Personal Health, Telemedicine and Access Collide

Props to HISTalk for coverage of the San Francisco Telemedicine case. There is no doubting the tragic loss of a young life to suicide (19 year old Stanford Student committed suicide) but the background to the case and in particular the telemedicine element emphasizes the archaic nature of laws and practice of medicine which may be nominally one country but behaves as though it were 51 states (I know 50 states plus a district but that behaves like a state albeit without “representation”). This is not a commentary on the treatment choices but about the surrounding legislation for the practice of medicine across state lines.

A lot of medication is prescribed over the Internet…..Can California regulate it in this fashion? … No out-of-state telemedicine provider has ever been jailed for practicing medicine in California

Best practice aside the litigation does not address the fundamental problems and why a 19 year old would be accessing an on line pharmacy for prescription drugs and even the reasoning behind such a choice. That aside the basis of the lawsuit is the Colorado doctor’s lack of license to practice in California….. he is licensed to practice in Colorado. Seems a license to practice in Colorado should be sufficient unless there is some disease, condition or drug that is unique to California that requires additional testing, licensure and validation to ensure that the doctor meets the necessary quality standards in ANOther State. It is bad enough that the International possibilities that used to be associated with a career in medicine have diminished over the last 50 years but it would seem that we are now placing artificial barriers up to the practice of medicine across state lines…..why?!

Current laws allow for:

…state law allows out-of-state doctors to practice “telemedicine” through the Internet or interactive audio or video transmissions, as long as they act in consultation with a licensed California physician.

Again this is archaic regulations and the only reasonable explanation must require that we “follow the money”… this is not about safety, quality of care or any other mantra.

Like Mr HisTalk I agree – we should be focusing on streamlining the regulations, standards and privacy requirements rather than creating a web of complicated and artificial reasons to prevent the application of technology to allow for telemedicine and remote treatment and diagnosis.

Lets hope this will be a part of any reform packages proposed – time for the US States to step out of the dark ages and catch up with the times and at the same times addresses some of the disparities in cost (and quality) that exists across state lines (some quality reports suggest better value for money paid in one state vs others) and even international borders (drug costs that are 77% higher in the US for comparable drugs).

Healthcare US vs UK Comparison

There are many comparisons of the US and UK health care system but there is hardly a UK citizen living in the US that does not worry that the nightmare described in this essay “Fragile American Dream – Part 1 and Part 2….

It boils down to the catastrophic coverage and end of life issues that have yet to be addressed or resolved. For those who grew up in the system there is probably some degree of concern but a vague acceptance that this the way it is. Rising costs as featured in the rising costs here manifest in escalating drug costs, covered to some extent by the insurance while you have it but at some point when it is either no longer possible to be employed (age or health reasons) you enter the nightmare scenario

Then came the day that I had to give up work, I worked for a Company who treated me very well when I retired. However this is when the American Dream started to turn into a nightmare. I was eligible for 6 months free medical coverage then a further 6 months at a cost to me of what the Company paid; a substantial hike, especially on an income reduced by 40%. After this period something calls COBRA kicks in for one more year and this is when it gets really expensive, approximately 3 times more than the cost the Company was paying but I would still have coverage. When COBRA runs out, effectively I am uninsured, yes there is Medicaid, but from what I have found out it is not easy to get coverage even with a terminal disease. I have overhead enough hardship discussions for people being treated at my Oncologists surgery to understand that everything has to be “battled for”. With a pre-existing condition it becomes almost impossible to get Insurance, some Insures say they will do it, but the cost for good coverage becomes prohibitive.

As the author states luckily he has a choice albeit less than ideal – leaving the country and returning back to the UK for treatment that will not bankrupt him and his family. He finishes with this statement

the UK has many faults but at least the NHS is a safety net for when
things go seriously wrong, unlike out here when effectively you are on
your own.

And that pretty much sums it up…….. there is no effective safety net in the US.

