Your Doctor and You – Looking for Answers Outside of Traditional Medicine, Thirteen in a Series, The Great Debate, Fraudulent Practitioners, A Realist

The Great Debate

In 1999, the alternative vs. traditional medicine debate reached a defining moment when the doctor hero of the alternative movement, Andrew Weil, MD, debated Arnold Relman, MD, staunch defender of scientific medicine.

Dan Rutz, Senior medical correspondent at CNN refereed the debate, which was held at the University of Arizona medical center. The debater’s credentials were presented to the audience.

In one corner was Andrew Weil, MD, an international authority on integrative medicine and director of the University of Arizona Program in Integrative Medicine. He was author of many scientific and popular articles and seven books. Named by Time magazine as one of the nation's most influential people of 1997, Dr. Weil was a recognized expert on alternative medicine, medicinal plants, and reforming medical education. He was a member of the American Academy of Achievement and earned degrees in botany and medicine at Harvard University.

In the other corner was, Arnold Relman M.D., outspoken critic of integrative medicine (New Republic cover story, Dec. 14, 1998). He had served as editor-in-chief emeritus of the New England Journal of Medicine and professor emeritus of medicine at Harvard Medical School. Dr. Relman was a Fellow of the American Academy of Arts and Sciences, and a former president of the American Federation for Clinical Research, the American Society of Clinical Investigation and the Association of American Physicians.

To give you the flavor of the debate, here were Relman’s and Weil’s opening remarks.
Doctor Relman: “Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance, but a return to the past, an interruption of the remarkable progress achieved by science-based medicine over the past century.”

“I can't see how such integration, even if it were possible, would improve medical care or further the cause of human health. Most alternative systems of treatment are based on irrational or fanciful thinking, and false or unproven factual claims.”

“Their theories often violate basic scientific principles and are at odds, not only with each other, but with modern knowledge of the structure and function of the human body as now taught in our medical schools.”

“It could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests.”

Doctor Weil: “In this country and throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help.”

“Why are people doing this? Clearly, there is dissatisfaction with conventional medicine. There is a large and growing gulf in this country between what patients expect of doctors and what medical schools are training them to do.”

“Patients want physicians who can take the time to sit down with them and listen and explain to them, in language they can understand, the nature of their problem; who are aware of nutritional influences on health; who will not push just drugs and surgery as the only approach to treating illness; who can answer intelligently questions about dietary supplements; who are sensitive to mind-body interactions; who will not laugh in your face if you ask questions about Chinese medicine; who are willing to look at you as more than just a physical body. I think those are very reasonable requests.“

Who Won?

Among the scientific community, Relman won the debate. The alternative community and the public felt Weil won hands down. Both sides remained unconvinced of the other’s position.

As time has passed, Relman’s position has been largely validated by government-sponsored double-blind, controlled scientific studies, which show most alternative products have no scientific value in relieving symptoms or curing disease.

On the other hand, Weil’s stature has gained widespread legitimacy in the public’s eyes and among some academic centers and mainstream practitioners, who know reality of alternative medicine’s popularity when they see it.

Beware of Fraudulent Alternative Practitioners

Unfortunately with legitimacy has come a rise in unprofessional, fraudulent practitioners (“Life and Death on Fringes of Medicine, Los Angeles Times, February 5, 2006).

Using the Internet and word-of-mouth promotion, peddlers of unproven cures offer hope to desperately sick people in imaginative new ways.

I had a friend with terminal pancreatic cancer who paid $10,000 for caffeine enemas and massive doses of multivitamins to treat his disease. Another friend, with advanced congestive heart failure, was told by a health food clerk that she had 20 proven remedies to treat heart failure. To doctors, thoughts of health food personnel dispensing medical advice can endanger and mislead patients.

The Case of Coretta Scott King

Some fatally ill patients forgo traditional care; others burn through their savings. Diagnosed with ovarian cancer, Coretta Scott King recently sought care at a Mexico clinic, Santa Monica Health Institute, known for its fringe medical treatments. She died there, and it was shut down by Mexican health authorities. Many patients merge conventional care with alternative practices without telling their doctors, risking dangerous side effects or drug interactions.

A Realistic Approach to Alternative Medicine by Doctors

For doctors, what is a reasonable approach to patients who are true believers in alternative medicine but whose health may be endangered through drug interactions or avoidance of proven traditional medicine?

As the editor of a monthly newsletter, Physician Practice Options, which reaches 100,000 practicing physicians, I endorse the approach of Doctor Neil Baum, a well-known urologist and medical marketing expert.

Baum advises doctors to learn from the effective humanistic techniques of alternative practitioners, ask patients about alternative drugs that may interact with prescribed drugs, show neutrality and understanding, and form relationships and develop referral relationships with legitimate alternative practitioners (“Clinicians Can Learn from Alternative Practitioners,” Physician Practice Options, October, 2004).”

