Posts
Today America does not have a true healthcare system that focuses on wellness and disease prevention. Rather it focuses on disease diagnosis and treatment paid for on a unit basis. Each visit, each procedure, each test, each drug, each hospitalization is charged for. The result is more and more units of care are given rather than a focus on how to give good preventive care and how to coordinate the care of those with complex chronic illnesses. As long as we have a disease industry – driven by our current payment system – we will have rising costs. It is inevitable because providers (and the affiliated hospitals, pharmaceutical firms, medical device manufacturers and others) will find new ways to diagnose and treat – and although these new approaches might be an improvement over what we have today it will also be much more expensive.
Eventually, as pressures mount, there will be a push for a change to a true healthcare system from the current disease-based system. This will probably take a fair length of time given that Congress did not address the payment system in the healthcare reform legislation. Basically on this point, they left it as just more of the same.
But there could be a breakthrough. Some group, some organization or some jurisdictions might create a model, gain some success and that might lead to wider adoption. Some of the large multidisciplinary “clinics” like Mayo, Geisinger, Dean and others which have contracts for “covered lives” have had success in giving more comprehensive care yet reducing costs. And some insurer/provider combined organizations – such as Kaiser-Permanente – have shown the same beneficial effects. Perhaps others will begin to adopt their examples toward better health care at lower cost.
Showing posts with label healthcare reform. Show all posts
Showing posts with label healthcare reform. Show all posts
Thursday, June 24, 2010
Wednesday, January 6, 2010
Misconception– Health care is or should be a right – not a privilege and not a responsibility
During the presidential debates, Tom Brokow asked “is healthcare a right, a privilege or a responsibility?” The candidates did not answer the question but now would be a good time for Congress and the Obama Administration to balance the rights being offered as part of reform with corresponding responsibilities.
We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don’t work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed - unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests - all of which lead to higher total costs of care.
Howard County, Maryland has instituted a program that offers the uninsured access to primary care for a minimal fee along with specialist care given pro-bono and hospital care for no charge. But in return, each patient works with a health coach to develop a set of goals for the year such as weight control, smoking cessation, exercise enhancement or stress reduction. Patients also are expected to receive appropriate vaccines and obtain basic screening such as checks for high blood pressure. The health coach assists the patient to overcome barriers to success such as helping to find a free smoking cessation program or an inexpensive gym. Patients have been pleased with the program and responded well to the responsibility element. It is a model worth emulating.
Congress is rightly seeking to assure all of access to care regardless of ability to pay. It is not inappropriate for the tax payer to expect the individual in return to lead a reasonably healthy lifestyle as a means to not only maintain and improve health but to lessen the cost of care. Congress also plans to ban the practice of insurers excluding individuals with predisposing conditions. A reasonable expectation [responsibility] in return is that everyone participates in insurance so as to keep the risk pool large and the costs down. In another pairing of rights with responsibilities, commercial insurers and Medicare should be able to incent patients to hold down costs with premium reductions for those who do have an appropriate weight, do exercise, do not smoke, do get their vaccinations and do have screenings done.
Primary care physicians should be able to have a reasonable income without a huge patient load nor the necessity of short visit times but in return the insurer/payer should be able to expect excellent preventive services and good coordination of the care of those patients with chronic illnesses. In this model, both doctor and insurer each have their rights and each their responsibilities, resulting in better care, healthier patients and reduced total costs to the system. Government, and therefore the taxpayer, in accepting the responsibility of universal coverage for those who cannot afford it should have the right in return of a reasonably healthy lifestyle by those covered. The result is better health with lower costs over the long term.
This combination of rights and responsibilities can assure that everyone has access to care and incentives to better health. Yet, it will reduce expenditures through improved quality and eliminate many of the current frustrations with the “system.” It satisfies the legitimate arguments of those who insist that medical care is a right with the equally important argument that we all have to accept a meaningful level of responsibility for our health and its costs.
We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don’t work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed - unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests - all of which lead to higher total costs of care.
Howard County, Maryland has instituted a program that offers the uninsured access to primary care for a minimal fee along with specialist care given pro-bono and hospital care for no charge. But in return, each patient works with a health coach to develop a set of goals for the year such as weight control, smoking cessation, exercise enhancement or stress reduction. Patients also are expected to receive appropriate vaccines and obtain basic screening such as checks for high blood pressure. The health coach assists the patient to overcome barriers to success such as helping to find a free smoking cessation program or an inexpensive gym. Patients have been pleased with the program and responded well to the responsibility element. It is a model worth emulating.
