come up with a more permanent solution.

But in my opinion, this isn’t one of medicine’s more pressing issues. We’re using a lot of political capital to keep the pay cut from kicking in, and the general public isn’t all that sympathetic to doctors’ pay. And asking for more money in this political climate is a complete non-starter. But the whole point of organized lobbying is that we’re far more effective as a group. So when the Academy holds a vote, and the majority of physicians are in favor of pursuing a pay fix, we all lobby for it, even if many of us aren’t convinced that it’s the most effective use of our resources.

The other two issues that we lobbied for are much more important to me, and I think that they will have a far greater impact on the overall healthcare system. We want to increase funding for primary care medical education. The trip that I took to the Hopi reservation last summer was funded by this pool of money, and the trip was probably the single most powerful event that convinced me to become a family physician. These programs are an extremely cost effective way to address the shortage of primary care physicians. However, this isn’t a great time to ask for more funding for anything, so we got some pushback from some of the more conservative members of Congress. It’s an investment that will save the system a lot of money over the long run, but many people don’t see past the initial cash expense.

The last issue was an interesting one, and one that has the added benefit of not costing the government any more money. It relates to how our country pays for residencies (the time between medical school and being a grown-up doc). Since residents are fully licensed physicians, they can see patients in the clinic and they can perform procedures. This brings in money for the program that is training them, but it is usually not enough money to offset residents’ salaries (which are usually in the ballpark of $40,000). So if this arrangment wasn’t subsidized, hospitals would have no financial incentive to train more physicians, and we’d have a serious, serious physician shortage in about 15 years.

Since we receive a collective benefit from having enough doctors, we all chip in to cover the costs. Part of our Medicare tax goes towards funding residency programs. You pay about $2.50 per year towards this, and we really do appreciate it. However, this money is paid to hospitals for them to use as they please. So it should come as no surprise that hospitals are going to funnel this money into the most profitable residency programs. So even though it saves us all an incredible about of money to have a primary care-focused healthcare system, it is far more profitable for a hospital to crank out more neurosurgeons (since neurosurgery residents perform procedures that bring in far more money than the procedures done by family medicine residents).  This is why "free market principles" work great when you’re making shoes or selling computers, but they are very counterproductive in most aspects of the healthcare system.

What we asked for is that Medicare distributes the residency money to a wider variety of players in the healthcare system. Hospitals will continue to (and should) receive the bulk of that money, but we want to see community health clinics, small physician groups, and rural hospitals also receive some of this money, since they are far more likely to train primary care physicians. And since this proposal has the added benefit of being budget neutral (we’re just moving money from one account to another), Congress was pretty receptive. The hospitals won’t be crazy about this proposal, but as long as they don’t fight it too hard, I’ll bet that Medicare will start diversifying its residency funds in a year or so.

Something about D.C. just keeps bringing out these political postings, but we’ll be back to poop jokes and travel photos in no time.

M

The District

After a mildly excruciating networking hour (I barely made it through fifteen minutes), the conference adjourned for the day. I went for a walk, and checked out the city. Here’s where the conference was held (the intersection, not the building).

That street name sounds familiar, doesn’t it?

Here is a road with a building at the end of it.

I kept walking towards the White House, but the back entrance was mysteriously blocked off. Security looked antsy, and they were telling everyone to step back. Then I started hearing a unique siren off in the distance. It wasn’t like a fire truck, police car, or ambulance, but it was definitely loud.

Then this pulled up.

OMG! OMG! OMG!

I was pretty confident that I had just seen the president’s motorcade. At least until I heard the same siren sound coming from the opposite direction.

Out of curiosity, I pulled up the president’s surprisingly public schedule. He was moving from a meeting with Janet Napolitano to one with the Chinese Ambassador.

And here we are!

And to put it in context…

You know what I love about D.C.? You’re walking down the street, minding your own business, and out pops the headquarters of the IMF. Just sitting there.

And the Mexican Embassy...

…right next to Metropolitan Optical. Only in D.C. 

Actually, the Mexican Embassy is a pretty cool structure. It looks like it was build right next to, and on top of, two houses that were already there.

I kept walking and walking, and happened to come across the GWU Med School.

I looked for an A to paint red, but no luck. 

And the headquarters of the World Health Organization, a personal favorite.

As the sun started to set, I made my way to the Lincoln memorial.

There is definitely a warm, reverent feeling in that building that doesn’t come across on postcards. Or on pennies.

Currently, the view from the Lincoln Memorial is less than spectacular.

I mean, I know that we’re broke, but do we really need be Canada’s trashy neighbor that doesn’t fill our pool? 

I’ll be here all week, folks.

And one more Lincoln photo to justify the cost my camera.

Now, you could say that this is group of D.C. staffers playing softball on the National Mall, while the Sun sets behind them over the Lincoln Memorial. Or you could just say, “America, fuck yeah.” 

But maybe you should save that for this photo.

I certainly am proud to be an American.

Talking shop

I was going to put this post up last night, but by the time that I got back to my friend’s place, I was too tired to think. What a day.

My morning started with a breakfast buffet at the Family Medicine conference. Now, I wouldn’t normally write about a hotel breakfast buffet, but I was struck by the difference between a medical conference and a medical student conference. Let me just say that I can get used to this. There was crab at the afternoon reception.

The conference programming started with a long-time Washington staffer going over the current Congressional dynamics. Short version: “You wouldn’t have had much luck getting anything done with this Congress, even if Osama Bin Laden wasn’t killed last week. But good luck.”