In other words, don’t denounce alternative medicine practitioners, learn from them. When necessary protect your patients from potentially harmful products, but show understanding.

Wrapping Up

Alternative and complementary medicine is here to stay. Recognizing this, the National Institute of Health is studying it; academic medical centers and hospital systems are setting up programs and accepting patients. The America public continues to embrace alternative practitioners’ hands-on, naturalistic, spiritual, and compassionate approaches. But on its fringes, danger lurks in thee form of untoward drug interactions, worthless and costly procedures engendering false hopes, and fraudulent practitioner.

Your Doctor and You.— Looking for Answers Outside of Traditional Medicine: Twelfth in a Series

“Unconventional treatments often seem to make people feel more comfortable, even when their accompanying theories are silly.”

Edward Champion, MD, New England Journal of Medicine, 1993

You're weary of seeing MDs. They usually prescribe drugs, dismiss your theories of self-care, and don’t have the time or interest to discuss vitamins, supplements or herbs or other things you consider good for your health.

For you, the time has come to talk of other things, herbs, acupuncture, chiropractic, naturopathic, and even exotic, quixotic procedures that may help, once everything else has been tried.

Your friends, the clerks at the local health food store, and multiple folks on TV, radio, and the Internet are telling you there’s relief to be found outside of traditional medicine.

After all, Chinese and other Oriental cultures believe in remedies outside of American scientific medicine. Surely thousands of years of experience mean something. These remedies have worked for them, why not for you?

Besides, alternative treatments are inexpensive, natural, and devoid of side-effects. You can choose which one works for you. You don’t have to argue about the bill with the insurance company. Control of your own health, in your own way, is important to you.

You and millions of other Americans have accepted complementary medicine as a legitimate “alternative” and “supplement” to conventional scientific medicine. The medical establishment is now grudgingly “integrating” alternative medicine into mainstream practices. Traditional doctors are aware alternative practitioners are on to something. They know practitioners outside of mainsteam medicine have succeeded in winning new patients by emphasizing humanistic, spiritual, natural, self-healing, and hope-engendering approaches to health.

Defining Alternative and Complementary Medicine

You might be interested in how The National Institute of Health, the most influential scientific establishment in America, defines alternative and complementary medicine(SOURCE: National Institute of Health, Division of Alternative and Complementary Medicine).

“Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.”

Proponents and Opponents Not Swayed by Each Other

Alternative medicine vs. scientific medicine is one of those debates in which neither side is swayed by the others’ arguments. Recently a spate of articles in the scientific literature using double blind techniques to remove bias have shown Palmetto for prostate overgrowth, glucosamine and chondroitin for arthritis, Echinacea for the common cold, and St. John’s Wort may not be worth the bottles they come in.

About the only thing conventional medicine will admit is that chiropractic medicine has some benefits for back pain, ditto for acupuncture for migraine, and the placebo effect. The placebo effect is powerful, i.e., if you think something is going to make you feel better, it will.

Loyalists of Alternative Medicine

Loyalists of alternative products are by scientific studies discrediting their beliefs. unimpressed (“Natural Remedy Users Loyal, Studies or Not,” Associated Press, February 27, 2006. Loyalists say they will keep accepting alternative nostrums, undergoing its procedures, and downing its pills as long as they make they make them feel better.

The debate is unlikely to reach any definitive conclusion. While the medical establishment denounces alternative medicine, patients embrace it. According to a February 3, 2006, New York Times article “When Trust in Doctors Erodes, Other Treatments Fill the Void.” consumers spend $27 billion a year on alternative medicine. Nearly half of adults used alternative therapy in 2004, up from 42 percent a decade before.

Favorite Remedies

Millions of patients now venture outside mainstream medicine. They are taking herbs for colds, depression, headaches, arthritis, and backaches; getting their spines manipulated; desperately seeking cancer cures with massive doses of multivitamins, enduring caffeine enemas to flush out toxins, and undergoing intravenous therapies to leach out calcium from atherosclerotic plaques to unclog their arteries.

Why You Like Alternative Practitioners

You like alternative practitioners because they spend time with you, give hands on therapy, promise results, and don’t “poison” you with expensive dangerous drugs. Besides, you don’t have to haggle with insurers or worry about drug or surgical side effects. Herbs, supplements, and acupuncture needles appeal psychologically because they are either “natural” or rooted in traditions of Eastern medicine.

Grudging Respect from the Medical Establishment

Let there be no doubt. Alternative medicine (also sometimes referred to complementary, integrative, holistic, or natural medicine) has gained a foothold in today's medical world.

