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.
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).