To Decrease Medical Costs We Must Expand Medical Student Positions

Utah is at a critical period in our access to affordable healthcare. Recent reports show that
we are one of the most under-served states in the county for Primary Care physicians.
This lack of patient access to our healthcare system results in higher medical costs,
increased waiting periods for patients, and in our more rural areas – forces patients to
travel long distances just to receive the attention they needs.

We have heard much in the news detailing what contributes to such high medical costs
in our healthcare system. One of the major contributors – and is a direct result of Utah
not having enough physicians – is the large amount of people that go to the Emergency
Room. Many of these patients see the Emergency Room as last resort – a “safety net”
even – to receive the medical attention they need. The vast majority of issues that our
Emergency Room patients face could be taken care of by Primary Care physicians, if
only our State had enough to serve our population.

ER care is expensive. However, if a patient has no other options and needs to be seen,
they have no other choice. We need more Primary care doctors to give patients the
opportunity to be seen and treated in outpatient clinics on a timely and affordable basis.

Here in Utah we are fortunate to have a highly rated Medical School at the University
of Utah. When I applied to the University Medical School twenty years ago, there were
102 positions for the first year class and Utah had a population of about 2 million. Today,
Utah has a population of nearly 3 million, an increase of over 30%, but the Utah Medical
school class was recently reduced to 82 positions, about a 20% decrease. To better serve
our community, we must rectify this disconnect and see that our desperate need for more
physicians and providers is met.

This reduction in positions at the University of Utah Medical School has resulted in
a great “brain drain” in our community – where many bright and capable students are
forced to look outside the state for Medical School, often to never return. Increasing the
medical school class size would allow us to retain more students and train them locally.
Studies have shown that medical students often choose to stay and practice where they
are taught. To help solve Utah’s desperate need for more Family Care physicians, we
must expand the class size of our local Medical School.

I recently met with Dr. Vivian Lee, a leader at the University of Utah Medical School,
and discussed plans and funding to increase the class size back to at least the previous
size. Estimated costs would be $12 million dollars, with a portion of that paid in tuition
by students. These costs for the increase in the class size at the University of Utah are
actually much lower than comparable per-student costs in other states. Part of the reason
for the lower cost in Utah is that we already have existing classrooms and teaching staff.
It would be funding well-spent as we could retain more of our own local students and
train more needed doctors to serve our growing population.

As an emergency room physician and a concerned resident of Utah, this is one solution
that I hope to propose as a State Senator to help meet our ever increasing health care
access needs in Utah. This is a common-sense measure that will benefit Utahans
immediately and in the long run.

Dr. Shiozawa is a family physician and emergency room doctor who is
running for State Senate District 8. He can be reached at (801) 230-3406.

Dr. Brian Shiozawa
3177 E. Fort Union Blvd
Cottonwood Heights
(801) 230-3406

A Voice for the Voiceless in the Utah State Legislature

Autism Speaks is a national advocacy group representing the tens of thousands of parents across the nation who have children with Autism. Recently, Autism Speaks released a public service announcement highlighting the prevalence of Autism in our society with Tommy Hilfiger – a parent of child with Autism – providing the commentary.

Autism Spectrum Disorder (ASD) is a complex neurobehavioral disorder that affects thousands of Utah pediatric patients.  Nationally, it is estimated that 1 in 88 patients is affected by autism spectrum disorder.  The prevalence is estimated to be even higher in Utah possibly affecting 1 in 47 children.  Why this prevalence is so high is not clear.  What is clear is that autism is even more common than many diseases such as breast cancer or juvenile diabetes.  Autism has devastating effects on the patients physically, behaviorally and intellectually.  It is often associated with other specific disease such as gastrointestinal and lung diseases.  Autism has collateral emotional, physical and financial stress on their families.

As we study autism, we learn about its complex genetic and environmental causes.  There are some studies that suggest that it may be decreased with prenatal vitamin and folate supplements. So far however, we have no single definitive cause and so more medical research still needs to be done.  We have made significant progress in treatment. One effective, evidence based therapy is early diagnosis and early intervention such as Applied Behavior Analysis (ABA) on affected children.  There are clear improvements in those who receive this treatment. 