Community Clinics Expanded Providing Essential Care

The NY Times article on President Bush’s health care legacy that has expanded the number of community health care access clinics providing much needed primary care to undeserved areas:

In Mr. Bush’s first year in office, he proposed to open or expand 1,200 clinics over five years (mission accomplished) and to double the number of patients served (the increase has ended up closer to 60 percent). With the health centers now serving more than 16 million patients at 7,354 sites, the expansion has been the largest since the program’s origins in President Lyndon B. Johnson’s war on poverty, federal officials said.

The effort is a great start and while this alone will not solve health care problems it is an imperative to reducing costs and providing ready access to health care everyone. The cost reduction comes in at least two forms, the reduction in costs associated with treating the sequelae of chronic diseases as they manifest from neglect and poor primary care but also the reduction in the unnecessary use of urgent care or Emergency Department visits which have ballooned in the last several years as seen in the McKinsey Report on US Health care Spending featured here

The centers serve 1 in 3 people living below the poverty line and 1 in 8 of those without insurance. It is a relative bargain ($8 billion) against other spending initiatives and the high cost associated with coverage plans and subsidizing insurance coverage. Better yet – if the trade associations are to be believed they save money by reducing unnecessary care and spending in the urgent care system (hospitals, ED’s and other access points)

Unfortunately this needs to be tied to a wider program that links the great care delivered by the front line of medicine – community or general practice to the inpatient, urgent and specialized care that has plenty of facilities but for the most part out of the reach of those unlucky enough to warrant the follow up or additional care for conditions that are outside of the capabilities of the community care health system.

This program should be expanded and be a core component of any future plans to help solve the problems of health care. Primary care is the bed rock of good health care and providing ready cost effective access for everyone will help improve the population’s health as well as controlling and decreasing costs.

Invest in Healthcare Technology

Bill Hersh – the Chair of Informatics at Oregon Health and Science University wrote an oped piece in the Oregonian on investing health care technology

The latest address from President Elect Obama suggest we must invest to prevent errors and save money but as Bill says IT investment does much more than that

The better use of health IT can improve quality, reduce errors, empower
patients and control costs through the use of electronic health
records, decision support systems, telemedicine, and other
technologies.

There is also a lot of job creation and re training that would benefit the economy and help mitigate some of the job losses in other industries. Oregon is poised but so are many other areas and the time is right – lets hope these words turn into actions that will drive the change that the healthcare industry has been crygin out for

cut out the middle (man) doctor – order your own lab tests…good idea?
http://ping.fm/w8kcb

Happiness is Contagious

Latest research published in the BMJ yesterday (Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study) proves that happiness is contagious and spreads from people to others around them

relationship between people’s happiness extends up to three degrees of separation (for example, to the friends of one’s friends’ friends)

So surround yourself by happy people and be a happy person – this is in social networks and not seen with coworkers. The “silver lining” is that unhappiness is not as contagious and has a weaker effect….

Happiness clustering and linkages represented graphically (or download as a ppt):

NICE Measures – How much is life worth

The National Institute for Clinical Excellence has been grappling with the issue of the value of life for some years in the United Kingdom. Other countries watch with great interest given the limited pot of resources available to treat the population. In the recent article in the NY Times British Balance Benfit vs Cost of Latest Drugs detailed the impact on one patient who’s treatment was

…at that price, Mr. Hardy’s life is not worth prolonging….decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

Which in this case created a storm and additional reviews. All this came out of the Viagra problem…. a new drug in a previously untreated group of problems – erectile dysfunction at a very high cost. The NHS placed restrictions and set in process the inevitable chain of law suits and access demands and rights. NICE became the formal independent mechanism to provide this judgement. As individuals we dislike these systems and they seem unpalatable when linked to individual cases but the concept is a necessary part of medicine and is really an extension of the Randomized Controlled Study designed to determine effectiveness scientifically. Clinicians face these issues daily and some are willing to make decisions, some are not but in all cases there does need to be some review. The world has a limited set of resources and applying those for best effect are one of the critical challenges facing humanity and in particular the medical profession over the coming months and weeks.

As customers, patients and consumers we have to participate in this process. Until such time as resources become unlimited these decisions will be made and it is better to be a participant and understand the decisions and even help influence and shape them than be a bystander. Learn about the choices, listen to your doctor and health care professional and help them to help you in making the right choices.