Legal Reform is Essential

Philip Howards Talk over at TED Talks is not focused on healthcare but the legal systems impact on society in general: Four Ways to Fix the Broken Legal System. It is 20 minutes long but worth watching in its entirety:

There’s a phenomenon that General Counsel is becoming CEO’s of companies because they need so much legal counsel

It applies to all areas of society. Law suits are out of control.

Healthcare system has been transformed into defensive medicine
Reliable estimates wasting $60 – $200 Billion wasted per year

Lawyers say the fear of law suits provides for better care – research says it does not. Doctors fear speaking up and talking to each other and fail to communicate. It spans environmental review that prevents any progress.

You can read the article on Tort Reform in the US here.

Take a stand, insist on change to the legal system and a full-scale reform of US law to free society.

Abuse of Resources – Its Everyone’s Responsibility

I spent the last weekend up to my neck in organizing a local soccer tournament with 280 teams, hundreds of games and thousands of participants. Weather challenged our scheduling with severe thunderstorms and rain but we managed to pull off most of the tournament and get everyone to play their games.

We had some injuries including at least one fracture to an arm, some cuts bruises and even some concussions. Local services provide excellent coverage and I have experienced the great response and work when I refereed a game when one of the players fractured their leg in a hard tackle. The local ambulance crew arrived quickly, drove onto the field to collect the player and took them to a nearby facility and where they received excellent care.

Since I am part of the tournament staff and easily identified I get included in much of what is going on. In once such instance one of the facility organizers stopped me to tell me that the medical crew were pulling in to the back to deal with the bee sting. I was immediately concerned thinking about anaphylactic shock and followed her outside to meet the ambulance crew and the police escort to get them across grass fields. The local facility staff meets the crew and says:

She’s inside

Wait a second I just walked out from there and I did not see anyone lying comatose on the floor? Did I miss something? We proceeded inside and I look at the patient. An middle aged lady sitting on a chair with one foot partially obscured with a bag of ice……..!

My initial thought is there’s some mistake the patient must be in a room nearby. But no – this is the bee sting patient. The detail was correct – it was a patient with a bee sting. A bee sting on her foot.

This is an abuse of the system. Its inexcusable. I challenge anyone to provide me with any reason that could possibly justify calling an ambulance for a bee sting to the foot. There is no anaphylactic shock problem. There is no transport issue here – for anyone to have arrived at the facility they had to drive or be driven.

This is inexcusable and there seems no other way to curb this wasteful selfish behavior that by imposing financial penalties. That individual should be required to pay for the cost of the ambulance, the crew, the park escort and any subsequent treatment she received in the Emergency room – at the full rate. No insurance coverage or subsidies.

Unfortunately that position is a slippery slope and will quickly lead to the requirement to justify every call for an ambulance and visit to the ER. Fine in such cases of flagrant abuse but what happens when its not so clear cut or the patient believes with the best intentions it was the right call. We want to err on the side of best choice and care without inhibiting those people that genuinely need these services but are afraid to call for fear of punitive charges.

The only solution I can see is have an independent body determine justifiable use. A body that is not linked to the payors, service providers or patients. Clear guidelines and a quick independent process for review and arbitration of cases that are not clear cut.

Maybe this is already in place. No doubt it can and will be abused – but if we cannot take our own persona responsibility then we can hardly expect the insurance companies to accept this level of abuse of coverage and to pay up for in appropriate use of expensive emergency services.

Litigation in Healthcare – The Two Sides to the Pond

I like Dr Crippen’s blog and enjoy reading his posts and commentary. He typifies the long suffering British doctor in many respects. He rails into waste as in this post on the ridiculous expenditure by Essex health commissars (!!) insisting on spending who knows how much on educating the population that they should eat more fruit and nuts. As Dr Crippen says:

..most of all, it is a waste of money. The hospital is on fire, burning to the ground. Why is no one doing anything? Where are the fire-fighters? They are in the local school lecturing children on the dangers of matches

But in this recent post: Paranoid Doctors he is distraught that in the US attorney’s advertise their services and offer a “No recovery, No Fee” option. As he puts it

So I can stop my medication. And thank God we don’t live in America

Yes and no…… as one of the comments on his post put it:

How would you respond to a patient whose GP had been giving him Steroid eye drops on repeat prescription for 11 years without reviewing him and who was not under the care of an Ophthalmologist, who now has bilateral steroid induced glaucoma and steroid induced cataracts?