From a health care standpoint this is effective and high quality care.  From a fiscal standpoint, such prevention just makes sense.  With early intervention patients can have long lasting improvements in social interactions, communication and behavior.  This may avoid very costly long term care or even institutionalization.  Some patients even are able to move off the ASD spectrum with therapy and support.

Utah needs to re-evaluate the current health care insurance definition and coverage of Autism.   Autism is a real disease.  We need to define it.   We need to treat it just like we do other serious, long term afflictions such as diabetes and high blood pressure, for which we know that intervention has long term positive health and financial benefits. 

Parents and families should not have to face bankruptcy or foreclosure just to see that their children receive necessary treatments. We can and must do better as a society.

Previous efforts in the State Legislature have failed to fully address the problems that parents of children with Autism face in ensuring that their children are insured and receive effective treatments. As our next State Senator I will continue the dialogue and further the action surrounding Autism to see that it is fully addressed in the home, the clinic and in the Legislature.

Dr. Brian Shiozawa is a family physician and emergency room doctor who is running for State Senate District 8. He can be reached at (801) 230-3406.

Reducing the Costs of Defensive Medicine

Defensive medicine costs are a big deal. They add so much in terms of actual dollar amounts to everyone's bills, whether in the clinic or in a hospital setting. Many studies estimate that up to 20-40% or more of our medical bills are inflated by defensive medicine costs. Given the huge costs we face, reduction of these would help reduce medical costs a lot.

Even more, excessive and unnecessary tests are dangerous to patients. For example, an Abdominal CT scan adds up to 30-50 times the radiation exposure of an ordinary x-ray. Imagine the effects this could have on your body in terms of injury. And this is done just because a doctor is in fear of being sued.

Here is one way I propose to reduce defensive medicine costs: I am one of the two physician members on the Lt Gov. Task Force for Medical Liability reform. We are working on a specific plan to help patients and physicians resolve medical injury disputes more quickly and less expensively through face-to face early communication between patients and hospitals and doctors when a suspected medical induced injury occurs. We believe that this new system, already successfully used in Washington and Michigan, will enable resolution with fairer, quicker compensation and preservation of the doctor-patient relationship. This early resolution process is virtually cost-free compared to the traditional tort system that involves formal lawsuits and all of the associated attorney fees. We are going to test this at the Univ. of Utah and hopefully then at IHC and HCA, etc.  This system benefits and makes sense for all parties involved.

Here's another idea: I would like to explore further a "de facto" protocol for medical quality of care as well. This is a system wherein we develop specific evidence-based guidelines for quality of care. In other words, we would develop specific testing protocols for a condition like chest pain. Affected parties of patients, trial attorneys and physicians could review and agree to these ahead of time. These protocols would ensure the high quality care based on the best medical practices. It would maintain quality for patients and reduce unnecessary other unneeded defensive testing.

Reforming healthcare is an important priority for me. It’s a task that will require bipartisan cooperation, with lawmakers from both parties coming together to figure out what is best for Utah. I am confident that I can and will be an effective part of this process and a strong representative of SD 8 residents.

Utah's Patient Advocate on the Hill

As many of you know by now, I have been serving our community as an Emergency Department physician for the past 20 years. Each day I have the opportunity to treat those who are sick or injured and work with them to improve their health and get them feeling better. 

As an Emergency Department physician my first and only priority is to help people get better. Each day I treat patients from all walks of life and from all social and economic backgrounds. I have firsthand knowledge and experience of the issues they face – not just with their health, but in trying to afford health care as well. I have seen too many instances where people have put off treatment – only to have their condition worsen – because they have been afraid of how much it would cost them to get better. 

That is why I have been actively engaged the past few years as a Patient Advocate up on Capitol Hill. As a physician, I am committed to helping patients improve their health. As an individual, I am committed to helping all of us receive more affordable healthcare. No one should have to put their health - and their family – in danger because of fear of the costs attributed with treatment. We can do better – we have done better –and we will continue to improve. 

