Friday, May 14, 2010
Prevention is the key to both better health and lower health-care costs over the long haul. This is where the nation — and each of us as individuals — needs to put energy and resources. In the long run, it is more important than addressing the high cost of new technologies and drugs or their inappropriate overuse.
Today, the U.S. basically has a medical care system rather than a health care system: We focus on treating illness when it occurs but not on preventing it in advance.
According to a recent New England Journal of Medicine article, there are about 465,000 preventable deaths per year in the U.S. from smoking, 395,000 from high blood pressure, 216,000 from obesity, 191,000 from inactivity, 190,000 from high blood sugar, and 113,000 from high cholesterol.
These are mostly due to our lifestyles: One-third of Americans are overweight, another third are obese, and 20% smoke. We eat too much packaged and prepared food rather than nutritious foods, and we do not exercise. Even children's physical activity now declines with age, from about three hours per day at age nine to less than an hour by age 15.
This helps explain why the U.S. ranks 39th for infant mortality, 43rd for female mortality, 42nd for male mortality, and 36th for life expectancy — but is first for per capita spending on health care.
Clearly, there is something terribly wrong with this picture. And unless we get serious about prevention, there will be a diabetes epidemic and more heart disease, cancer, arthritis and other chronic illnesses. Life spans will shorten rather than lengthen, and the costs will be enormous.
I firmly believe that each of us must each take responsibility for our own preventive health care. That said, other players in society should assist us in the following ways:
Our government should insist that restaurants post calorie counts and fat content and schools restrict the availability of sodas and other non-nutritious foods in cafeterias. In addition, it can provide a food pyramid — recommended diets or eating plans — that is not influenced by vested interests.
Our employers should provide wellness programs like Safeway's, which encourages staff to utilize smoking-cessation, weight-reduction, stress-management, and nutrition counseling at no charge. Those who participate are given a reduction (incentive) of their portion of the health care premium. In a Wall Street Journal op-ed describing the program, CEO Steven A. Burd reported that over four years Safeway's per capita health-care costs (including both the company's and employees' portions) did not rise while those for most American companies had increased 38%. In addition, the company had less absenteeism and higher worker productivity.
Insurance plans should offer subscribers lower premiums for not smoking, for being at reasonable weight, and for exercising.
Physicians, especially primary care physicians, should spend the time necessary to provide good preventive medicine, which includes counseling, screening tests (high blood pressure, weight , cholesterol, cancer), and immunizations.
Prevention is valuable at any age. At the Erickson Retirement Communities, residents can opt for a program that includes health-promotion classes for all (similar to Safeway's) and care coordination for those who do develop a chronic illness. The physicians limit themselves to about 400 patients (compared to about 1,300 to 1,500 for most primary care physicians) and offer same same-day visits and as much time as needed per visit. They use an electronic medical record system, nurses to assist with care coordination, visits to each hospitalized patient, and an automatic office visit within 72 hours of a hospital discharge. The results are striking: fewer hospitalizations, shorter lengths of stay for those who are hospitalized, and a drop in the "bounce rate" (i.e., unplanned readmissions to the hospital in the 30 days after discharge) from the national Medicare average of (an outrageous) 24% to less than 10%. In other words, better health, better care and reduced costs.
In summary, a combination of nudges and incentives can assist us in achieving our responsibilities for health promotion and disease prevention — responsibilities commensurate with the new right of all Americans to have insurance.
This would be a start toward a true health care system and away from a medical care system. What else do you think needs to be done?
Stephen C. Schimpff, MD, is a retired CEO of the University of Maryland Medical Center in Baltimore and is the author of The Future of Medicine — Megatrends in Healthcare. He blogs at this website and can be reached at firstname.lastname@example.org
Tuesday, May 4, 2010
Retainer Based Practices – Primary care physicians find that their incomes have been flat or reduced, their work hours increased, their time with each patient shortened and their frustrations with insurers heightened dramatically over recent years. Some are just saying “I can’t take it any longer” and switching to a different type of practice model. Some simply will not accept Medicare, telling their older patients that they must either pay out of pocket or go elsewhere. Others are converting to “retainer-based” practices. Here the patient pays a flat fee each year, often $1500 to $2000, in return for having their PCP available by cell phone 24/7 and responsive by email. Appointments within 24 hours are guaranteed. The physician will see you in the ER, take care of you in the hospital and do home or nursing home visits as needed at no extra charge. But you still need your insurance in case you have need to see a specialist, have tests or imaging studies or are hospitalized. So the cost to you is extra. This is very disruptive of the standard approach today but I predict it will become very common in just a few years.
Smart Phones – Physicians, especially younger physicians and residents, are becoming very reliant, although not dependent, on these devices. They use them as shortcuts to knowledge, to stay well informed, and to communicate, argue, and debate with one another, which is a excellent form of learning. Smart phones keep being refined and as they are, more and more physicians want them, use them, rely on them and become more effective physicians as a result.
Greater Clarity with Imaging – Today’s CT scanners and other devices can produce remarkable images of the body’s internal organs, better than those of a medical illustrator. And the clarity of the images increases dramatically each year with engineering refinements. Virtual colonoscopy using a CT scan, for example, can now be done in a manner such that the viewer can see a high resolution magnified image of the inside of the colon, capable of visualizing small details of a polyp, a diverticula or other anomaly. It can be projected on a large TV screen where a group can review it together and jointly consider the situation and make recommendations for care of the patient.
Surgical Robotics – Today the daVinci robot is used primarily for cardiac surgery, prostate cancer surgery and some gynecologic surgery. But soon it will be used by other surgeons in diverse fields. An otolaryngologist for example, might perform surgery on the base of the tongue to remove a cancer while avoiding the critical nerves and blood vessels in the area. The visualization of the site is much better than with conventional surgical approaches, the margin of safety is improved and the patient’s outcome is bettered with more effective surgery, more salvage of critical anatomy and faster recovery. These refinements in the use of the robot will likely lead to considerable demand from both patients and physicians.
Image Guidance – We tend to think of “X-rays” as being used for diagnostics and the newer technologies have dramatically improved this ability. But think of the surgeon who “wants no surprises” once inside and operating. The greatly improved ability to visualize organs makes no surprises a near reality. But the imaging can also guide the surgeon to improve on his or her technique during the procedure. Intra-operative CT scanning can be used intermittently and at low dose to assist the surgeon to know the location of critical vessels or nerves. Ultrasound can be used to give real time direction to the placement of radioactive seeds into the prostate to treat cancer. These and similar image guidance techniques improve safety and effectiveness.
Fewer General Surgeons – It has been known for some years that there are too few general surgeons; fewer are entering the field and some areas, especially rural and urban poor areas, have all too few general surgeons today. The reasons for the reduced interest of graduating medical students is not completely clear but the trend is obvious.
Reduced Career Time as a Minimally Invasive Surgeon – Laparoscopic or minimally invasive surgery spread across the country and the world with remarkable speed after its introduction some 20 years ago. The patient has smaller incisions, faster recovery time, less time in the hospital and the costs are lessened as well. Surgeons rapidly learned the techniques and patients demanded it. But there is a price not fully expected. Surgeons are developing a variety of occupational problems from carpel tunnel syndrome, to neck disorders, to low back pain. It is all about ergonomics – “the patient is better off but the surgeon is suffering.” Indeed it may well be that their practice lifetimes may be substantially curtailed unless these ergonomics issues are addressed and quickly.
There are many changes coming in medical practice and these are but a few. The ones noted here will have significant and ultimately disruptive effects on the way medicine is practiced today and tomorrow.
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).