Healthcare Reform Misconception - Costs are rising because of the avarice and greed or just unregulated “bad guys,” including drug and technology com

Each of these deserves some approbation and bears some responsibility at the margin, but these are not the major reasons why costs are rising. But it seems that politicians, the media and so many others seem to believe what’s convenient rather than what is accurate.

The real culprits are: 1) the poor coordination of care of those with chronic illness resulting in excess visits to specialists, excess tests, unneeded procedures and even hospitalizations, 2) overuse [often as a result of #1] of expensive drugs, devices or procedures when they are not needed or truly necessary or when a generic drug, older device or no procedure at all would be more than adequate and appropriate, 3) a wide divergence in the use of medical care and technologies based on geographic region with no evidence that those who receive “more” have better health or longer lives 4) an aging population [older people get sick more often and consume more medical care]; and 5) physicians/patients/relatives who are unwilling to accept the inevitability of death and insist on “one last try.”

6) A big driver of high costs is preventable errors. We know that at least 100,000 people die annually of safety lapses like developing a hospital-acquired infection, drug errors, or procedural errors. Many more are harmed. This lack of quality greatly adds to costs.

7) One of the biggest drivers of increasing costs over time will be our own behaviors along with a lack of preventive medicine or wellness programs. We are a nation that is obese, has poor nutrition, lacks exercise, and is over-stressed. We have dangerous habits of smoking, drinking and driving, and not wearing seat belts. Too many of us do not get immunized to common yet often lethal infections such as influenza, nor do we practice good dental hygiene. We avoid basic screenings to detect high blood pressure, high cholesterol, or cancer. Unfortunately, many government policies actually aid and abet us in maintaining these behaviors.

Add these together and our costs are higher than most other developed countries.

Misconception - Universal coverage for all Americans will reduce costs

Unfortunately that is not the case; indeed it will create substantial added expenditures. Today we spend about $7500 per capita for medical care each year. That is built into our insurance whether it is commercial or Medicare along with co-pays and deductibles. In my view it is unfortunate that Congress has not done much to address the high and rising costs of medical care in the reform bills.

America is the only country in the developed world that does not have some system to ensure everyone of at least basic medical care coverage - shame on us. The bills in Congress now will mean that another 30 million individuals will have some form of insurance – this is certainly good. And those with pre-existing conditions will no longer be denied coverage. And that is certainly good as well. But offering coverage to all will cost someone, you and me, in taxes since the newly insured will presumably now expend the same $7500 each.

Certainly it is true that access to a physician for basic medical care will mean fewer visits to the ER, less hospitalizations, and better overall health for the individual. This will mean better medical care, a healthier population and it will reduce the cost of care some but there are still substantial real costs for getting medical care to 30 million of those not insured today. To think otherwise is to ignore reality.

Misconception – Healthcare reform will fundamentally improve how we receive care going forward.

This is also not at all likely except for those who do not now have medical care insurance. For the rest of us, medical care delivery will change but it will change not because of reform but because of some fundamental societal and demographic reasons along with a marked change in the types, severity and chronicity of illnesses that is occurring right now. The combination of an aging population and our non-healthy lifestyles (obesity, poor nutrition, lack of exercise, stress and smoking) are leading to epidemics of diabetes and heart failure plus increased numbers of cancers, kidney disease and others – diseases that are lifelong, complex and expensive to treat. What reform may do is protect those of us with “pre-existing conditions” to be able to purchase insurance and do so at a reasonable premium cost. And it may put an end to lifetime limits on insurance and the practice of “rescission” or dropping a person once they develop a serious illness. But the care itself and its delivery to us will probably not change much as a result of reform.

Here is some of what will change in the coming years irrespective of healthcare reform: There will be more people with chronic complex illnesses and these will require more drugs, more technologies, more testing, more imaging, more procedures and more hospitalizations – all of which will cost more money. There will be more hospital beds constructed, more operating rooms built, more intensive care units. At the same time there will be more and more that can be done as an outpatient as or with less invasive approaches than current surgery. There will be a need for newer pharmaceuticals and medical devices; these will be expensive but capable of reducing the cost of care if used wisely. Smaller hospitals will merge into systems to access credit markets so as to purchase technology and to enlarge physical plant. There will be greater use of eMedicine – telemedicine consults, moving medical information from site to site digitally rather than by courier, telediagnosis techniques such as digital weight or blood sugar recordings from home to the doctor’s office for review daily, and electronic submission of prescriptions and with it alerts to the doctor as to allergies or drug-drug incompatibilities.

These are but a few of the changes that are coming in the delivery of healthcare during the next five to fifteen years.

Misconception – The remarkable medical scientific advances are rapidly made available to the care delivery system.

We should so hope but often that it is just not the case.

Laparoscopic surgery took medicine by storm 20 years ago but some new technologies of great value are slow to be adopted, such as simulation for teaching procedures rather than learning by practicing on the patient. Sometimes it is because the old way is “the way we have always done it” and sometimes it is because those holding the purse strings just do not appreciate the underlying value. Laparoscopic surgery got patients out of the hospital faster with fewer sequela and was endorsed by surgeon, patient and administrator alike.

Simulation – although it will markedly improve safety and quality and even shorten training times – is often perceived as just a “cost” by hospital executives and hence not worthy of investment.

Simulation was key to saving the US Airways plane last January. The captain had practiced landing with no power multiple times in the company simulator. That was crucial since there was no time 3000 feet above New York City to pull out the manual and read up on what to do. Simulation has come late to medicine but now there are many new technologies to teach students, residents and even expert physicians and surgeons. Everything from practicing drawing blood [instead of practicing on your classmate], to using an endoscope for colonoscopy [instead of learning on a patient], to very sophisticated approaches to surgery for the experienced practioneer. This is a revolutionary change in medical education and training and a very disruptive technology. It means that the trainee does not “practice” on a patient until he or she has proven competent on the simulator. For some this might take many trial runs; for others it might be much easier to master. No matter, the test is competency; not “how many times did you practice?” As a patient, you might want to know if the surgical resident assisting the attending surgeon has completed his simulation requirements; don’t be afraid to ask. And for the hospital executive, it is worth noting that simulation can actually shorten the training time required since the simulator is always available whereas the “right” patient may not be admitted until next week or later. And it means much improved patient safety since no one gets to touch a patient until competency has been demonstrated; safer care saves a lot of money.

Simulation is coming but still not fast enough given its value to trainee and patient alike.

Video Conference with Becton Dickinson – The Future of Medicine

I was recently invited to present my thoughts on the Future of Medicine, based on my book of the same name, to the worldwide medical affairs group at Becton Dickinson, the giant medical device and diagnostics company headquartered in Franklin Lakes, New Jersey. Their senior vice president for medical affairs, Dr David Durack, requested that I review the basic megatrends developing as a result of the scientific advances from genomics, stem cells transplantation, vaccines, pharmaceuticals, medical devices, imaging, operating room technologies and the digital medical record. From these I proposed five basic megatrends that will significantly impact medical care moving forward – the development of custom tailored medicine; much more attention to preventive care; markedly improved ability to repair, restore and replace organs, tissues and even cells; greater safety for patients: and, finally, digital medical information instantly available anytime and anyplace.