Alternative medicine has garnered respect from many mainstream physicians and researchers. Medical centers such as UCLA and Memorial Sloan-Kettering Cancer Center in New York City have created integrative programs, and medical schools increasingly offer courses in the field.

Even the vaunted National Institutes of Health, the government’s premier scientific arm, has gotten into the act. In 1998, the NIH established the National Center for Alternative fro Complementary and Alternative Medicine, or CAM.

Next: Your Doctor and You – Looking for Answers Outside of Traditional Medicine, Thirteen in a Series, The Great Debate, Fraudulent Practitioners, A Realistic Approach to Alternative Medicine by Doctors

Your Doctor and You.— Looking for Answers Outside of Traditional Medicine: Twelfth in a Series

“Unconventional treatments often seem to make people feel more comfortable, even when their accompanying theories are silly.”

Edward Champion, MD, New England Journal of Medicine, 1993

You're weary of seeing MDs. They usually prescribe drugs, dismiss your theories of self-care, and don’t have the time or interest to discuss vitamins, supplements or herbs or other things you consider good for your health.

For you, the time has come to talk of other things, herbs, acupuncture, chiropractic, naturopathic, and even exotic, quixotic procedures that may help, once everything else has been tried.

Your friends, the clerks at the local health food store, and multiple folks on TV, radio, and the Internet are telling you there’s relief to be found outside of traditional medicine.

After all, Chinese and other Oriental cultures believe in remedies outside of American scientific medicine. Surely thousands of years of experience mean something. These remedies have worked for them, why not for you?

Besides, alternative treatments are inexpensive, natural, and devoid of side-effects. You can choose which one works for you. You don’t have to argue about the bill with the insurance company. Control of your own health, in your own way, is important to you.

You and millions of other Americans have accepted complementary medicine as a legitimate “alternative” and “supplement” to conventional scientific medicine. The medical establishment is now grudgingly “integrating” alternative medicine into mainstream practices. Traditional doctors are aware alternative practitioners are on to something. They know practitioners outside of mainsteam medicine have succeeded in winning new patients by emphasizing humanistic, spiritual, natural, self-healing, and hope-engendering approaches to health.

Defining Alternative and Complementary Medicine

You might be interested in how The National Institute of Health, the most influential scientific establishment in America, defines alternative and complementary medicine(SOURCE: National Institute of Health, Division of Alternative and Complementary Medicine).

“Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.”

Proponents and Opponents Not Swayed by Each Other

Alternative medicine vs. scientific medicine is one of those debates in which neither side is swayed by the others’ arguments. Recently a spate of articles in the scientific literature using double blind techniques to remove bias have shown Palmetto for prostate overgrowth, glucosamine and chondroitin for arthritis, Echinacea for the common cold, and St. John’s Wort may not be worth the bottles they come in.

About the only thing conventional medicine will admit is that chiropractic medicine has some benefits for back pain, ditto for acupuncture for migraine, and the placebo effect. The placebo effect is powerful, i.e., if you think something is going to make you feel better, it will.

Loyalists of Alternative Medicine

Loyalists of alternative products are by scientific studies discrediting their beliefs. unimpressed (“Natural Remedy Users Loyal, Studies or Not,” Associated Press, February 27, 2006. Loyalists say they will keep accepting alternative nostrums, undergoing its procedures, and downing its pills as long as they make they make them feel better.

The debate is unlikely to reach any definitive conclusion. While the medical establishment denounces alternative medicine, patients embrace it. According to a February 3, 2006, New York Times article “When Trust in Doctors Erodes, Other Treatments Fill the Void.” consumers spend $27 billion a year on alternative medicine. Nearly half of adults used alternative therapy in 2004, up from 42 percent a decade before.

Favorite Remedies

Millions of patients now venture outside mainstream medicine. They are taking herbs for colds, depression, headaches, arthritis, and backaches; getting their spines manipulated; desperately seeking cancer cures with massive doses of multivitamins, enduring caffeine enemas to flush out toxins, and undergoing intravenous therapies to leach out calcium from atherosclerotic plaques to unclog their arteries.

Why You Like Alternative Practitioners

You like alternative practitioners because they spend time with you, give hands on therapy, promise results, and don’t “poison” you with expensive dangerous drugs. Besides, you don’t have to haggle with insurers or worry about drug or surgical side effects. Herbs, supplements, and acupuncture needles appeal psychologically because they are either “natural” or rooted in traditions of Eastern medicine.

Grudging Respect from the Medical Establishment

Let there be no doubt. Alternative medicine (also sometimes referred to complementary, integrative, holistic, or natural medicine) has gained a foothold in today's medical world.

Alternative medicine has garnered respect from many mainstream physicians and researchers. Medical centers such as UCLA and Memorial Sloan-Kettering Cancer Center in New York City have created integrative programs, and medical schools increasingly offer courses in the field.