I bet you dollars to donuts that this is a real case not just a hypothetical and therein lies the challenge. While there is abuse (as there is in any system) the idea that making it so costly and difficult provides good protection for the patient is wrong. A very good friend of mine was treated for a complex fracture of radius and ulna at some local hospital. The gung ho orthopedic surgeon decided he was up the task of treating this set of fractures and left him with permanent disability and finished his tennis career. No amount of money will ever make up for that but without accountability that surgeon would continue his treatment of other patient instead of referring them to a specialist. This all the more worrying since it occurred in the NHS a system that does not reward by number of patients/procedures carried out

For a more detailed look at the state of medical litigation this piece by Atul Gawande in the New Yorker – The Malpractice Mess provides more detail and an interesting slant on the topic. The case under review was for medical malpractice from nine years ago but what makes this more interesting is the lawyer for the patient Barry Lang was an orthopedic surgeon for 23 years. He had even been an expert witness on behalf of other surgeons defending their treatment in court. He certainly did not do it for the money and ended up in his new career because as he described:

because he thought he’d be good at it, because he thought he could help people, and because, after twenty-three years in medicine, he was burning out

Part of his original intent was to be a defensive lawyer for his colleagues but nobody would hire him as he had no experience. But as he advertised his expertise as the “Law Doctor” he managed to carve out a business working on behalf of patients. He does not take every case and in fact takes only a small percentage of the cases that comes his way. For him there are two basic requirements

1. You need the doctor to be negligent
2. You need the doctor to have caused damage

Most fail on both but when they don’t he spends time investigating and applying his years of clinical practice and experience to understanding the case to determine if there is malpractice. Many factors contribute but he takes the risk on a case since his payment is dependent on a successful outcome. There is much to dislike about a system of accountability that can reward inappropriately but accountability and review is an essential part of any high quality system.

Somewhere in this mess there has to be a better balance and approach. Malpractice is not bad – it is the abuse of Malpractice that is bad. Consider the MGH physician Bill Franklin who’s son’s developed a lung tumor that had been identified on a Chest X-Ray 4 years previously but never followed up and acted upon. His attempt to understand the reason for the failure to prevent the occurrence happening again to some other patient were met with

The (hospital) director told him that he couldn’t talk to him about the matter. He should get a lawyer, he said. Was there no other way, Franklin wanted to know. There wasn’t.

He was left with no other course than to open a malpractice suit which was won. It left an indelible mark on the son and the father and changed the way both practice medicine. But the method is still unsatisfactory

litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn-out, and painfully adversarial. It also helps very few people. Ninety-eight per cent of families that are hurt by medical errors don’t sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted. Of those who do sue, most will lose. In the end, fewer than one in a hundred deserving families receive any money. The rest get nothing: no help, not even an apology

There have been many attempts and much like the healthcare debate the special interests weigh in quickly when they feel their turf and income stream might be threatened. One such system started for vaccines where a surcharge is made to the cost of the vaccine that is placed in a fund set aside for the purpose of compensating the small percentage of people harmed by side effects. Some countries have tried to instigate systems along similar lines – New Zealand which has a set of limits, clear defined liability and importantly quick payouts (within 9 months). There are better models and solutions. The answer lies in a fair timely system that helps those that have been hurt, identifies fault in an effort to prevent future errors without over burdening the system and the clinicians.