 Recently, I have served as the President of the Utah Medical Association. This past session I worked tirelessly to see laws passed that truly advocated for patients. In fact, the last piece of legislation that was passed protects patients who struggle to pay for medications. 

As a physician, I prescribe medications that help to improve the health of my patients. However, studies show that a large portion of the prescriptions that physicians write are not filled, because patients cannot afford them. Too often, patients are faced with the dilemma of either paying for food or purchasing their prescriptions. This should not be the case! 

This past session I helped to pass legislation that puts patients first. Under our old law, doctors were only allowed to give up to 3 days of samples of medications to patients to improve their health. It was my great pleasure to advocate for patients in seeing the law change so doctors can now give free samples to patients for up to 30 days! Now, patients no longer have to face the difficult position of choosing between food and potentially life-saving medications. I helped to pass legislation that makes healthcare more affordable, saves patients’ money, and has the potential to save lives! 

My pledge to you is that I will continue to be a Patient Advocate on the Hill. All of us have been or will be patients. I will do all I can to ensure that you and I receive affordable healthcare. I have many innovative ideas that I will take to the legislature to improve our health care system. They include: 
• Increasing Patient Accessibility 
• Improving Healthcare Quality 
• Reforming Medical Liability 
• Improving and Reforming Medicaid 
• Lowering Healthcare Costs 

I personally have been blessed to work in the Emergency Department for over twenty years. I am grateful to treat patients, whoever they are, wherever they are from, to work hard and do the very best job I can. As a physician I recognize that I do not know everything but I act with patients' welfare in mind and in good faith. I am grateful to advocate for patients in the Emergency Department and will continue to do so at the State Legislature.

Response to "Desperate parents surrender autistic children to state custody"

My response to an article in the Salt Lake Tribune titled: Desperate parents surrender autistic children to state custody

"Autism is a real neuro behavioural disease. It does have many different presentations and degrees of severity. Some patients can be relatively high functioning, but as this article illustrates, many patients and their loved ones can be devastated for both the short and long term due to the many problems which are so destructive. Further, this disease is widespread with the studies showing up to 1 in 47 children afflicted. It may be even more prevalent. Families suffer in so many ways: financially, emotionally and physically. Unfortunately, due to the many presentations and due lack of primary training in this area, many physicians do not diagnose this condition early nor know the best ways to treat. Research is on going and treatments are evolving that promise to be more effective. 

 Clearly, early intervention can be very beneficial. But treatments can be and are expensive--as are too many areas of medical care nowadays--and often not covered by traditional third party insurance, so patients and their families are left to cope with the costs and go without or experience crippling healthcare related costs. I support increased research in the area of autism by our medical centers. We need to know more about causes and develop evidence based treatments. I encourage inquiry by our legislature into fairer and more effective ways to fund treatment of autism. Our current legislation in Utah is incomplete and we need together to meet as patients, families, insurers and medical providers to resolve this problem of recognition and under treatment of this condition." 

 Brian Shiozawa MD FACEP

Women's State Legislative Council of Utah

My Year in the UMA

Last Friday, I was joined by my wonderful family as I passed the torch of leadership of the Utah Medical Association to its new President, Dr. Brian Hales.  This was a bittersweet experience for me; I will miss my time as President, but I know that Dr. Hales has much to add in this new role.  I think this is an appropriate time for me to reflect on the things we were able to accomplish in the last year.

Here are a couple of legislative highlights:

House Bill:  this legislation which we advocated, was to allow physician offices the right to dispense free samples of medications for up to 30 days or longer, depending on medical necessity.  Previously, DOPL regulations prohibited clinics sending home more than 3 days worth of medications.  We recognize that patients often do not fill their prescriptions due to cost and studies have shown that over half of prescriptions are never filled thus putting the patient in significant danger.  By increasing this sampling time, doctors can  provide free medications, for a significant length of time, to patients who may not be able to afford them.