Even the vaunted National Institutes of Health, the government’s premier scientific arm, has gotten into the act. In 1998, the NIH established the National Center for Alternative fro Complementary and Alternative Medicine, or CAM.

Next: Your Doctor and You – Looking for Answers Outside of Traditional Medicine, Thirteen in a Series, The Great Debate, Fraudulent Practitioners, A Realistic Approach to Alternative Medicine by Doctors

Your Doctor and You – What You Know and Might Not Know, The Money Problem, Hope Better Than Hopelessness, Eleventh in a Series

What You Know

One thing’s for sure. You know you want to live. As a transplant surgeon, John Najarian of the University of Minnesota, once said to me,

“I have never met a patient who didn’t want to live another day.”

From your research, you know clinical trials out there might yield a miracle drug. You know heretofore incurable cancers – childhood leukemia, Hodgkin’s disease, testicular malignancies, stromal tumors of the stomach, myeloid leukemia in adults and other cancers treated early and aggressively – are often cured.

You know about Lance Armstrong. You know today there are more cancer survivors than ever, 10 million of them (American Cancer Society).

What You Might Not Know

But, alas, you might not know most new drugs may are marginally effective, only occasionally curative. What you might not know is that 80 percent of oncologists are willing to try a drug if it prolongs life by two months (American Cancer Society survey). Oncologists want you to survive as long as you can, and they are willing to try any drug to prolong your survival.

These new drugs include.

• Avastin for colon, breast, .lung, and pancreatic cancers.
• Erbituz for advanced colon cancer
• Gleevec for chronic myeloid leukemia
• Herceptin for breast cancer
• Rituxan for B-cell non-Hodgkin’s lymphoma
• Tarceva for non-small cell lung caners and pancreatic cancer
• Thalomid for plasma cell myeloma

The Money Problem

These drugs may cost from $25,000 to $100,000 for a year’s treatment. Critics question the ethics of pharmaceutical companies in charging “outrageous prices.” (“Cancer Drugs Offer Hope, but Expense Worries Doctors and Patients,” New York Times, July 12, 2005).

Yet, even in the face of these criticisms, doctors and patients are reluctant to confront the pharmaceutical companies, perhaps because it is unseemly to put a value on human life. Some fear drug firms will stop research into newer more effective cancer drugs, and they hope, against all odds, the money will come from somewhere in this vast affluent nation.

Hope Better than Hopelessness

And so hope lives on that somewhere out there a cure lurks, a cure that may be just around the corner. We always have hope we will be one who wins the “battle against cancer.”

According to a New York Times piece “ The Ethics of Hope: Doctors' Delicate Balance of Keeping Hope Alive,” Meg Gaines, director of the Center for Patient Partnerships, a patient advocacy program at the University of Wisconsin, Madison, false hopelessness is worse than false hope.

"I tell people to ask the doctor, 'Have you ever known anyone with this disease who has gotten better?' If the answer is yes, just say, 'So let's quit talking about death and talk about what we can try!' "

Some patients beat the odds; others succumb even when the odds are piled in their favor. But total ignorance about the odds, she cautions, can be dangerous.
She says,

"People should know about prognosis to the extent that it's necessary to make good decisions about monitoring your health care,"

"You can't be an ostrich in the sand. When the stampeding rhinoceros is coming, you have to be able to get out of the way.”

Wrapping Up

Cancer remains a feared disease. Detected early, many cancer victims are cured. More than 50 percent of cancer patients now survive. There are now more than 10 million survivors. Although chances for cure are greater than ever, new more effective cancer drugs may cost $25.000 to $100,000 each year. Doctors who treat cancer patients will treat advanced cases with drugs if data shows these drugs will prolong live by two months or more. Cancer doctors must combine realism with hope, and if all hope evaporates, they can comfort patients by saying they will be with them until the end.

Your Doctor and You - With Cancer, With Hope, Tenth in a Series

“While there are several chronic diseases more destructive to life than cancer, none is more feared.”

Charles Mayo, MD, Annals of Surgery, 1926

You passed your 50th birthday sometime ago. You were looking forward to a prosperous middle age and secure retirement. But suddenly you were diagnosed with cancer. The very word “cancer” filled you with dread.

But you have hope. Your cancer can be cured with chemotherapy drugs, and more people are surviving cancer. A report from the American Cancer Society on January 18, 2007, reported cancer deaths have dropped for the second year in a row in 2004, the latest statistics available. That's the first time that has happened in 70 years. Cancer deaths fell by 3014, but there were still 553,888 deaths so these numbers may not mean much for you. But some hope is better than no hope at all. You know more than 50 percent of all cancer victims now survive, and there are more than 10 million cancer survivors out there.