Malpractice or some variant of oversight is an essential part of our healthcare system and needs to be included in any debate of reform but as with all things balance and informed debate is the way to go

Healthcare Historical Solutions

Unfortunately history does not bode well for our ability to solve the current healthcare crisis and while it seems the accepted norm to find blame in all manner of elements and contributors it turns out that we have tried much of this in the past and as this chart shows
Over the last 35 years we have seen all manner of attempts but none have managed to curb costs and expenditure……Health Affairs featured a short piece titled “The Sad History of Health Care Cost Containment” which makes sobering reading. Interesting in the Carter years there was a similar sequence of events with the government flexing its muscles and the health care industry quick to offer

what it called the “Voluntary Effort.” The rate of increase in per capita private-sector health spending fell rapidly but then bounced back within a few years

Sound familiar….? Same old story same old special interests. At some point the we the consumer will have to take control over our own destiny and apply market pressures and economics. Get ready to take control of your own healthcare and become an e-patient as described in this white Paper: e-Patient’s and the focus of the e-patients.net site

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.

Healthcare Standardization and Rationing

The knee jerk reaction’s are out – this one from Bloomberg that suggests the Stimulus package and Obama will “Ruin your Health”, and this an “alert” on a blog suggesting this is “nationalizing” healthcare. There is a mad dash to kill the stimulus bill and in particular the health care elements that could limit access to health care by developing standards, defining protocols and determining if care is cost effective.

These are all hard discussions and hard decisions and I talked about this before in my posting on “Who Should pay for healthcare” that detailed some of the challenges faced in other countries in particular the UK which has developed the National Institute for Health and Clinical Excellence (NICE) group to attempt tackle these problems in a more scientific and rigorous fashion. This kind of reaction typifies the channel that everyone is listening to WIFM (What’s in it for me). Of course no suggestion of what we can do to deal with the rising cost of healthcare – the most expensive delivered in the world but only No 23 in quality of life measures. The scaremongering on this issue is based on scant data – if you want a sobering read I suggest you look at this report from the Insure the Uninsured Project web site titled: “Health Care Systesm Around the World” (warning pdf). While they all suffer some of the same challenges they are attempting to address them and in most cases doing a better job at delivering care.

I have to ask…..Betsy McCaughey says:

Keeping doctors informed of the newest medical findings is important, but enforcing uniformity goes too far

Why exactly? Do you want each physician trying his own brand of medicine, sampling different techniques, reading about some new innovation or drug and using that. You only have to look at the lack of science behind the Alternative Medicine billion dollar industry in Trick or Treatment to get a sense of how easy it is to be deceived into believing something offers value when it does not. Then look at the low compliance with known treatment protocols to understand that the system and its care givers are creaking under the strain of overwhelming data and choices. This from the AHRQ site on quality measures:

In one study, the overall rate of prescribing beta-blockers to patients after suffering an acute myocardial infarction (AMI) was 50%, and the rates of prescribing for family physicians was lower than those of specialists.

Yet we know this saves lives. But perhaps it is Betsy’s view that we are wrong to see healthcare as a “cost problem instead of a growth industry” and suggesting Healthcare “produces almost 17% of the nations’s GDP”……this is just astounding. I am certain that our car industry does not want to see healthcare as growth industry. They cited healthcare costs as a major contributor to their difficulty in competing.

If we made every last cent of our available resources available to pay for healthcare we would still not have enough. The industry and our technology will continue to create treatments, drugs, therapies to consume those resources (and typically those treatments are of higher in cost especially when first launched).

None of this is easy – but the resources are limited and as such there must be some mechanism to share the care and get the best we can for as many that we can. We don’t currently on all the generally accepted healthcare quality metrics and we pay by far the most per head of population. The system is broken. Left to our own devices we all clutch at any possibility no matter how remote or how unlikely the improvement in outcome might be (and in some cases actually harmful).

Perhaps the alternative is to leave it to the individual – put the patients in a room and ask them to justify the treatment amongst themselves and share the limited available dollars on the care. When they agree the care can be delivered. Of course that won’t work – no one wants to face those difficult choices or decisions and overlaying the additional emotional burden on this decision is not going to help. So others will have to make some of these choices and providing sufficient data to make informed decisions is essential and trying to apply some level of analysis and data to try and make it as “fair” as possible.