BD had me present via videoconferencing which eliminated the need for travel yet allowed them to see me and my slides and I could see/hear them concurrently.

Their group asked many very challenging questions after my presentation and presented some excellent concepts. They suggested, for example, that in addition to positive trends that will improve medicine, I might also consider negative trends and their impact. Examples were government instability in many developing countries, climate change, and the current financial challenges. Each could and probably already has created major adverse consequences for the delivery of medical care worldwide. Another area of interest was the implication of privacy on the development of genomic information; would having genomic data determined on yourself lead to insurance denials or higher priced premiums? A real concern of many despite the legislation that passed last year to limit this possibility. And what was the scientific basis for the use of complementary medicine approaches such as acupuncture, meditation and massage? Here we discussed acupuncture for osteoarthritis, the nausea of chemotherapy and low back pain; massage for neonates in the intensive care unit and mind body approaches combined with diet, exercise and support groups for those with coronary artery disease.

The final question was what would I write differently if doing the book over again? For that one I had an answer – updates of course and some added sections on pharmaceuticals, diagnostics and nanomedicine/biomaterials. But The Future of Medicine only dealt with medical advances, not the myriad problems of getting the new approaches to the patient. There are all too many problems with the delivery of health care today and, to compound them, there are some very powerful forces that will lead to delivery changes in the coming years no matter what happens with health care reform. This bog attempts to address these.

Misconception - “Health care reform” will improve the delivery of care and offer us better care opportunities.

In fact, healthcare reform is not about healthcare; it is mostly about paying for medical care for the uninsured and only somewhat about the rising costs of medical care. I use the term medical care here to emphasize that today American “healthcare” is all about treating disease and injury and very little about promoting wellness and preventing illness. The reforms being proposed are about addressing the financing of medical care but not the quality, the safety or the way that healthcare will be delivered nor who will deliver it given the coming shortages of professionals at all levels. Certainly it is important to assure access to care for everyone but don’t let that confuse you into thinking your healthcare delivery will be improved. It will not.

Misconception - Healthcare reform will have an impact on the advances in medical science.

This sounds logical but there are frankly amazing advances in medicine that are around the corner no matter what “reform” occurs. These advances are related to our national commitment to basic science and to engineering and computer science developments and their translation to clinical care. The National Institutes of Health, research organizations such as our medical schools, the pharmaceutical and biotechnology industries and the medical device industry are constantly bringing forth new knowledge and new approaches to care. Among them are advances in genomics, stem cells, transplantation, vaccines, pharmaceuticals, medical devices, imaging modalities, OR technologies and the digital or electronic medical record. [For more of this subject see “The Future of Medicine – Megatrends in Healthcare.”] The reforms being discussed will have little or no impact on the development of these advances; rather they are coming and they will have a major impact on the care we will receive in the near future.

Common Misconceptions About Healthcare Reform

American medicine must change - and the change will be both substantial and difficult to achieve but change is critical if we are to have a well functioning healthcare system that affords all of us safe, quality care at a reasonable cost in a customer-focused manner.

Today there are many misconceptions about healthcare reform - misconceptions about who will have access, how much it will cost, who will pay the bills, whether it will benefit those who currently have insurance, whether there will be good preventive care and good coordination of chronic illnesses, whether individuals will still be able to lose their insurance if they change or lose their jobs, whether Medicare benefits will be reduced, whether it will include rationing and whether there will be "death panels." Indeed the misconceptions like these and others are rampant and need to be addressed in a realistic, nonpartisan manner. I propose to explain what must change and why and then to dispel the misconceptions with straight forward factual information so that you can be properly informed. In the process I will explain the need to balance rights such as access with responsibilities such as leading a healthy lifestyle. Beginning with this post, I plan to review the common misconceptions, one or two at a time, entering a new post very few days until completed.

Misconception - America has the best healthcare in the world.
Sorry, but this is just not true. As stated before, we have a medical care system not a healthcare system meaning that we focus on disease and pestilence but not health promotion and disease prevention. We do spend more per capita than any other country but our quality does not measure up to what we spend. We have a higher infant mortality rate [6.9 per 1000 live births] than many countries [e.g., Japan – 2.8, France – 3.9] and our lifespan [77.9 years] has not kept up [Japan – 83, Switzerland – 82]. We have lifesaving vaccines available but they go unused by nearly 20% of infants. We are overweight with only about one-third of us at a healthy weight. About 20% of us still smoke. Regular exams are simply not regular and screenings for preventable or reversible problems like high blood pressure, high cholesterol and cancer are all too often not obtained. In short, the American healthcare system responds, and responds fairly well, to illness and trauma but is not focused on preventive medicine as the numbers above document. Further we do not have coordinated care for those with complex, chronic diseases like heart failure and cancer. These diseases cannot be treated appropriately with our current helter-skelter approach with independent physicians referring to each other as the situation warrants instead of a well-coordinated system for addressing all of the patient’s needs in an organized manner with multidisciplinary teams.

We have incredible resources in people, technology and infrastructure but we do not bring them to bear on the problems of healthcare delivery in an effective manner. This needs to change.

Mammograms as a Stalking Horse for Issues in Healthcare Reform

As we watch the reform movement in Washington, we see and hear so many misconceptions. A current one relates to mammography. A few weeks ago guidelines were published in the prestigious Annals of Internal Medicine stating, in effect, that women between ages 50 and 75 with no history of breast cancer in their family and normal mammograms to date could probably switch from annual to biannual exams. And women between ages 40 and 50 probably did not need to get mammograms as had been previously recommended unless they had certain high risk circumstances. These recommendations were made by an expert, non-partisan panel with no apparent conflicts of interest in the guidelines. The recommendations were made based on careful examination of all of the relevant data on the benefits and risks of mammography to detect early breast cancer. With a lifetime risk of breast cancer being about 9%, women need unbiased advice on what to do to detect cancer early when it is most curable. But they also need advice on when a testis not needed or can lead to unnecessary biopsies, anxieties and expense.
These newly released guidelines from the Preventive Services Task Force ignited some firestorms. The first was from various advocacy groups who have worked for years to assure that women could access mammographic screening programs annually and have the procedure paid for by insurance. Women have begun to understand the importance of routine screening and often set their exam dates by their birthday other annual event. This relatively easy approach to remembering to get a needed test has been useful but might be lost with biannual exams and this worries many advocacy groups. Second, many women chimed in saying that they developed breast cancer at a young age and it was only for the mammogram that it was found at an early stage and hence was cured. A third group, the many providers along with the manufacturers of mammographic equipment, see that reducing the frequency of mammograms will substantially impact their businesses and profits. Some smaller breast evaluation centers might go out of business altogether if procedures drop by 50% as would happen if the guidelines were fully followed. None of these groups want new guidelines that will encourage fewer women from having routine mammograms at the same schedule as formerly advised. But that was only part of the problem with the new guideline recommendations.
Those who want to defeat the current healthcare reform proposal in Congress are using these new guidelines as their "proof" that reform will mean rationing. To them, it represents the “heavy hand” of government making decisions rather than the patient or her physician. This is an excellent approach to raise high levels of concern especially in a population of individuals that tend to vote and tend to contact their elected representatives in Congress. In fact the Task Force did not suggest that insurance standards be changed although one could surmise that insurers might decide to limit reimbursement if the accepted guidelines so suggested. And so the secretary of Health and Human Services felt compelled to state that this would not impact insurance and Senator Barbara Mikulski of Maryland offered the first proposed amendment to the Senate health reform bill to prevent just such a possibility.
These firestorms erupted rapidly when in fact the new guidelines are just a reasonable attempt by a group of nonpartisan experts to offer women and their physicians the best current evidence as to what is most efficacious and least risky so that they, and they alone, can make rational decisions about care.
Truth is that medicine needs more and more efforts to assure that the care of patients is based on solid evidence. All too much of medical care is based on what we learned in medical school years ago, what we read about recently or what our personal experiences have been. This must change and guidelines from well respected unbiased experts can make a big difference in improving the quality of care.