But then you are shocked to find how much cancer drugs cost, to learn that most health plans don’t cover full drug costs of treating your cancer, that the new Medicare Part D bill requires a $4800 co-payment for certain expensive drugs, and that your prognosis remains unpredictable, making planning difficult.

The psychological and emotional impacts of the disease are devastating, and you may turn to prayer and support groups to prop up hope. You learn there is still a long way to go for ultimate answers – biological, psychological, ethical, and economical – and for converting cancer from unmanageable malignancy into a manageable chronic disease.

You will search for the best care medicine can offer and for compassionate doctors. You hope and pray you will beat the odds with the money and support needed to survive.

America’s Top Doctors for Cancer

I sit on the advisory board of a publication America’s Top Doctors for Cancer (A Castle Connolly Guide, New York City, 2005). The publisher and the Board have evaluated and selected 2000 of the nation are leading cancer specialists engaged in preventing, diagnosing, and treating cancers in children and adults.

Friends, relatives, colleagues, and others frequently consult board members about whom we would suggest as the best specialist and the best medical center for a particular cancer. These top doctors, and the latest drug or radiation therapy, may give you your best shot at cure.

Many cancers are potentially curable if caught early. More than 10 million cancer patients have been completely cured (Source; American Cancer Society), and most survivors can cope with their cancer like any other chronic disease. That said, it is important to say no cancer specialists or institution devoted to cancer is perfect. Cancer remains a disease calling for Art, Science, and Hope.

Cancer a Disease of Hope

Perhaps my son, Spencer, who is a nationally known poet because of his book The Clerk’s Tale (Houghton-Mifflin, 2004) ought to be writing this chapter rather than myself.\
Why?

Because, when chances for a cure dim, cancer is primarily a disease of hope. You hope against all odds you will survive. Cancer becomes a disease of the soul, mind, and spirit as well as the body. Cancer evokes the language of hope, and poetry lends itself to that language.

Maybe that’s why Amazon.com lists 100 books of poems by cancer victims. Emily Dickinson (1830-1886) penned these lines "Hope is the thing with feathers that perches in the soul,” and John Keats, a medical student at the time, composed the following poem with these opening and closing verses.

To Hope, by John Keats, 1795-1821

When by my solitary hearth I sit,
And hateful thoughts enwrap my soul in gloom;
When no fair dreams before my "mind's eye" flit,
And the bare heath of life presents no bloom;
Sweet Hope, ethereal balm upon me shed,
And wave thy silver pinions o'er my head!

And as, in sparkling majesty, a star
Gilds the bright summit of some gloomy cloud;
Brightening the half veil'd face of heaven afar:
So, when dark thoughts my boding spirit shroud,
Sweet Hope, celestial influence round me shed,
Waving thy silver pinions o'er my head!

The Medical Ethics of Offering Hope to Cancer Victims

For cancer doctors, offering hope, particularly false hope, can be a tricky and cruel ethical exercise.

• Should doctors offer false hope by placing a terminal patient on a ventilator, or should they give morphine or some other powerful pain killer to soothe the passage?

• Should doctors give a precise prognosis, because the law says patients have a right to be realistically informed about their prognosis? Prognosis estimates are based on statistical aggregates, but patients die individually, long before and long after any statistical mean.

• Should doctors passively issue a bleak prognosis, or should they aggressively encourage the patient to pursue unproven cutting edge treatment?

• Should they subject the patient the toxic therapy when, in your heart of hearts and in their experience, they know it will likely fail?

• Should they admit to the patient and family that no doctor knows how long the patient will live – that cancer survival statistics are notoriously imprecise?

• Should and when should they recommend the patient enter a hospice, a tacit admission that the end is near?

Answering any of these questions entails the Art of Medicine, rather than blind belief in the Science of Medicine. Doctors can’t always say precisely when and how things will turn out, but they try can do the best they can and offer emotional support.

When The End Nears

There comes a time when everybody knows – the patient, the family, and the doctor – the end is near. What does the doctor do then?

In Oregon, the patient can consider euthanasia. For most states, hospice is a more realistic option.

I have a friend and colleague, Dr. John Burns, an internist, who has something important to say about terminal care. When confronted by a hopeless situation, Dr. Burns said to patients, “I will always be with you. I will never abandon you, and we will face the end together.” This message, he says, always comforts patients.

Next: Your Doctor and You – With Cancer, With Hope, What You Know and Might Not Know, the Money Problem, Hope Better Than Hopelessnes

Grand Rounds of Blogging Competition Entry*

The Grand Rounds of Blogging have requested I enter a blog to compete for the best blog on the importance and status of the consumer healthcare movement.

