Universal Health Care – Pay While You are Healthy

The fear uncertainty and doubt over the issue of providing healthcare to everyone in the US is debilitating. And consider the range of special interests who reject the notion and fear any solution that involves the government. The recent press conference by President Obama (full text here and on the whitehouse blog in video format) while focused on the economy mentioned healthcare (17 times by my count) as the underlying problem:

the biggest driver of long-term deficits are the huge healthcare costs that we’ve got out here that we’re going to have to tackle and we

And

But it is — it is going to be an impossible task for us to balance our budget if we’re not taking on rising healthcare costs

And

…the reason it’s hard is because we’ve accumulated a structural deficit that’s going to take a long time, and we’re not going to be able to do it next year or the year after or three years from now. What we have to do is bend the curve on these deficit projections. And the best way for us to do that is to reduce healthcare costs. That’s not just my opinion. That’s the opinion of almost every single person who has looked at our long-term fiscal situation.

Naturally the reactions were wide and varied but I think he’s right about the healthcare cost issue and the need to focus on this. The proposal he floated at the recent healthcare forum was a Medicare like insurance plan to anyone at any age concurrent with commercial insurers offering private insurance. The detail was covered in the NY Times Piece: Health Plan for All and the Concerns It Raises that detailed the inevitable rejection by the insurance industry:

But the insurance industry and others wary of too much government intervention vehemently oppose the idea. They say the heavy hand of the government will eventually push out the private insurers, leaving the government option as the only option. That is why the industry seems unwilling to give ground on the issue, even while making other concessions to national health reform — like the industry’s announcement on Tuesday that it might be willing to stop charging sick people higher rates than healthy customers.

Interesting that finally there is some focus on the terrible circumstance that the uninsured and sick people find themselves in. The issue of the costs for uninsured patients was highlighted in a compelling episode of “30 Days” by Morgan Spurlock (of “Supersize Me” fame) titled Minimum Wage. The series was simple – take on a specific circumstance and live it for 30 days. Morgan did with his girlfriend living on a minimum wage (summary and the episode here). As he said

We don’t see the people that surround us. We don’t see the people who are struggling to get by that are right next to us. And I have seen how hard the struggle is. I have been here. And I only did it for a month, and there’s people who do this their whole lives.

and Alex his girlfriend who unfortunately developed a Urinary Tract Infection that required treatment said:

Even if you are among the “working poor”, and working two jobs at even above minimum wage, you’re still just barely gonna make it, and God forbid anything happen to you. It’s really, really, really hard

They just about coped but it was the healthcare costs that drowned them. Alex’s urinary tract infection required an early morning trip to the ER to be seen and receive a prescription for antibiotics that they had to fill at CVS across town for $20 – this on top of 1-2 days of not working. Morgan hurt his wrist but had to keep working as he had no sick time and that made his wrist worse. He tried to use a free clinic but it only took 20 people and he was number 35. A days wage lost and still no treatment. He eventually had to take a trip to the ER where he got a $40 ACE bandage. With no insurance and hence no cap or control on the bill their total bill was around ~$1,000 or put another way three months salary.

It’s no wonder the insurance industry is vehemently opposed to any intervention that might provide alternative choices to the outrageous bills leveled on individuals who have no insurance. This was very much the principle behind Jay Parkinson‘s service that he started offering some time back in NY and has since moved to Williamsburg with Hello Health. Providing affordable access to healthcare to everyone and identifying the best suppliers of drugs, procedures and health care services for his patients.

For the healthcare providers there is a tremendous fear that the price pressure of such a system will bring them to their knees. This process has already driven down the time available to see patients to ~7 minutes……why because to maintain income if the price paid per unit falls you need to do more units (in this case units = patients).

The trouble with all these methods is we value the healthcare received incorrectly based on activity without focus on prevention and keeping people healthy. The system is complex, stocked full of a wide range of special interests and groups that have and want to continue to make great money from the system. The system is also full of many well intentioned clinicians and care givers who struggle to maintain their income and deliver the service that their patients need and want – it’s a mess.

So here’s a radical thought that I have no doubt will raise a few eyebrows and there will undoubtedly be a host of people suggesting reasons why it might not work but here goes:

Hark back to days gone by in Chinese villages where the villagers paid the medicine man when they were healthy. When they fell ill they stopped paying until they were better and able to work again.

• Incentive – keep patients healthy – check
• Compensation – reasonable and paid based on population under care – check
• Cost – see above based on reasonable level set for population cared for – check
• Catastrophic coverage – check
• Shared insurance risk – check

I know too simplistic for our complex world today but you have to admit there is a certain elegance and beauty to the proposal. Like it, hate it have ideas on how to make it better – leave your comments

The EMR – Value add or not?

A recent opinion piece in the Wall Street Journal this week Obama’s $80 Billion Exaggeration created a veritable firestorm of comments and was possible one of the most active discussions I have seen on one of the listservs I belong to. The writers were responding to the claims made from the recent Health Care Group (also referred to as a summit – but since this did not seem the “highest level” I think group is a more accurate term). The claims:

…the national adoption of electronic medical records — a computer-based system that would contain every patients clinical history, laboratory results, and treatments. This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.

As the authors stated there are

there are real benefits from electronic medical records. Physicians and nurses can readily access all the information on their patients from a single site. Particularly helpful are alerts in the system that warn of potential dangers in the prescribing of a certain drug for a patient on other therapies that could result in toxicity

But at issue is do “these benefits translate into $80 billion annually in cost-savings?”. And certainly of more concern were the specific issues of additional errors introduced as a result of these systems and lack of data to support the increase in quality of care post implementation of these systems and after Doctors are burdened with checking off scores of boxes on the computer screen to satisfy insurance requirements, so called “pay for performance.”