Agree…..disagree let me know. This is nto an easy issue but it does need to be addressed as satus quo is failing…rapidly.

Who Should Pay for Healthcare

A recent twitter on my part to an article by Health Imaging titled: “Americans want healthcare reform, but divided on how to pay for it” raised some comments that are worth exploring. The simplistic 4 word response I got back from one individual:

The Government should pay

Simply passes the responsibility from individuals to a group who receive power, authority and most importantly money from the same individuals . They are then charged with the responsibility of sharing out the limited resources “fairly”. As history has vividly demonstrated the challenge with fairness and charging a smaller group with equal distribution and fairness is problematic. George Orwell’s allegorical novel Animal Farm detailed some of these challenges.

Healthcare remains a central challenge to countries worldwide. Those with more resources do spend more of them on healthcare for their population. But there is no bottomless pit of money to pay for healthcare and unfortunately as the population gains increasing access to better healthcare their reaction is not satiation to the higher levels and increased life expectancy but wanting more. Countries approach this challenge in different ways – the UK healthcare system rationed healthcare with waiting lists and limited availability. In recent years they have attempted to define the rationing standards for healthcare under the banner of the “National Institute for Health and Clinical Excellence (NICE)“. A recent ruling on drug therapy

… it ruled that four drugs for advanced kidney cancer were too expensive for NHS use. The four treatments, NICE acknowledged, ‘have the potential to extend  progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year’.

Their methodology assesses value against “Quality Life Adjusted Years” (QALY’s) that attempt a cost benefit analysis on treatments relative to potential outcome and quality of life. This is a difficult calculation even in the best of circumstances because the assessment of benefit changes dramatically from the perspective of the individual who in most cases assesses the value even if limited in time or effect.  In the case of the drugs for kidney cancer drugs NICE’s QALY assessment was”

Translated into QALYs—quality adjusted life years—that works out at between £71 000 and £171 000 a year; well above the rough threshold of £30 000 a year that NICE broadly applies other than in exceptional circumstances.

I commented on the NICE measure before where an individual wanted to pay for the drugs himself but in doing so fell out of the group coverage and was refused access.

There is no such thing as “free healthcare” – free at the point of service removes personal responsibility and encourages abuse. A simple case in point is the nuisance charge or co-payment. The United Kingdom has provided free home visits and free access to their General Practitioner for years.  But you only have to spend a night with an on call General Practitioner, especially round any holiday to experience the abuse. Calls at 3am for a headache. And not a new onset headache but one the patient has been suffering from in some cases days, weeks and even months. The introduction of a payment for all visits would discourage some of this and those opposed would suggest that it might discourage patients that should make the call. It might but the underlying issue of value would be solved – if the service is “free” then the value is perceived to be the same.

Providing healthcare to as many people as possible is right but in all cases a line must be drawn that is entirely dependent on the resources available. One can imagine that the availability of healthcare is much diminished in Zimbabwe. There the provision of midwifery delivery services to a preganant mother would require the patient to personally provide $20 Billion  Zimbabwean dollars (nearly US $40). But the resources available make this a bridge to far. And so to in all other countries – where we continue to consume every available healthcare resource made available. There is no instance where a country so much makes healthcare available that there is resources left unused, clinics and doctors desperate for patients because they are underutilized.

So what is the answer – personal responsibility and a full understanding of the cost and benefit of healthcare resources available. Attaching value to those resources helps comprehension. Patients can make informed choices in the same way that consumers do – why pay more for the iPod when a Micosoft Zune or SanDisk Sansa does the same job at a lower cost. Some do make the choice for iPod, others do not but they do so based on the available data and a cost benefit analysis. But if all the MP3 player’s were free or the same “cost” to us then the selection is harder and less informed. Free healthcare is a misnomer – everything has a value and attaching a value to healthcare but making it accessible to as many as possible is better strategy than just making it free.

Featured in the March issue of the British Journal of Healthcare Management – Stimulus and Effect: Rationing (full pdf subscription required)

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).