Tuesday, December 29, 2009
Healthcare Reform Misconception - Costs are rising because of the avarice and greed or just unregulated “bad guys,” including drug and technology com
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.
Wednesday, December 23, 2009
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.
Monday, December 21, 2009
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.
Wednesday, December 16, 2009
Misconception – The remarkable medical scientific advances are rapidly made available to the care delivery system.
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.
Monday, December 14, 2009
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.
Saturday, December 12, 2009
Misconception - “Health care reform” will improve the delivery of care and offer us better care opportunities.
Friday, December 11, 2009
Wednesday, December 9, 2009
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.
Monday, December 7, 2009
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.
Wednesday, October 21, 2009
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.
Tuesday, September 1, 2009
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.
Wednesday, August 19, 2009
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.
Sunday, August 2, 2009
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.
Sunday, July 26, 2009
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.
Monday, July 20, 2009
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.
Monday, July 13, 2009
Sunday, July 5, 2009
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.
Sunday, June 28, 2009
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.
Thursday, June 11, 2009
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.
Monday, May 25, 2009
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.
Tuesday, May 12, 2009
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
Saturday, May 2, 2009
Wednesday, April 22, 2009
Thursday, April 9, 2009
Sunday, March 29, 2009
Thursday, March 26, 2009
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.
Tuesday, March 10, 2009
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.
Thursday, March 5, 2009
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.
Praise for Dr Schimpff
The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.
-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).