But again, there are no compelling data to demonstrate that such voluminous documentation translates into better outcomes for their sick patients. As one commentator put it

I don’t think you can honestly disagree with the comments about the poor signal-to-noise ratio of electronic notes

True and the EMR has the potential like many technologies to increase the noise and make some of the noise poorer quality but this depends very much on the usage and the way in which the technology is incorporated.

There was some suggestion that the major drive behind the changes and the EMR related to fraud and the identification of fraud. This raises some significant concerns on the part of clinicians who already feel challenged by the burden of data capture and entry asides from the need to practice of defensive medicine. The addition of a further level of scrutiny focused on tripping up the beleaguered physician is a major concern. There is fraud and unfortunately a need to search and identify cases but to many upstanding responsible clinicians feels very much like a very broad brush that catches good and bad alike. This report from ONCHIT Report on the Use of Health Information Technology to Enhance and expand Health Care Anti-Fraud Activities (caution pdf) from 2005 estimated that in 2003 $51 Billion was lost to fraud (and could have been as high as $170 Billion). So there is warranted focus on fraud prevention but this should not be a focal point and does create an element of mistrust – the best analogy I can offer is having the IRS providing everyone with personal financial systems to replace Quicken for instance. I suspect many would be uncomfortable trusting the IRS with all our personal data not that we are trying or intending to commit fraud but as we capture and monitor our own finances not all of this information is relevant or something we would want ot share with the IRS.

But putting aside the challenge of fraud systems in EMRs many of the groups and chats I follow most are in agreement that EMR’s offer the potential to improve the quality of care, making it safer and better. But technology is just a part of the equation and just focusing on medication errors misses the bigger picture of fixing the a more systematic approach to the whole process that includes tools, checklists and decision support systems. This was covered in an thoughtful piece in the Journal of the American Medical Association (JAMA) titled: Diagnostic Errors—The Next Frontier for Patient Safety (unfortunately a subscription is required to access the full text) by David E. Newman-Toker, MD, PhD; Peter J. Pronovost, MD, PhD.

it’s high time for diagnostic errors to get the same attention from medical institutions and caregivers as drug-prescribing errors, wrong-site surgeries and hospital-acquired infections (the technological and cultural lower hanging fruit of safety reform)

Many weighed in to say that there was much personal and anecdotal experience to suggest the value that could be linked to some obvious benefits of the EMR associated with easier and more ready access to information – detailed here from one author:

suggesting that EMR’s do not help with diagnostic decision support is overlooking all of our anecdotal experiences….this is not studied well at all, but I think that the most important type of decision support, while not very exciting or complicated, is having all the data at your fingertips. In the past with hit or miss medical record availability, long delays in receiving old records even when available, and illegible notes, clinicians were making both diagnostic and therapeutic decisions on incomplete data. Almost all clinicians that have practiced in a system that can provide old data within seconds as compared to maybe hours to days, if available, feel that they make better  diagnoses and treatment decisions with the availability of that data. This is not something that is easy to prove, but I think that most would agree is true.

This is fair comment and there is data to support the value of EMR’s – this study: RTI Report on Data Quality in EHRs, released nearly 2 years ago (pdf) and the summary here and included some recommendations on how to avoid EHR-mediated fraud.

The consensus was that EMR’s do provide value, just perhaps not $80 Billion savings per year. Questioning the financial justification for investments in these systems is appropriate and the piece in the WSJ article does just that. The authors in this case want more data to justify these large investments and to help derive the most value from the necessary and inevitable changes to our healthcare system

So do EMR’s offer value – absolutely and as patients, clinicians, healthcare professionals we should be asking that this technology is part of what is included in the changes and updates to our healthcare system. Let me know what your experiences are as a consumer of these systems as a patient or healthcare provider – good or bad.

Incentivise Healthy Behavior

Stephen Colbert “the Word” segment – this time on “Share the Wealth”. He sees a silver lining to the Obama Policy on Healthcare – Here’s the link

Joking aside there is an interesting thought in this piece – providing care should come with some demands on personal behavior. Self destructive unhealthy behavior has significant consequences and finding some way to incentivise healthier behavior as part of providing complete coverage has some merits.

Is that really possible – it is fraught with problems and issues but Adam Bosworth floated a similar concept some weeks ago at TEPR (The Changing World of Healthcare) providing cash incentive’s to the population to encourage weight loss. Radical thinking, but in terms of value for money he made a compelling argument that this would pay of handsomely in the future given the high cost of treating diseases later in life.

Blogging Makes you Happier and Healthier

Apparently proven by science! A study from Taiwan that administered a self-reporting tool to about 600 college students found they felt “better social connections”

• sense of greater social integration
• an increase in social bonding
• social bridging

Not all that surprising as this is just another variation on well worn advice of sharing of problems and worries :a problem shared is a problem halved. There is historical research that supports this base don personal writings (the diary for instance) and even when the content is made more public

when people share their innermost thoughts of their moods or feelings with others through writing, they may gain greater social support and improve their social relationships and feelings of connectedness

Especially important when people blog on personal challenges and int he case of a friend of mine ePatientDave (his blog and twitter feed) he described his blogging and ability to share the experiences efficiently as a big benefit to the his healing process as well as the therapeutic effect of sharing knowledge learned with others and learning from others in similar circumstances. It has clearly been so inspiring for him that he’s started up another work related blog – No Lines, No Waiting that offer advice on getting the most out of your time including age advice for employment in the downturn. There are many other support networks and infinitely more available than they used to be in the days of visiting your local hospital in search of the photocopied list of support groups!

Patient’s Like Me is a great Place to Start assuming it has a group for your area of interest but if not as in all cases these days – Google is Your friend to finding a relevant support group to join

Do you know any others that are helpful starting points – if so please post comments and links