Here’s my entry.
I’ve been asked to comment on the healthcare consumer movement; whether it will solve economic, treatment, and societal healthcare problems; and on my personal experiences with the consumer movement.

Here goes.
1. The consumer movement will prevail. Why? Because everything else has failed to stem costs and to rationalize care. Medicare has failed. Managed care has failed. Self-funded employers have failed. The only alternatives left are cost-conscious consumers spending their own money, or a government single payer system. Our culture is not likely to accept the latter.

2. Will consumerism solve healthcare problems? Not all at once, but perhaps in the long run. Market-based solutions lurch forward in incremental, experimental bursts and reverses. An HSA, HRA, and FSA here. A high deductible or high co-pay there. A tax system tweak here. A tax subsidy there. A specific comprehensive consumer-oriented website here. Inexhaustible Internet-rich health information lore there. A technological innovation here. A political setback there. But always forward the market will go.

3. My personal experience? As a practicing physician in Minneapolis, I was present at the creation at one of the centers of the HMO movement and of United Healthcare. I predicted physician-punishing and patient-depriving HMOs would ultimately fail (And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, Media Medicus, 1988). Doctors and patients, I said, would rebel. I saw first hand how powerful market forces could be — how they forced Mayo to set up satellite sites in Jacksonville and Scottsdale, closed multiple Twin Cities hospitals, force Minnesota doctors into economic servitude, pushed the University of Minnesota hospital into economic retreat and into an unwelcome acquisition by a community health system.

Based on these and subsequent experiences, I believe market-based innovations - HSAs, high deductible health plans, technological innovations, and cost-sensitive consumers — will, for better or worse, be stronger change agents for lowering costs and rationalizing care than government.

Our capitalistic culture demands individual freedom and choice. The market is more likely to provide these attributes than government.

This submission argues healthcare market forces are more powerful and more likely to prevail than a government single-payer system. My blog is http;//www.medinnovationblog.blogspot.com
Comment by Richard L. Reece, MD — January 27, 2007 @ 11:43 am

* Grace Marie Turner, founder of the Galen Institute sends this correction and clarifying comment on my last blog which implied that a national single payer might be illegal,

“ I have a quibble with your blog: You say that “Three of the Democratic candidates for President – John Edwards, Barak Osama, and Hillary Clinton – don’t share the Journal’s views” and are pressing forward with universal health coverage. The Journal is writing about the illegality of state-based universal coverage schemes. But ERISA preemptions wouldn’t apply if the federal government creates a new, national single-payer health care system. ERISA only is there to protect companies from having to comply with 50 different state regulatory schemes.

I worry even more about the risk that Sen. Kennedy will prevail with his Medicare-For-All plan than I do about the attempts by the states, which are failing of their own weight.”

State Universal Coverage Plans May be Illegal

Periodically I will bring you up to date on the credibility of my January 11 blog predictions for 2007.

Prediction #2 for 2007

“The Universal Health Care movement will take shallow roots in states at the edge of the continent – California, Massachusetts, Maine, and Vermont.”

Prediction Progress

When I used the term “shallow roots,” I may have been prescient. According to a January 23 Wall Street Journal editorial, “Illegal Health Care,” California and Massachusetts “pay or play” plans may be illegal. The WSJ editors base this illegality on a ruling by Judge J. Frederick Motz of the Fourth Circuit of Appeals, who ruled that Maryland’s Law forcing Wal-Mart to” pay” 8% of its payroll for health benefits if it were going to “play” as a Maryland business was illegal.

The judge ruled that the “Wal-Mart tax” violated Erisa, the federal law permitting multi-state employers to maintain nationwide benefits and uniform administration from state-to-state. The Journal editorializes, ”We’re all for state policy experiments, but these ballyhooed health care reforms are policy blunders that won’t stand scrutiny in court, much less in the marketplace.”

We shall see. Three of the Democratic candidates for President – John Edwards, Barak Osama, and Hilliary Clinton – don’t share the Journal’s views. All have put their variations of universal coverage on the table (Mike Dorning, “Healthcare coverage gains political steam: candidate embrace universal coverage,” Chicago Tribune, January 26, 2007). Only one thing is for sure. No state or the nation as a whole can afford first-dollar universal coverage. Somebody, probably everybody, will have “to pay to play” the universal game.

Your Doctor and You -- Tired and Sick of Waiting – Times Vary in U.S., Are Longer in Canada, Can Endanger Your Health, and Require Time Management,

Waiting times for appointments to see specialists vary across the United States. Waiting times are a demand-supply problem. The greater a given specialist shortage, the greater the number of patients, the longer the wait times.

Take cardiologists. Heart disease is the most common disease in America, and by far the greatest killer.