Another bill dealt with the treatment of cancer patients.  This bill allows oncologists and cancer clinics to treat patients at the time of service at the clinic with specific anti cancer medications provided at cost.  Previously, patients had to leave the clinic and obtain their oncology medications.  Often, patients are very ill from the disease itself or from the side effects of their treatments.  This bill helps patients to obtain these vital medications and then post treatment to go directly to their homes or rehab centers without the delay in getting their medications filled or ordered.

I really liked both of these bills as they truly helped patients.  

SJR 15 was a very important bill that I testified on before the Senate Committee.  In late 2011, a District Court ruling struck down protection of peer review in hospitals.  This ruling created the dangerous potential of limiting the frank and open discussion by physicians and  hospital personnel about patient complaints, injury and system problems. The result would be lack of discussion due to fear of litigation. This bill restored an amendments of the Rules of Civil Procedure, the confidentiality and peer review protection.  This restored the confidential review of cases in order to improve quality care.  Importantly, the bill did not limit the rights of the patient to their records nor inhibit their rights to litigation, if they choose.

Another rewarding role was to be the physician representative on the Utah State Medical Liability Reform Committee.  Chaired by Lt Gov. Bell, this committee has worked with many stakeholders including the trial attorneys, Utah Medical Association, Department of Health, etc. to consider alternatives to current medical liability system which is very problematic.  The current liability system is fraught with adversarial, hugely expensive legal proceedings which does not help the injured patient.  We are studying an early dispute resolution program as an alternative to the traditional tort system.  This program, if adopted would allow patients and physicians to communicate and resolve their disputes sooner and in a much more open and collegial manner.  Similar programs in Michigan have found much lower costs, fairer and quicker dispute resolution;  further, patients retain their ability to opt out to the traditional system if needed.

These are just a few of the legislative highlights of the past year for me.  It was engaging, and rewarding as we successfully advocated for patient care, public health and preserving the doctor patient relationship.

Healthcare Reform is an extremely important issue to me, and I hope to continue to fight for reasonable, bipartisan healthcare reform on Capitol Hill.  

Autism in Utah

I enjoyed attending the recent Autism Conference at Sugarhouse  Park.  Autism is a neuro- behavioral disease which has recently received increased attention locally and nationally.  There is an especially high prevalence of autism in Utah. The conference was well attended and very informative.  Even as a physician I learned a great deal, especially about the efficacy of early recognition and treatment.  Such early diagnosis and intervention by trained medical personnel can result in better outcomes and improved prognosis.  This can result in lifelong benefits of improved academic, behavioral and social functioning of the autism patient.  However, many patients remain untreated and under-treated due to lack of insurance or private funds by patient's families.  This  under-treated condition then becomes chronic, resulting in huge medical, social and long term economic costs, estimated to be 1.5-3 million dollars per patient.  This a huge, unaffordable, unsustainable burden to the patient, their loved ones and our communities.  Some families are forced onto Medicaid insurance due to the costs.

In Utah we have previously had legislation that addressed the recognition of autism as a disease and also insurance coverage.  However, we still have gaps in coverages.  The estimated increase in insurance costs resulting from treating autism, if any, would be relatively small.  The  long term health, social and economic benefits of early treatment to the patient, their families and to the community are very big.  It makes good sense on many levels to address a change in insurance to treat and prevent the consequences of this disease.  It is a common-sense measure for which I am proud to voice my support.

Support for Small Business

I am grateful to be both a healthcare professional and an owner of a small business.  This gives me the great blessing and opportunity to care for people and make positive changes in their healthcare and their lives.  I also appreciate how important it is to have a job and to be able to provide for my family and to provide jobs for others who work with me. 

When my grandparents immigrated to America, they embraced the great American Dream, which includes the freedom to choose a job or profession and then excel in it through hard work, education, and innovation.  This is what has made our communities, our state and our nation great. 