Congress is rightly seeking to assure all of access to care regardless of ability to pay. It is not inappropriate for the tax payer to expect the individual in return to lead a reasonably healthy lifestyle as a means to not only maintain and improve health but to lessen the cost of care. Congress also plans to ban the practice of insurers excluding individuals with predisposing conditions. A reasonable expectation [responsibility] in return is that everyone participates in insurance so as to keep the risk pool large and the costs down. In another pairing of rights with responsibilities, commercial insurers and Medicare should be able to incent patients to hold down costs with premium reductions for those who do have an appropriate weight, do exercise, do not smoke, do get their vaccinations and do have screenings done.
Primary care physicians should be able to have a reasonable income without a huge patient load nor the necessity of short visit times but in return the insurer/payer should be able to expect excellent preventive services and good coordination of the care of those patients with chronic illnesses. In this model, both doctor and insurer each have their rights and each their responsibilities, resulting in better care, healthier patients and reduced total costs to the system. Government, and therefore the taxpayer, in accepting the responsibility of universal coverage for those who cannot afford it should have the right in return of a reasonably healthy lifestyle by those covered. The result is better health with lower costs over the long term.
This combination of rights and responsibilities can assure that everyone has access to care and incentives to better health. Yet, it will reduce expenditures through improved quality and eliminate many of the current frustrations with the “system.” It satisfies the legitimate arguments of those who insist that medical care is a right with the equally important argument that we all have to accept a meaningful level of responsibility for our health and its costs.
Monday, January 4, 2010
Healthcare Reform Misconception - Giving patients more control of their healthcare expenditures will lead to lower costs
It makes good sense to have all of us more involved in our healthcare decision-making and with that its payments. But individuals purchase healthcare in a manner unlike any other purchase. Patients or their loved ones do not “shop” for the best price the way they shop for a new washing machine. They shop for the best [as they understand it] physician, hospital, etc. Mostly they accept the advice of their personal physician as to drugs, surgery or rehab. That said it makes sense to have high deductible policies with or without health savings accounts or medical savings accounts (HSAs/MSAs.) We should not be fooled that these will necessarily lead to substantially more prudent purchasing as their proponents believe. Their real value is to give individuals the opportunity to purchase care with pretax dollars, a nice saving, and to help put insurance back to being true insurance for catastrophic expenses and not prepaid total healthcare as is most insurance today.
The biggest drivers of costs are related to the lack of preventive care for many of us and the lack of good care coordination for those of us with complex chronic illnesses (e.g., heart failure, diabetes with complications) as discussed in the previous post. These will not be affected much if at all by patients having more “skin in the game.”
But the more we know about our medical care costs and the more we ask our providers why a test, a drug or a procedure is necessary then the more likely it becomes that there will be a reduction in total costs. Being more directly invested in the costs of our care will ultimately have a market effect. This is particularly important when told to get a test, X-ray or drug. Ask your physician if the test is really important or is just being done to “be complete” (i.e., avoid malpractice litigation.) Will the results really effect what the doctor decides to do next? And as for drugs, is a drug what is needed or is it a life style change such as Lipitor versus a change in diet and exercise? Or is a generic available? Or another drug that is equally as effective as the branded drug? It is our money so it is important to have these discussions. Unfortunately, as patients we still have an information gap relative to our provider and we tend to accept advice without questioning – this needs to change and being directly responsible for dollars spent may just provoke that change.
The biggest drivers of costs are related to the lack of preventive care for many of us and the lack of good care coordination for those of us with complex chronic illnesses (e.g., heart failure, diabetes with complications) as discussed in the previous post. These will not be affected much if at all by patients having more “skin in the game.”
But the more we know about our medical care costs and the more we ask our providers why a test, a drug or a procedure is necessary then the more likely it becomes that there will be a reduction in total costs. Being more directly invested in the costs of our care will ultimately have a market effect. This is particularly important when told to get a test, X-ray or drug. Ask your physician if the test is really important or is just being done to “be complete” (i.e., avoid malpractice litigation.) Will the results really effect what the doctor decides to do next? And as for drugs, is a drug what is needed or is it a life style change such as Lipitor versus a change in diet and exercise? Or is a generic available? Or another drug that is equally as effective as the branded drug? It is our money so it is important to have these discussions. Unfortunately, as patients we still have an information gap relative to our provider and we tend to accept advice without questioning – this needs to change and being directly responsible for dollars spent may just provoke that change.
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
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.
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
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.
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 14, 2009
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.
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.
Friday, December 11, 2009
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.
Wednesday, December 9, 2009
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.
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
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.
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.
Thursday, June 11, 2009
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.
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.
Thursday, April 9, 2009
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.
Thursday, March 5, 2009
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.
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.
Subscribe to:
Posts (Atom)