Chronic Fatigue Syndrome Shown to be Caused by Virus

A very recent discovery may lead to significant advances for the estimated 4 million Americans and 17 million worldwide who suffer with chronic fatigue syndrome. CSF is, like its name suggests, a persistent extreme level of fatigue that does not resolve with rest or sleep. It may also be accompanied by memory lapses and other neurological issues. All too many individuals have been branded as having a “psychological problem” and as not really being ill. No cause had been known although viral infection, immune dysfunction or both had been thought possible. There has been no specific treatment.

Now researchers at the Whittemore Peterson Research Institute in Reno, Nevada have shown that CFS is likely caused by a virus. Known as xenotrophic murine leukemia virus – related virus, or XMVR, it is a retrovirus that is suspected of being transmitted by intimate human contact. The discovery means that a definite diagnostic rest can be created. And hopefully it means that scientists will be able to shortly find or create drugs to both prevent the disease and to treat those who have it. It also means that no loner will these patients be labeled as not having a real medical problem.

The researchers’ early studies suggest that perhaps 4% of us carry the virus. If proven correct, then an immediate goal is for a quick and inexpensive test to screen donated blood so that the virus is not transmitted inadvertently via transfusions. And it raises the intriguing question of why some but not all of those infected go on to develop CSF.

In study done at the Cleveland Clinic, scientists have found the same XMRV virus in prostate cancer samples. It is too soon to say that the virus is causative; if might be just a “passenger.” Additional research will be done to make a clear determination.

Meanwhile, the Whittemore Peterson researchers have suggested a new name – x-associated neuroimmune disease [XAND], a name that clarifies that this is a real disease and suggests some of its implications.

This finding of XMRV as the likely cause of CFS is a major medical advance.

Additional Advances To Expect in Medical Care

In the last post I referred to the advances in biological sciences and some in engineering and computer science. Here are some more that will have a tremendous impact on your care now and into the future.

With the improvements in imaging devices such as MRI and CT scanners, it is now possible to do many procedures much less invasively in the radiology suite rather than in the OR as before. Uterine fibroids can be destroyed by passing a small catheter [about the size of a spaghetti noodle] into the arteries that feed the fibroid. Then small particles are inserted that block off that blood supply and the fibroid basically withers away. It is a rapid procedure with minimal recuperation time, especially compared to surgical removal of the uterus [hysterectomy.] Another example is resolving an aneurysm in the brain using similar catheters without the need for open neurosurgery.
Some tumors of the brain can be successfully treated with the “gamma knife” which is designed to give a huge dose of radiation to the tumor but not the rest of the brain. It is done in one procedure and the patient goes home the same or the next day. Other new radiation therapy procedures utilize very sophisticated equipment that can deliver the correct dose of radiation to the tumor, say in the prostate, but avoid most of the surrounding tissue such as the rectum and bladder. This makes the treatment more effective yet with fewer side effects.

Slowly but surely, all medical information is being digitized. As this happens it will be finally possible to have a total electronic medical record. This will mean your medical data is available anyplace, anytime. And it will mean that if you are sent to a specialist that your CT scan is available on line and you will not have to go to the radiology office to get it before visiting the specialist. This will save you time; the specialist can make an informed opinion immediately and will mean reduced costs. There are some important hurdles to overcome before this will be a reality but I am confident that they will be solved relatively soon.

With these and other advances medical care will be more custom tailored just for you; there will be a greater focus on prevention; it will be possible to repair, restore or replace a damaged organ; your medical data will be instantly available and medical care will be safer. Big advances.

Medical Megatrends –Expect These Advances in Medicine Soon

In the book “The Future of Medicine-Megatrends in Healthcare” I refer to several medical megatrends will profoundly affect medical care advances in the coming five to 15 years. Some are due to the explosion of basic understandings of cellular and molecular biology. Others are related to improvements in engineering and computer science. Together they will create huge shifts in medicine: First, medical care will become custom-tailored for the individual patient; second, prevention will come to the fore with the medical model moving from “Diagnose and Treat” to “Predict and Prevent”; third, repairing, restoring or replacing tissues and organs will be much improved; fourth, your medical information will be available, instantly, no matter where you are; and, fifth, medicine itself will become much safer and be of much higher quality.

Here are some of the advances in biological sciences. Genomics is at the heart of many. : Drug companies will be able to develop drugs that are designed from the beginning to be “targeted” to a specific problem – custom tailored. Already there are a number of new cancer drugs that fit this model such as Gleevec for chronic myelocytic leukemia. Today a physician must prescribe a drug knowing only that it works in “most” people but not whether it will work in you nor whether you will be among those to get a side effect. With genomic information, doctors will frequently be able to prescribe a drug for the individual knowing that first it will actually work and second that it will not have unexpected side effects. That will be a major advance. Genomics is already helping to subcategorize patients with the same type of cancer into those with good or poor prognoses – the former may need less aggressive treatment and the latter more aggressive approaches. Genomics also helps in early diagnosis. Imagine taking a sample of pus and knowing in less than an hour if it is infected with “staph” and whether it is resistant to antibiotics or not – a multiday process currently. And being able to predict what diseases a person might develop later in life [e.g. heart disease or colon cancer] would mean that a “prescription” for life style changes could be started to prevent or slow the disease occurrence [e.g., diet, exercise]. Or a drug might be prescribed early in life [e.g., statin to reduce cholesterol] or a procedure begun sooner than usual [colonoscopy for the person at high risk of early colon cancer.] All of these will mean more custom-tailored medicine for you and will change today’s medical paradigm from “Diagnose and Treat” to “Predict and Prevent.” And all of this will occur regardless of whatever healthcare reform emanates from Washington.

Other scientific advances are those of immunology which are making it possible to create new vaccines and improve our ability to transplant organs. There will be more vaccines to prevent many troublesome infections such as the new vaccines that prevent the “shingles” in older individuals and rotavirus diarrhea in infants. There are already vaccines that can prevent hepatoma, a type of liver cancer caused by one of the hepatitis viruses, and cervical cancer, usually caused by the human papilloma virus. And I will predict that there will be vaccines to prevent others cancers soon such as some types of leukemias and lymphomas and perhaps stomach cancer and some cancers of the head and neck. Look for vaccines to prevent or treat some of the most important chronic illnesses such as atherosclerosis and Alzheimer’s – these will be major advances. As to transplants, some day it will be possible to transplant an organ from a pig into a human without it being rejected. No longer will someone have to wait for another person to die to receive a heart, a lung, a kidney or liver.

