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

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

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

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

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

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

Misconception - Universal coverage for all Americans will reduce costs

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

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

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

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

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

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

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

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

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

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

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

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

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

Video Conference with Becton Dickinson – The Future of Medicine

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

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

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

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

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

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

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

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