When I started at St. Mark’s Hospital over twenty years ago, we had a modest-sized Emergency Department staffed by five full-time physicians.  Since that time, we have grown our physician group to twenty-three physicians and now care for over 40,000 patients annually.  We strive to provide high quality healthcare and great customer service.  These are the same principles that make any small business successful and provide jobs for many. 

I understand the needs of small businesses and their employees.  I have had to make payroll through challenging economic times and find ways to improve efficiency and provide benefits and care for our fellow employees.  Recently, we merged our group with an even larger group so that now we cover nine hospitals along the Wasatch Front and employ over one hundred physicians.  Altogether this group cares for a significant fraction of emergency and hospitalized patients in this area. 

My experience as a small business owner will guide me to support small businesses throughout Utah as your next State Senator for District 8.  I believe in a balanced budget, fiscal responsibility, and efficiency in our government while providing the highest quality services to our citizens. 

I believe that small business is absolutely essential for the success and prosperity of our state and our country.  I am grateful to be a healthcare professional and grateful to our patients and customers for their trust.  As your next State Senator, I commit myself to represent you effectively and to see that your voice is heard in the Capitol.  I commit myself to supporting measures that will assist Utah’s small businesses as they provide jobs for Utahns, the most important issue in this election.

My experience in Health Care Reform

This past legislative session, as the President of the Utah Medical Association, I was involved in sponsoring legislation that supports patient advocacy, public health and preserving the doctor–patient relationship.

Here are some highlights:

We were able to enact legislation that increased the amount of free samples that doctors could give to patients from a three-day supply to a month or more.  The effect of this bill will help patients receive medications that they might not otherwise afford and that are vital to their health.  On a similar note, we were able to get legislation passed that allows cancer specialists to dispense cancer-treating medications directly to their sickest patients at the office, at cost to the patient. 

The Utah Medical Association also supported legislation to require minors to have a guardian approve their obtaining tanning at local salons.  This requirement will protect youth from excessive UV radiation that has been shown to increase cancer risks.

Another important patient quality measure that we supported restored confidentiality to the ‘peer review’ process.  ‘Peer review’ allows physicians, nurses and other members of the health care team to meet to discuss patient quality care issues and have those issues protected. The legislation, which had strong bipartisan backing, does not hide or obscure patient complaints or errors and does not interfere in the discovery process. This allows for frank and open discussion and is vital to patient quality improvement.

These are some examples of the important advocacy for patients, the public and for the healthcare team that I am pleased to support.

Affordable Health Care

As an Emergency Physician, I am concerned about the effects of the Affordable Care Act (ACA) on Utah.  I agree that we need affordable health care available to all citizens.  We also need better access for patients.  However, a couple of observations: 

First, Utah currently has about 13% uninsured patients.  Most of these patients have no regular physician.  Currently, due to the EMTALA laws, any person seeking emergency medical care must be seen and treated in the ED at any time without regard to their ability to pay.  This effectively provides a safety net for them.   However, the safety net can entrap patients:  the care is episodic and the patient is often discharged without a primary care doctor relationship.  It is not ideal. Further, ED care is the most expensive outpatient treatment available.  Pres. Obama noted that each ED bill exceeds a thousand dollars or more.  This is NOT affordable or sustainable health care. However, thousands of uninsured Utah patients utilize EDs each month, because they have nowhere else to go. 

Next, under the SCOTUS ruling Utah will choose if we embrace expansion of Medicaid  eligibility.  According to the Dept of Health, the Utah Medicaid expansion under the ACA will provide health insurance to 100,000 or more currently uninsured Utah patients.  This will provide much needed insurance and it will cost millions of tax dollars.  Further, currently Utah is already underserved in Primary care and many specialties.  We do not have enough physicians for our existing patient population.  Adding thousands more to the Medicaid insured pool of patients will further crowd existing clinics and systems.  As a result, Medicaid patients who according to State Medicaid officials already over utilize EDs, will increasingly seek care in EDs due to limited Primary care access. 