Engineering and computer science is also advancing medicine rapidly. The new CT and MRI scanners give incredible images of our anatomy in a completely noninvasive manner. This means that diagnosis is much easier and more accurate and a surgeon knows exactly what he or she will find during surgery – a major advance.
Simulators - like those used by airline pilots for practice – will assist trainees before they ever approach a patient and will be used to test for competency and certification.
New technology in the OR will mean less invasive yet more effective surgery with a shorter recuperation time.
And there are many medical devices that have meant a restoration of normal function for many people. Think of the new heart pacemakers that regulate the heart’s rhythm or the defibrillators that prevent sudden death. Look for major advances here in the coming years. And similar devices can be used to reduce the frequency of epileptic seizures and even assist in treating depression.
In time, all medical information will be digitized and this will mean that there will finally be an electronic medical record – one that is available anytime, any place. This will mean much better health care for you, a big improvement for the doctor and a lower cost of care.
These are but some of the advances coming in the next few years. They will mean more custom-tailored medicine, better prevention, an increased ability to repair, restore or replace damaged organs, a medical record that is instantly available anytime or place and much safer medicine. It will be an exciting time to watch as medical care improves for all of us.

World Class Health Care - An Imperative

In appropriating funds for the new Walter Reed National Military Medical Center and the new Fort Belvoir Community Hospital, Congress determined that the military should receive only “world class healthcare” but did not define the meaning of the term. When the Health Systems Advisory panel of the Defense Health Board described in the previous blog was assembled, it decided that its first order of business was to establish a benchmark for world class. After much discussion, research and debate, a document was prepared and is available at the web site listed below, in Appendix B. Here is a summary of what the panel felt were the key elements of world class.
The principal summary statement would be: A world class facility combines the best of the art and science of medicine in a focused manner, consistently and predictably delivers superior care and value, meaning high quality at a reasonable cost to both patient and society.
World class can be further defined as follows:
“A medical facility achieves the distinction of being considered world class by doing many things in an exceptional manner, including applying evidence-based healthcare principles and practices, along with the latest advances in the biomedical, informatics and engineering sciences; using the most appropriate state of- the-art technologies in an easily accessible and safe healing environment; providing services with adequate numbers of well trained, competent and compassionate caregivers who are attuned to the patient’s, and his or her family’s culture, life experience and needs; providing care in the most condition-appropriate setting with the aim of restoring patients to optimal health and functionality; and being led by skilled and pragmatic visionaries. The practices and processes of a world-class medical facility are models to emulate.”
“A world-class medical facility regularly goes above and beyond compliance with professional, accreditation and certification standards. It has a palpable commitment to excellence. A world-class medical facility has highly-skilled professionals working together with precision and passion as practiced teams within an environment of inquiry and discovery that creates an ambience that inspires trust and communicates confidence. A world-class medical facility constantly envisions what could be and goes beyond the best known medical practice to advance the frontiers of knowledge and pioneer improved processes of care so that the extraordinary becomes ordinary and the exceptional routine.”
The panel further defined all of these issues and those further comments are available at the site below. The critical point to make however is that world-class is not just about buildings, not just about people, not just about technology, not just about specific practices but it is about how all of these and more are interwoven together for the benefit of the patients and the patients’ loved ones in a manner that delivers superior care at a reasonable cost.
These are recommendations that all hospitals [and their boards of trustees] and providers across the country should consider and consider seriously. Nothing less should be acceptable.
http://www.health.mil/dhb/meetings/NCR%20BRAC%20HSAS%20Report%20-%20Final.pdf

World Class Health Care at Walter Reed

Last fall I was asked by Maryland Senator Benjamin Cardin to join a group evaluating whether the new Walter Reed National Military Medical Center [WRNMMC], when completed in a few years, would be “world class.” The group, a subcommittee of the Defense Health Board, met multiple times to learn about the plans and develop a report for Congress. The report is now available at http://www.health.mil/dhb/meetings/NCR%20BRAC%20HSAS%20Report%20-%20Final.pdf . Here is a brief summary. The Base Realignment and Closure Commission [BRAC] determined five years ago that the current Walter Reed should be closed and the functions moved to two facilities. One would be a community hospital and outpatient facility at Fort Belvoir, VA just south of Mount Vernon. It would give primary and secondary care to active and retired military that live in the southern half of the national capital area. The other would be on the grounds of the current National Naval Medical Center in Bethesda, MD just northwest of Washington. This conjoined facility would be renamed the WRNMMC and would have multiple functions. Primary and secondary care for those military personnel who live in the northern half or the capital area; tertiary care to those from throughout the region and total care for the wounded warrior.
We found that the Fort Belvoir facility was well designed but that the new WRNMMC had some definite deficiencies. Here is a summary. There was never a master facility plan for the campus which currently houses multiple functions and has many older buildings that over time should be replaced in an orderly manner. There was not a “demand analysis” completed to determine what the needs would be in to the future. For example, with the wars in Iraq and Afghanistan, would there be need for more, less or different OR configurations? With a growing retired military population in the area, what would be the new needs? Instead, a static approach was used, shifting the current functions at Walter Reed to the two future facilities. We also found that there would be no in-house simulation laboratories for learning OR procedures, cardiac cath or GI endoscopy techniques. In a modern hospital these are critical and must be immediately adjacent. The campus has externally mandated constraints on parking, logical from a local roadway perspective but not recognizing that staff from one shift cannot leave until the staff from the next shift has arrived – this means more spaces, not fewer. There is a METRO stop at the corner but in the winter it is a long walk to the hospital – some type of tunnel or people mover is needed to encourage ridership.
The report just went to Congress and to date the following has occurred:
House -- FY10 Defense Appropriations
“Medical care in the National Capital Region - The Committee continues to be concerned over the impact of care in this area with the consolidation of WRAMC and Bethesda Naval. Congress’ independent evaluation of DoD’s comprehensive plan was positive, for the most part. They await DoD’s 30-day assessment of that review’s findings and recommendations.”
Senate -- FY10 Defense Appropriations - Amendment by Senator McCain “Requirement for a master plan to provide world class military medical facilities in the National Capital Region” - agreed to by unanimous consent.
It is encouraging that Congress is taking the report seriously.