Here are cardiologist waiting times Merritt Hawkins, a national physician recruiting firm in Irving, Texas, found in various metropolitan areas across the country in a 2004 survey. If you’re a Medicaid patient with a heart problem, it’s the most difficult to get a cardiologist appointment in Dallas, New York City, or Seattle.

City Shortest time Longest time Average time Accept Medicaid
Boston 18.7 days 120 days 37 days 11%
Philadelphia 20.1 days 136 days 27 days 80%
Portland 20.2 days 128 days 25 days 100%
Denver 20.2 days 128 days 23 days 30%
New York 20.2 days 26 days 20 days 0%
Miami 15.3 days 45 days 21 days 40%
Detroit 17.7 days 42 days 20 days 65%
San Diego 19.9 days 72 days 17 days 68%
Atlanta 20.3 days 28 days 17 days 80%
Minneapolis 20.2 days 105 days 15 days 80%
Los Angeles 18.1 days 23 days 13 days 22%
Washington, D.C. 16.0 days 23 days 12 days 100%
Houston 20.2 days 43 days 11 days 85%
Dallas 17.2 days 16 days 10 days 0%
Seattle 18.1 days 24 days 9 days 0%

Source: Merritt Hawkins Associates, 2004 Survey

Waiting Times in Canada

Waiting times for a specialty appointment are longer, on average, in Canada than in the United States.

In Canada, the median wait time between a referral by a family doctor and an appointment with a specialist increased to 58 days in 2005 from 25 days in 1993, according to a recent study by The Fraser Institute, a conservative research group.
Meanwhile the median wait between appointment with a specialist and treatment has increased to 66 days from 39 days over the same period.

Average wait times between referral by a family doctor and treatment range from 39 days for oncology to 280 days for orthopedic surgery.

Some Canadians die while waiting for an appointment, others have radiation treatments delayed, and still others cross the U.S. border for treatment.
In June, 2005, the Canadian Supreme Court struck down a provincial law banning private medical insurance and ordered the province to initiate a reform program within a year.

The decision ruled that long waits for various medical procedures in Quebec violated patients' "life and personal security, inviolability and freedom," and that prohibition of private health insurance was unconstitutional when the public health system did not deliver "reasonable services."

In February 2006, Quebec proposed to lift a ban on private health insurance for several elective surgical procedures, and announced it would pay for such surgeries at private clinics when waiting times at public facilities were unreasonable.
Nationalizing a health system may not solve the waiting problem. It often exaggerates it.

Indeed, in most nations with centralized government systems, more waiting is the rule rather than the exception. Universal government coverage prolongs waiting, for there no economic incentive to please patients.

Dying While Waiting

In the United States, patients can die while awaiting an organ transplant. The same goes for severely ill or injured patients in emergency rooms. Some doctors double-book appointments to make up for patient cancellations. And doctors say they are pulled in so many directions – phone calls, emergencies, interruptions, meetings, unexpectedly complicated patients.

Some Waits Unavoidable

In some cases, long waits may be unavoidable. Add to this that medicine is unpredictable and the fact that Medicare, Medicaid, and insurance companies are reimbursing doctors at such low rates that doctors feel compelled to see more patients. Consequently doctors may over-schedule and fall further behind as the day progresses. It may pay for you to schedule appointments early in the day.

Managing Time, The Inelastic Asset

For doctors shortening waiting times for you is all about managing time while showing you the courtesies you deserve. In the larger scheme of things, these goals require increased physician productivity (Marshall Zaslove, MD, The Successful Physician: A Productivity Handbook for Practitioners, An Aspen Publication, 1998).
For increased productivity, which translates to more time for patients, doctors can go to open access scheduling, delegate tasks to nurse practitioners and physician assistants, manage patients through email communications, conduct “virtual office visits, “encourage you to come bearing specific questions.

But in the end doctors cannot change the doctoring process – history, review of systems, physical, and treatment.

And doctors can’t create more time. Time is inelastic, irreplaceable, and unique, and they cannot make more of it. And everything a doctor does take time.

Wrapping Up

Doctors are shortening waiting times through open-access scheduling. This permits them to see patients on the day they call. Still doctors may not see you on time because of the unpredictable nature of medicine and increased demand for services in the face of a national doctor shortage.

Your Doctor and You - Sick and Tired of Waiting, Eighth in a Series

“I am ready any time. Do not keep me waiting.”

John Mason Brown, 1900-1969

“Most patients are satisfied with their doctors, but there are complaints, particularly about time spent in the waiting room, according to a survey of about 39,000 patients and 335 primary care doctors that appears in the February edition of Consumer Reports….. Patients' top complaint about doctors was time spent in the waiting room. Nearly one in four patients (24%) said they waited 30 minutes or longer.“

Sources: WebMD, Inc, January 8, 2007, News Release, Consumer Reports, Re: Consumer Reports, February 2007 issue pages 32-36

You’re sick and tired of waiting -- waiting to get an appointment, waiting in the doctor’s waiting room, waiting to get the procedure done, waiting to get test results, waiting to see the specialist to whom you were referred, waiting in the hospital admitting suite, waiting in the emergency room, waiting to have your operation.