The SCOTUS ruling will also affect those currently with private insurance.  The popular provisions such as additional coverage of patients to age 26, elimination of pre-existing conditions, and other modifications has and will raise insurance premiums.  Many patients will opt to use higher deductibles, health savings accounts and other methods to keep their costs down.  In order to save money, these patients may not visit their physicians as much, and get sicker and then, end up in the ED with even more serious conditions. 

From the emergency medicine view, implementation of this far-reaching law will be complex and challenging.  Here are some solutions I propose for increasing affordable and timely medical care: 

Restore the existing University of Utah Medical school class size to at least one hundred students a year.  Cutting class size was short sighted and this needs to be remedied this coming year. While a longer term solution, it will keep more talented Utah college students here and provide for physicians in the future. 

Increase Utah Medicaid community clinic staffing with more same date and weekend appointments.  This will provide lower cost, timelier access for patients and decrease ED over utilization by Medicaid and other patients. Primary care physicians would lead teams of mid level providers, nurse practitioners, etc. to expand affordable access while ensuring quality of care. 

Use coordinated care counseling in the EDs to educate patients on preventative medical care and appropriate utilization, communication and continuity of care with their primary care physicians. 

Encourage insurers and hospitals to establish lower cost urgent care hospital clinics as an alternative to full emergency care. 

Expand community clinics for substance abuse and psychiatric counseling and care.  Currently, thousands of such patients are treated in EDs, each year, due to lack of outpatient facilities. These clinics would be a more effective, lower cost resource for and an alternative to the EDs.  Further, the jails and corrections facilities could also use such clinics and decrease the recidivism rates of their inmates.   

In summary, we are in a crisis regarding health care and reform.  The SCOTUS interpretation of the ACA is both a threat and an opportunity.  How we deal with this will make all the difference. 

Miracles and Tragedies

I witnessed a miracle last week.  At about 1030 AM, a 64-year-old female patient had the abrupt onset of slurred speech and left sided weakness and sagged to the floor.  Her husband immediately called the ambulance and the patient was transported to the Emergency Department. The field diagnosis was a stroke in evolution. Our ED team quickly confirmed the ominous signs of a stroke and started the protocols within minutes of arrival: Head CT, neurology consult and then, thrombolysis emergently.  After the infusion of the medicine, the patient’s headache improved, her speech was clear and coherent, her facial droop gone and she could move her left arm and leg almost normally.  The patient sustained this clinical return to her normal state and a few days later walked out of the hospital.  The family was overjoyed and grateful and all of the staff justifiably was pleased and gratified.  Medical care worked:  Smiles and high fives all around.

Last week, I witnessed a tragedy.  A 40-year-old female was brought into the Emergency Department, unable to walk.  An admitted, long-term IV drug abuser, she had developed a severe left leg infection for several months.  She never saw her physician and by the time she was treated in the ED, she had a huge left leg wound that had literally destroyed the soft tissue and eroded into the underlying tibia. The patient got immediate IV antibiotics, an ED orthopedic consult.  She was admitted and will have a probable amputation of the lower leg.  She will never be normal again and will not walk out of the hospital.  Medical care worked again and the patient’s life was saved.  The family was grateful but appalled at the outcome.

Every day, we as physicians are the unique witnesses and participants in the most important part of people’s lives:  their health care.  No one else can do what we do. We see real life miracles and tragedies in our patients.  Most of the time we can remedy their injury and illnesses.  Almost all of the time we can comfort them. Sometimes they are angry and yell at us; many times they are frustrated with their lives.  But, they always need us.

Susan Evans Mc Cloud wrote:

I would be my brother’s keeper

I would learn the healer’s art

To the wounded and the weary,

I would show a gentle heart

Recently, I met with a recently retired fellow physician, who is now doing the medical directorship of a large government health program.  A superb clinician and individual, he for decades had treated his patients with compassion and care.  Now, he was embarking on a new career:  administering to thousands of patients needs but in a new and different role.  He also remarked how as he stepped away from his practice how impressed he was with the wonderful, unique opportunity he had been given to treat patients and be part of their lives.  He gave me some wise advice: to savor and cherish the moments we have now and everyday, in our various medical practices.