Maximizing Rights with Responsibilities to Enhance Access and Reduce Total Costs

Healthcare reform was supposed to be about both access to care and reducing the cost of care. So far it is only about the former and the new costs look to be huge with only a portion of the uninsured actually benefiting. As to cost reductions, the only suggestions have been mostly just about reducing payments to providers with the assumption that they can figure out how to provide good care with less funding. That is not a strategy but just a tactic – and it will backfire.
There does need to be a way to reduce costs and the way to do so is a combination of rights and responsibilities related to the development and the care chronic illnesses. It is possible to reduce health care expenditures without rationing and without draconian across the board cuts to providers. Much of the rapid rise in costs is due to the increase in chronic illnesses that last a lifetime and are expensive to treat – heart failure, diabetes with complications, cancer, etc. Over 70% of healthcare costs go to treat these individuals who are only about 15% of the population. And these illnesses are increasing in prevalence as the population ages and as we persist with adverse behaviors such as smoking, over eating, lack of exercise and stress.
Chronic illness should be addressed from two perspectives – coordinating the care of those who are already ill and preventing new illness from occurring. Both will reduce costs and improve the quality of life.
What has become very clear is that chronic illness needs intensive care coordination to prevent unnecessary specialist visits, procedures, tests and even hospitalizations – the source of excess expenditures. Primary care physicians [PCPs] are in the best position to coordinate care but do not do so because they are not reimbursed for the effort. They receive about 5% of the healthcare expenditures but can have a major impact on the other 95%. Changing the reimbursements to PCPs with the proviso that they coordinate care would have an immediate impact.
Workplace wellness programs that offer reductions in health insurance payments in return for healthy behaviors reduce over-all costs and improve the health of the workforce. Safeway, General Mills and others have convincing data on the value of wellness programs. It’s an incentive toward healthier living.
Similarly, insurance policies should have variable rates for behaviors and preventive medicine – not smoking, weight control and obtaining simple screening tests like blood pressure and cholesterol would mean lower premiums.
Combining rights [access to insurance at lesser cost] with responsibilities [live a healthy life style] for patients and rights [increased pay] with responsibilities [coordinate care] for PCPs will have a major impact on the total costs of care and do so quickly.

Care Coordination in a Retirement Community – Better Care at Lower Costs

Older individuals tend to have more complex chronic illnesses and they need lots of preventive care. The Erickson Retirement Communities determined to learn if attentive primary care would lead to better quality care, better quality of life and yet lower costs overall. By way of background, their basic goal was to improve the quality of life for their residents – good marketing. So they built in nutrition, exercise and other programs for the residents who live in a campus-like setting. Yet they found that their biggest failure from the retirees’ perspective was medical management. The Community hired a physician who initially spent about thirty minutes with each patient’s visit. The word got around and more and more residents signed up for his care. Once that happened he had to cut back until he was seeing each patient for about ten to twelve minutes per visit. And so the residents were again not satisfied. So the Community hired additional full time primary care physicians and paid them enough in salary over what Medicare paid so that they could afford to take the needed time with each patient. It quickly became apparent that the residents liked this approach but it meant only about 400 or so patients per physician rather than the national average of about 1500+ for a primary care doctor. It was more expensive up front but Erickson found that the number of hospitalizations for this group declined by about 50% suggesting that good coordination of care was effective in not only increasing satisfaction and quality but also in reducing costs. Of course, the reduction benefited Medicare but Erickson still had the extra expense of the added physicians to make the program work. Erickson then went to Medicare and petitioned for a demonstration project. To date over four thousand retirees in multiple retirement communities joined this Medicare Advantage program. The results again confirmed the value of good care coordination, the value of a computerized medical record and orchestration of chronic care by a primary care physician who could spend adequate time with each patient. At one retirement center, inpatient hospital days dropped from a national average of 2096 per 1000 Medicare enrollees per year to less than 500. And since these retirement communities generally have older residents, age adjusting the data meant that it was equivalent to only about 200 hospital days per enrolled resident. Another key metric is an unplanned return to the hospital shortly after discharge. The national rate for Medicare recipients is near 25% but the Erickson plan has kept these to less than 10%.They found that one key to success was having the primary care physician be the “orchestrator” among all of the patient’s specialists, being sure that the patient’s medications were appropriate, not mutually adverse, and in the correct dosage for a geriatric person. The primary care physician attends the resident when hospitalized, bringing the patient’s electronic medical record to the hospital on the doctor’s laptop. [They found that if the patients were cared for only by the hospital-based hospitalist, the tendency was for the acute problem to be well managed but for other issues to get out of control leading to longer lengths of stay and various complications.] As a result, they can assure that the individual continues to get appropriate care for all of their needs, not just the one problem that sent them to the hospital this time. Care coordinators are used as well but in tandem with the primary care physician who has the needed time with each patient. They conduct regularly scheduled programs of health management. There are behavior modification courses as in employer-based wellness programs but also specific programs for monitoring, coaching and prevention for specific high risk diseases. To reiterate, the program provides what a typical primary care physician either does not or cannot provide today [although most would like to provide.] It includes the behavior modification programs, plus the monitoring and coaching for patients with cardiac, chronic lung, diabetes and other diseases found in wellness programs sponsored by employers. To this is added aggressive management of these complex chronic diseases with close care coordination from their very beginning rather than when they become problematic later on. There is extensive use of non-physician providers which helps to keep the costs down but the contact level high. In short it is a wellness program, a care management program and a disease management program all rolled into one.

Disease Prevention For All And Care Coordination For Those With Catastrophic Illness

The care coordination described in the previous post is a major part of the new CareFirst Blue Cross Blue Shield plan. But there are three other important components.

First, the PCP will receive increased compensation for all of his or her CF-insured patients, not just those with complex chronic illness. Hopefully, this will be enough to assure that every patient gets the time and attention needed for the best possible care. It also means, hopefully, that the PCP will be less inclined to quickly refer to a specialist rather than taking the time needed to sort out the patient’s problem [This happens a lot today and drives ever more specialist visits.] By the same logic, it is anticipated that the physician will do a more complete history and physical exam, negating the need for more tests and procedures. The result is better care for the patient, a more satisfied patient since the doctor will not be in a “rush” and a more satisfied physician. Better care at lower total cost.

Second, CareFirst recognizes that over 90% of their clients remain with them year after year so it is financially logical to try to assure good preventive care. This will cost more today but should pay off in the years to come with lower costs because the patient will remain healthy. So in this new practice arrangement, CareFirst will pay for any preventive/ screening program/ test that is well defined by evidence. This might include cholesterol measurements, mammography and colonoscopy and it might include dietary consultation, or a smoking cessation program. As an added incentive to get this type of preventive care done, CF will waive any co-pays or deductibles that the patient might have to otherwise pay.

Finally, it is recognized that some small percentage of patients will develop a truly catastrophic condition such that the PCP can no longer easily coordinate the care. These are the 5% of patients that consume a very large portion of the healthcare dollar. This is the patient that must be referred to a specialty center or an academic medical center, have major surgery or perhaps receive an organ transplant. My own observations over the years demonstrate that these are the types of patients who get less than the best possible care because the hand offs and referrals among providers are less than satisfactory. This is where quality breaks down, where safety issues arise, and where all too often excess tests and procedures get done. And since no one is orchestrating the entire care program, the patient is left with well intentioned caregivers but less than the best care.
In this situation, CareFirst will develop an incentive-based relationship with the specialty provider – probably a hospital system – to assure care coordination. The hospital system will assign a “navigator” to each such patient. The navigator will have the responsibility to be sure that the care of the patient within the system is well coordinated, just as the PCP does in the community setting. This navigator will work the interface among the myriad specialists, departments, even hospitals and centers that the patient must utilize for his or her care. The result could be much better care quality yet at a substantially reduced total cost.

The whole concept here is to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It will mean a real change in how the primary care physician functions – a change from being an intervener to be an orchestrator. And a major change for the hospital system in that it will need to become an orchestrator as well, not just a place for specialty care. And it is a change for the insurer, one that accepts that care coordination and disease prevention costs money but recognizes that the end result is better care at a lower cost. This plan uses various incentives to align needs – we could say that it gives rights but with corresponding responsibility.