Not surprisingly, there isn’t a lot of compromise in the D.C. air, but the speaker did bring up some interesting issues. Over half of the representatives in Congress have had absolutely no government experience. Now, that may seem like a good thing to some of you (we're all sick of the usual Washington gridlock), but it's actually pretty terrifying when you think about it.

The speaker said that the freshman members of this Congress are on a mission from God, and they only care about a couple of pet issues. They are in Congress to lower the deficit and to repeal healthcare reform at any cost. (Ironically, the healthcare reforms have done more to lower the deficit than any other piece of legislation has in the last decade, but don’t try to tell them that.) 

The new members are not particularly interested in hearing about why we need to shift more residency positions from specialties to primary care, or why the single-doctor medical practice is becoming a relic of 1970s TV shows. But good thing for us that there are still a handful of people left in Congress that do want to hear about these things.

Our speakers throughout the rest of the day went over everything from the current state of medical education to the value of primary care in the US healthcare system. And let me tell you, if I wasn’t already in love with becoming a family doc, I would be after yesterday. Here are some of the pearls:

Family Doctors provide 50% of all medical care in the U.S., and do so with only 35% of the physician workforce.

Investments in primary care pay 2 to 1, meaning that if a health facility or insurer pays $1,000 to increase primary care services, it will save $2,000 that same year. And this is very conservative data from Blue Cross/Blue Shield. The Academy of Family Physicians says that this number is actually significantly higher.

Restructuring Medicare to be more primary care focused would not only save Medicare the cost of the restructuring, but also the entire cost of primary care. Read that again: if Medicare would make some small changes (like tying physician payment to the outcome of their patients, and paying for more frequent check ups by physicians and nurses), Medicare would effectively remove the entire cost of primary care from of their books. The good news is that Medicare has already started making these changes. Thank you, President Obama. There’s a reason that the Affordable Care Act (healthcare reform) was 2,000 pages long. This isn’t simple stuff.

For anyone more interested in that last point, Google “Accountable Care Organizations”. That’s the new buzz phrase that people are using to talk about these restructured primary care services. These “ACOs” are essentially home bases for patients’ medical care. Need a check up? Go to an ACO (your primary care doctor). Need surgery? You’d still go to a hospital, but the report would also be sent to your primary care doctor. The only thing different between an ACO and a regular doctor’s office is that the primary doctor is held ‘accountable’ in an ACO. This means that if your doctor does a poor job helping you reduce your cholesterol and you need to go in for heart surgery, the doctor’s pay takes a hit. And conversely, if a doctor’s patients are doing really well and have fewer chronic diseases, that he or she receives a pay bonus. It’s a very simple concept, but it is almost impossible to implement in a healthcare system that rewards doctors for doing a bunch of extra procedures and unnecessary surgeries. However, pilot projects that are experimenting with this concept are already saving Medicare millions of dollars. Again, thank you, President Obama.

Want to be in a bad mood? Keep reading the next two paragraphs. Showing where their true priorities lie, the insurance companies are fighting ACOs tooth and nail. They say (and they’re right) that more ACOs would lead to better primary care, which would lead to fewer hospitals, since there would be less need for high-level care if health problems are treated before they become huge issues. You’d think that the insurance companies would like this, since it will cost them less money in hospital payments. But they’re worried that fewer (and therefore more powerful) hospitals will no longer put up with the bullying that they receive from the insurance companies.

Insurance companies pay hospitals based on a percentage of Medicare rates. In some cases, insurance companies pay as little as 51% of the Medicare rate for the services that hospitals provide (and it's not like the Medicare rates are all that high to begin with). If a hospital doesn’t like that payment arrangement, the insurance companies will just funnel their patients to a nearby hospital, and the protesting hospital is shit out of luck.

The insurance companies are claiming that ACOs will lead to hospital monopolies, and are using federal antitrust laws to fight them. That’s right, the same laws that were used to break up the railroad, oil and communication monopolies are being used to fight better primary care. And here’s the kicker, there are two industries that are exempted from Federal antitrust laws: professional baseball and health insurance. So it’s fine for the insurance companies to consolidate their operations, but it’s not ok for doctors’ offices to do the same. 

I told you not to read those last two paragraphs.

But all told, I had a much better time discussing health policy than any rational person should have had. And the headliner at yesterday's event? Not U2, not Justin Bieber, but the one and only director of Medicare.

The crowd went wild.

-M

P.S.  No politics in the next post.  I promise!

Mr. Stone goes to Washington

I’m tempted to say that it’s been a while, but that’s how I open up the first post of every trip. Clearly, no matter how long it’s been, I still wish that each trip came sooner!

That said, holy crap it’s been a long time. Or at least it feels like it. This year has been pretty unreal. I’m finally ready to admit that med school is hard--really hard--and maybe I’d be best served by focusing on it exclusively. But that’s not me. (Exhibit A.)

My last exam was on Thursday, and I’m almost ready to start my Year in Beer. I say "almost" because I still have a couple of loose ends to tie up with school, including the first part of the three-step medical licensing exam. But at least I’m done with class.

Which brings us to today. I’m sitting on a Southwest airplane on my way to Washington D.C., and I have the good fortune to be one of Arizona’s representatives to the Family Medicine Congressional Conference. I’ll be meeting with Senators, Representatives, and their staffers to talk about the value of primary care medicine. There are few things that I like talking about more than politics, and to be able to do so on behalf of family medicine is a sweet gig for this med student.

I mentioned how stressful this year has been, and there’s no better anecdote to this fact than my flight reservation for this trip. As I worked my way through Southwest’s website, I entered my personal information and booked a flight on my new favorite airline. Only yesterday did I realize that I had booked a round trip flight from Washington D.C. to Tucson and back. From Washington.

I need this vacation so bad!

-M