One Approach To Improving Care Coordination While Assisting PCPs

Good care coordination will improve the quality of care for the individual patient and yet will reduce costs by eliminating excess visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. With primary care physicians [PCPs] not able to take the time necessary, it is clear that something needs to be done to get care coordination for those with complex, chronic illness.

Here is what one insurer, CareFirst Blue Cross Blue Shield [CF] of Maryland, DC and portions of Virginia is planning. CF knows that about 65% of their medical expenditures go towards the care of just 5% of patients and 80% go for about 15%. These are patients with catastrophic problems in the 5% and complex chronic illnesses for the remainder. CareFirst also knows that primary care physicians receive about 5% of total healthcare expenditures yet they are in a position to impact the other 95%. So the agenda is to create incentives for them to do so in a way to reduce that total while improving the care of the patient. It would work like this [somewhat oversimplified to account for space limitations here.]

PCPs would form into groups of 5 to 10 and enter into an agreement with CareFirst. In return CareFirst would increase their reimbursement by 15% for each visit. There will be another 5% increment in return for using an electronic system provided by CareFirst that will assist with billing. This system will check their submissions, do edits and corrections and then submit the claim to CareFirst [or any insurer], all automatically and electronically. I am told it is easy to use and will greatly improve the doctor’s office productivity thus creating savings. No longer will there be claims denials over billing errors or the need to repeatedly resubmit until the claim is remediated – it will be correct the first time. In addition, Carefirst will agree to pay the physician within one business day, dramatically reducing the need for working capital.

CareFirst will do an analysis of the PCP group’s patients using claims data from the prior year. CF will be able to “flag” the 15% or so of patients that need care coordination.
The PCP’s obligation in this new system is to give the patient whatever added time is needed per visit and to create a good care plan and post it in an electronic medical record. This will serve as automatic preauthorization, no further calls to CF will be needed for tests, procedures, etc. – another major time saver for the PCP and his or her office staff. When the patient needs to see a specialist, the PCP will refer the patient but also call the specialist and clarify expectations and review the results of the referral when done. Finally, CareFirst will make available a “care coordinator” [a nurse] to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever that the PCP has built into the care plan. If the care coordinator cannot resolve an issue or sees a developing problem, she will report in to the PCP.

The expectation is that this approach of incentives for giving the patient the care coordination needed will enhance quality yet reduce the overall expenditures for that patient’s care.

To further add to the incentives, CareFirst will do an actuarial analysis of the expected claims for the coming year for the PCP group’s patients. If, at the end of the year, the patients have had fewer claims, CF will give back a portion through yet higher reimbursements. With this added incentive, it is anticipated that the PCP will be sure to carefully coordinate care so that there are no excess specialist visits, no unneeded tests or procedures and, with better care overall, less hospitalizations. The end results, hopefully, will be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Of course, the devil is in the details but it seems to be a worthy plan, one that might just have a real impact. It appeals to me because it begins with an attempt to improve quality and improve the PCPs situation as a means of reducing costs – rather than the other way around.

Improving Access to Primary Care and Coordination of Complex Chronic Illness

Primary care physicians find that their income is flat or declining despite rises in practice costs such as office expenses and malpractice insurance. They generally are in small groups so they have little or no negotiating power with the insurers. And antitrust requirements prevent them from banding together for negotiating purposes. The insurers see their costs rising so they look for ways to keep expenses down, including payments to PCPs.
In order to maintain income levels, they resort to many techniques. One, of course, is to see more patients per day but each for less and less time. This means they spend all too little time taking a through history or physical and instead send the patient off for expensive tests and X-rays or to specialists for referral. If a patient cannot get through to their PCP and instead goes to the ER for an urgent problem, the patient will probably spend hours there and the costs will be much more. The ER physician does not know the patient, does not have access to the old record and as a result feels obliged to obtain multiple tests and images to make the proper diagnosis. This is “nuts” – the person’s PCP might have been able to solve the problem quickly, with fewer or no tests. Better, quicker care for the patient and less expense for the insurer.
PCPs also try to increase income by arranging for tests to be done at their office like stress tests. A technician arrives with the equipment and does the test for which the PCP gets a fee. Are more tests done than truly necessary? Should these tests be done only in consultation with a cardiologist and under their supervision?
Something needs to be done to alleviate these problems. Somehow the PCP needs to have an incentive not to have too many patients and to spend the time needed with each patient. This means a higher per visit reimbursement. But it needs to come with incentives. PCPs receive about 5% of the medical care dollar but can and could greatly affect the other 95%. So there need to be techniques tried to allow and encourage the PCP to give good preventive care, counsel about important issues, meet their patients at the ER, use email and the phone more [neither are currently reimbursed] and coordinate care when the patients needs to be seen by a specialist or have a test or procedure. Coordination of care is especially important for the 5-15% of patients who have complex chronic illnesses and hence need a team of providers to give care. The “team” needs to actually function as a team and it will do so only if someone is orchestrating its work. Primary care physicians need to change from the long held practice of being interveners to being orchestrators, especially for their patients with chronic diseases. This will be a culture change but it will also require monetary incentives – it will not occur otherwise.

A Crisis in Primary Care

We are entering if not already in a crisis of primary care. Each of us needs a competent, caring and available primary care physician but that is less and less possible. Many can’t find one; others cannot afford one; and others have one but cannot get adequate time and attention from him or her. PCPs will tell you that they do not have enough time with each patient; are overwhelmed with paperwork and mandates; and are earning less and less per year. There are about 1000 graduating physicians entering primary care per year in the USA but about 3-4000 retiring. Average income after about ten years in practice of $150,000 has been stable or decreasing for some years while the costs of practice including staff wages, rent and utilities, malpractice insurance and supplies has been rising. Most medical school graduates have about $155,000 in debt to pay off. To make ends meet and retain the same income, PCPs are seeing more patients with longer days and shorter visits. This is not good for them and it definitely is not good for you. Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system.
To counter the problem, more and more PCPs are taking steps to increase their income while decreasing the number of patients seen per day. Some approaches are frankly disappointing such as the doctor with a sign in the waiting room that you may “only raise one problem per visit.” A colleague told me last week that her internist is no longer taking Medicare. She will have to pay for each visit. Perhaps not a problem if you only go for an annual exam and then once or twice for minor problems. But if you develop a complex chronic illness that requires multiple visits it could add up quickly, especially for someone on a fixed income in retirement. Other PCPs are opting for “retainer-based” practices, sometimes called concierge or boutique practices. Here you pay $1500-2000 [or more] per year and in return your PCP reduces his or her practice from 1800 patients to 500 and guarantees that you can be seen the same or the next day, that he or she will be available by cell phone and email 24/7, will visit you at home, will meet you at the ER as needed, and will care for you in the hospital and the nursing home. And each visit will be as long as needed for you and your issues. This is the way it used to be and is the way it really should be now but is not. Another advantage of this type of system is that it becomes a true relationship again between the doctor and the patient with the patient contracting directly for services from the physician – not through a third party. The downside, of course, -- this is extra money out of your pocket since you will still need your insurance for specialists and hospitalization.
What is clear is that the current system does not work and either PCP reimbursements by insurers will go up or more and more PCPs will either retire early or switch to retainer-based practices.

Putting It Together To Bring Down Costs

President Obama is working hard to address the issues surrounding health care in the USA. Two days ago he hosted a group representing many of the major providers such as physicians, hospitals and pharmaceutical companies. They promised to work to reduce the rate of rise of costs of care over the coming ten years. No specifics were given out. Here is what I would suggest as the first steps.

If we take the comments from my last few blogs and put them together, we see that a few critical forces have come together to push up the costs of care. To be sure, there are other reasons for the rising cost of care and I will address them in later blogs. But these few are they key ones and are the ones to aggressively address now if we are ever to slow the rise of expenditures much less actually bring them down. Here they are:

Our population is aging – simply stated, “old parts wear out.” We have bad behaviors – poor nutrition, overweight, lack of exercise, stress and tobacco with many of these starting in childhood. Both age and behaviors are leading to the development of complex, chronic diseases [heart failure, diabetes with complications, cancer, etc]. This is much different that the acute illnesses that we generally think of such as appendicitis or pneumonia. In those cases a single physician can treat them and the result is a cure. But these chronic illnesses once developed persist for life and they require the expertise of many providers.

These chronic diseases are expensive to treat – today they consume about 70% of all US health care expenditures although this care is going to only about 10% of the population.
But our care system is poorly coordinated and this results in far too many doctor visits, procedures, test and even hospitalizations. That is the reason for the excess costs and these could be brought down with resulting improved quality of care, safer care and more satisfied patients.

What is needed, more than anything else, is a cadre of primary care physicians [or sometimes specialist a physician] to carefully coordinate the care of those with chronic illnesses. Without question, this approach will bring down costs.

Sounds simple and is in concept but the reality turns out to be not so easy

Personal Behaviors That Damage Our Health

A very important reason for medical care cost escalation has to do with our own personal behaviors. We are a country of people who are overweight --one-third are overweight and one-third or more are frankly obese --, under-exercised, poorly fed from a nutritional perspective and highly stressed. And it gets worse each year. Even children have progressively declining physical activity from about three hours per day at age nine to less than an hour by age fifteen. And this will correlate to obesity beginning in adolescence. Twenty per cent of us still smoke tobacco. These are some of the major reasons that medical costs will rise in the future. Diabetes will accelerate to epidemic proportions, heart disease will follow, arthritis will be exacerbated by obesity, life spans will be shortened and along the way there will be enormous medical bills to pay. We need a government that encourages good health, regardless of the economic interests that such a program will affect. It will mean less fatty food, less red meat, less whole milk and cheese on our pizza, less sodas [and everything else made with high fructose corn syrup], less prepared and take out meals and more home cooking, more whole grains (whole wheat, brown rice, oatmeal) and a real change in the cereals sold in supermarkets. We need to shop the periphery of the supermarket and leave the aisles with all the prepared foods alone. We still smoke in high numbers with all too many teenagers picking up the habit. They will incur the wrath of lung cancer, heart disease, chronic lung diseases and others in the years to come. And we must finally come to accept that weight gain is a function of the number of calories consumed minus the number expended by exercise. That’s so simple but apparently so difficult that we try all sorts of diets that ultimately don’t work but cost lots of money and frustration. Chronic stress is a cofactor in heart disease, back pain, gastrointestinal disorders and many others. Some alcohol may be good for our heart but it is never good to drink and drive yet all too many do so. At the same time many people do not wear their seatbelts. Add up all these adverse behaviors and they have a very marked effect on the diseases that occur – chronic, complex diseases that last a life time and which are very expensive to treat.

Lack of Care Coordination

The switch from acute to complex chronic diseases and the wide variation in care patterns are closely related. It is the complex chronic diseases that need the most attention and hence are most expensive to treat. But as a country we have long had the tradition of the independent, autonomous practioneer in the community taking care of us. This was fine for acute illnesses. The physician could either treat you him or herself or else would refer you to a particular specialist for needed care. Maybe to the surgeon to remove your appendix or gallbladder. Once the surgery was done, the problem was “cured.” Not so with chronic illnesses. Often the patients need multiple physicians, each with different skills and expertise such as the cancer patient would need a surgeon, a radiation oncologist and medical oncologist. But these three and the primary care physician are not likely to be well coordinated. They may have offices in different parts of town and possibly use different hospitals for some of their work. Communication is weak and the PCP often does not feel able to serve as the coordinator or quarterback. And, since these chronic illnesses often occur in older individuals, there is a good likelihood that other illnesses will develop concurrently. Maybe high blood pressure, heart failure or diabetes with complications. And so off to more specialists who do not communicate well and who do not understand the implications of the other illnesses, the other medications, etc. the result is often extra doctor visits, extra procedures, tests and X-rays and even extra hospitalizations than would have been necessary with well coordinated care. Unfortunately, this is the way medicine is practiced today and it is a real problem. It means that care is not as good as it should be or could be, not as safe as it should or could be, not as customer [patient] friendly as it should be or could be, and it means that it costs far too much.

Care Costs Vary By Geographic Region

When thinking about health care reform it is important to realize that there are wide variations in care expenditures from geographic region to region. One might assume that those regions with higher expenditures reap better health but that is simply not the case. Unfortunately, much of medical care is not delivered based on evidence of efficacy but rather on long standing practice, tradition or training many years before. Indeed there is some pretty firm data that suggests that where there are more specialists, and where there is “more capacity” that it will get used more and drive up the total cost of care. Some very interesting studies coming from Dartmouth Medical Center have tracked this over the years. In a recent analysis of Medicare data from 2001-2005, the Dartmouth investigators looked at the last two years of life for Medicare recipients with complex chronic diseases such as heart failure, kidney failure and dementia. They picked those two years of life because they account for about one-third of all Medicare expenditures. What they found was a wide variation in costs or expenditures due to a wide variation in the use of services such as specialists, intensive care unit days, hospital days and so on. And this related directly to local medical care capacity. Where there was more capacity, there was more use and therefore higher expenditures. On average these Medicare patients each accounted for about $46,000 of expenditures by Medicare during those last two years of life. But in states with high capacity like New Jersey the average expenditures per patient were $59,000 and in an area like North Dakota where capacity is relatively low the average expenditure was $33,000. Certainly a wide difference and yet they could find no significant difference in the quality of care or patient outcomes. So they made a suggestion. If the use rate across the country was equivalent to the use rate in Minnesota, which is also where the Mayo Clinic is located, Medicare would have saved $18 billion per year for each of the years 2001-2005. They were not suggesting trying to bring it down to the North Dakota expenditure rate but they were suggesting that there was no reason why it could not be brought down towards the national average, an average which just about everyone would agree can produce a very effective medical result. The Dartmouth investigators pointed out that the “variations allow us to rule out two overly simplistic explanations for spending growth. First ‘technology’ is clearly an insufficient explanation: residents of all US regions have access to the same technology.” Second, these regional differences cannot be caused by “differences in the current payment system” since they all were on fee for service Medicare plans. “The causes must therefore lie in how physicians and other respond to the availability of technology in the context of the fee-for-service payment system.” They studied physicians in various regions and were able to show that physicians in all regions recommended specific evidence-based interventions for similar problems. But those in high consumption of resources areas were much more likely to recommended discretionary services, such as referral to a subspecialist for typical esophageal reflux. It was this use of discretionary services that resulted in the wide variation in per capita spending.

Complex, Chronic Illnesses That Last A Lifetime

Our medical care system has developed around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gave an antibiotic for the pneumonia and the patient got better. The surgeon cut out the gall bladder or the appendix and the patient was cured. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that remain with the individual for life and these diseases and patients need a different approach to care. These patients need long term care, not episodic care; they need a team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers to allow for a unified, coordinated care management approach. And these diseases are very expensive to treat today; 70% of our medical care expenditures go to treat 10% of us, those with these chronic illnesses of health care costs in America. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs. But the new approach actually exists in some locations – the need is to understand what works and then replicate it nationally.

America Has a Sick Care Not a Health Care System

We Americans like to pride ourselves as having the best healthcare system the world but unfortunately that is not the case. We have a medical care system, not a healthcare system. We give lip service to prevention and spend only about 3% of our $2 trillion in medical expenditures on public health. By many measures we do not rate favorably compared to many of the other industrialized societies. As citizens we have behaviors that are driving more and more illness, illnesses that at chronic, complex, lifelong and life shortening. That $2 trillion is by far more than other nations spend per capita and it is seriously and adversely affecting businesses, government and each of us. Meanwhile, we may be pleased with our doctor but not the delivery system as a whole. Quality is subpar, preventable errors are rampant and some 47 million of us are without insurance access to medical care – the only such industrialized country. Health care reform is now a topic of great interest but politicians and media focus on the access issues predominantly, cost issues somewhat and the quality, safety and prevention/ public health needs only rarely.
Let’s take a closer look at what we have today. The current system of care focuses on “disease and pestilence.” It is a disease oriented system and certainly not a health management system nor a patient-oriented system. Mostly, this is due to a reimbursement methodology that under-rates the generalists and tilts toward those that do procedures. That is not what we need; what we need is a payment system that rewards the generalist for working in rural or socio-economically deprived areas, for taking the time to listen to the patient, for being attuned to prevention and wellness management. Today, that is just not where we are in America. So we need a change to a system that is focused on disease prevention, health promotion and with ready access to primary care and providers. Then, when necessary, access to specialists, hospitals, rehabilitation and all of the other requirements for good medical care when disease or injury does occur.

Embryonic Stem Cells and the Future of Transplantation

Stem cell therapies promise to be one of those true scientific breakthroughs that will have an impact on health care in the future. Stem cells will bring us closer to the goal of personalized medicine, just as genomics is doing. With stem cells, projections need to be five, ten, even fifteen years out – because this is truly an emerging science. The course of a disease will change once we have the technology to insert stem cells into the human body to actually create a tissue. For example, a person with a heart attack will not go on to live the rest of his or her life with damaged heart muscle and resultant heart failure. Instead, stem cells will regenerate the heart and make it whole again. Similarly, a person with Parkinson’s disease will recover full faculties thanks to the ability of stem cells to regenerate the damaged area of the brain. The person with type I diabetes will be free of the disease because of the formation of new pancreatic islet cells. The athlete will play again because new cartilage will be created for the worn knee. This is the promise of “regenerative medicine.”
It is a promise that is already being kept with adult stem cells used for treating patients with immune defects, usually children, or those with some cancers. Sometimes doctors use the patients own stem cells to give the bone marrow a “boost” after intensive chemotherapy for cancer [called autologous transplants.] Or the stem cells of a closely matched donor are used for a leukemia patient to not only restore the bone marrow after aggressive therapy but also to attack any remaining leukemia cells [known as allogeneic transplants.]. And adult stem cells are being used today in research studies of patients who have had heart attacks leaving their heart muscle weakened.
The president has just created an important enablement to further research on stem cells. Yes, it is true that much can be done with adult stem cells but science so far suggests that embryonic stem cells hold promise for much more benefit. It will probably be embryonic stem cells that pave the way for replacing the islet cells of the pancreas with new insulin producing cells to cure diabetes or replace the damaged cells in the brain that are key to Parkinson’s disease. Some strongly feel that it is wrong to use cells form embryos. It is important to remember that these are fertilized eggs that were prepared for couples that could not conceive and so had eggs and sperm placed into a dish with special fluids. Experience has shown that success is better if the doctor implants a few embryos into the woman’s uterus rather than just one. But the doctor may have more than enough embryos and the extras will be discarded if the woman becomes pregnant. I look at it this way. Since the embryos will be destroyed anyway, why not use them for creating stem cells that perhaps many people with diverse diseases might benefit from. It is not dissimilar to transplanting the organs of a person who has died in a car accident rather than burying them in the grave. And there is no issue about “human cloning” – that is just not what is being done or proposed. And the embryo, made up of just a few cells, is disrupted so each cell grows independently. Now the cells can be stimulated to become heart cells, liver cells or what ever might be useful in treating a disease. It will take some years but there will certainly be major advances in how we can repair, restore or replace damaged tissues or organs.

Electronic Health Records

President Obama as part of his health care reform agenda is aggressively pushing the electronic health record [EHR]. will be a major improvement to medical care and to patient safety over time. But there are two major problems that need to be overcome before the EHR will ever be fully functional – interoperability and physician documentation. By interoperability I mean that each of the companies that produce the software do so in a proprietary manner. The result is that they cannot interact. So if a patient is discharged from one hospital today and goes to another hospital’s ER tomorrow, the information from the first hospital will likely not be accessible. This must change and it appears that the federal government is attempting to have standards established for all to follow. That will be a big improvement. There are issues however as to who should set the standards – government or a multidisciplinary working group. Either way, standards are needed.
The second obstacle is that physicians find that most of the current systems actually impede productivity rather than enhance it. This is because the software creators have not spent the time necessary to understand how physician work and are intent on making the document easy to manipulate by the computer. Here is an example. Say a doctor admits a patient with pneumonia. He or she might want to insert the following into the chart: “55 year old nonsmoking male, sudden onset of high fever, shaking chills, productive cough and pain at left lower chest with inspiration. Temp 103, pulse 94, BP 128/74, abnormal breath sounds and dullness to percussion in left lower chest. Chest X-ray shows infiltrate in left lower lobe and sputum exam shows gram positive diplococcic. Diagnosis – pneumococcal pneumonia. Treatment – antibiotic.” Sorry for some “doctor speak” but in essence this is a fairly classical description of a pneumococcal pneumonia. It takes about 30 seconds to say, the same to dictate and perhaps 60 seconds to write or type these words. But to enter it into the chart as per the dictates of the software takes much longer because it requires following a long branching tree of choices. You might liken it to using Word for a document that can be read later versus Excel for a spreadsheet that can be manipulated. Physicians really dislike the extra time it takes and the fact that it is not consistent with the way they “think” about the patient and his or her problem. So they rebel and will not adopt. But this problem, like interoperability, can be overcome.
Once these two issues are resolved, the EHR can become a reality, but not before.