Why can’t doctors and hospital be more efficient?

Don’t they understand your time is just as valuable as theirs?

For patients tired of waiting, there is good news and bad news.

The good news is:

Doctors are working to shorten waiting times.

The bad news is:

Waiting lines are growing longer. The best advice: call ahead and insist on being seen on time.

Doctors are as concerned as you are about long waiting lines in their offices. They are keenly aware of new assertive “health care consumers,” who will be spending more of their own money, and will want to be seen promptly on time. So doctors are doing something about shortening or even eliminating waiting times for appointments. They want to please health care consumers and please patients.

Doctors and practice managers across the land are diligently introducing “open access scheduling,” or other forms of “wave” scheduling, in their clinics.

The “open access” concept is simple enough – leave slots open daily in the doctors’ schedules so you can be seen on the day you call.

“Wave” scheduling is based on the fact that patients come in “waves,” e.g., on Monday mornings and Friday afternoons, and you can more efficiently arrange your schedules to anticipate patient waves.

Switching from the present way of doing things, tight schedules with no openings, to seeing patients on the day they call or anticipating and planning for waves in which they appear, doesn't happen overnight.

Doctors must readjust practice habits. Open-access scheduling involves "doing today's work today," i.e. physicians going home with all work done, immediately dictating or otherwise entering their findings, eliminating appointment backlogs, and seeing patients on the day they call for an appointment.

Meanwhile, in the Short Run

Meanwhile, in the short run, waiting problems have grown worse.

Advances in technology have created more tests and procedures to wait for, and new drugs and treatments mean more people need more doctor visits.

Over the last ten years, the National Center for Health Statistics says doctors' appointments for people over 45 increased by more than 20 percent and emergency room visits went up by 23 percent.

Doctor Shortage

And then there’s the complicating factor of the doctor shortage. In the February, 2002 edition of Health Affairs, Richard Cooper, M.D. of the University of Wisconsin in Milwaukee projected a shortfall of 50,000 physicians in the U.S. by 2010 and 200,000 by 2020. At a 2005 national conference on the physician workforce sponsored by the Association of American Medical Colleges, most leading physician supply analysts agreed physician shortages will be serious and sustained.

This shortfallof physicians and lengthening waiting times for seniors may be greatly exaggerated by government policies calling for continuing cuts in Medicare fees for the next five years. According to a new AMA survey, nearly half of physicians plan either fewer new Medicare patients or will stop seeing new Medicare patient’s altogether if Medicare physician payments continue to be reduced.

Next : Tired and Sick of Waiting, Waiting Times Vary in U.S., are longer in Canada, can Endanger Your Health, Require Time Management, Ninth in a Series

Three Duties of A Medical Blogger

As a medical blogger. I have three essential duties:

1) To access accurately healthcare trends, to make predictions that matter, and to remind you occasionally when those predictions are coming to pass.1.

In my January 11, 2007 blog, Twelve Predictions for 2007, I predicted:

"Taking care of health problems of employees, both on an acute and chronic basis, at the worksite will become a growth industry. American HealthWays has made a science of reaching chronically ill clients both at home and work with protocol-bearing nurse extenders. Their evidence-based programs provide specific and personalized interventions for each individual in a population, irrespective of age or health status, and are delivered to consumers by phone, mail, Internet and face-to-face interactions. American HealthWays is contracting with a number of Blues plans and large employer grous. Niche companies, led by physicians and often using Internet technologies, are springing up at the edge to supply workplace health services... These include onsitedoctor.com and teladoc.com. These various efforts could be characterized as disease management at work."

On January 14, three days later, the New York Times carried an article entitled: "Company Clinics Cut Health Costs," with these opening two paragraphs.

“Frustrated by runaway health costs, the nation’s largest employers are moving rapidly to open more primary care medical centers in their offices and factories as a way to offer convenient service and free or low-cost health care.
Within the last two years, companies including Toyota, Sprint Nextel, Florida Power and Light, Credit Suisse and Pepsi Bottling Group have opened or expanded on-site clinics. And many employers are adding or planning to add even more clinics, which were experimented with about 30 years ago but fell out of favor amid questions about their cost-effectiveness.”

2) To write of how patients and doctors can create clinical partnerships, communicate with each other better, and strengthen the patient-doctor relationship. I have done this with a 20 part series on “Building Patient-Doctor Trust” and a current series on “Your Doctor and You.”

3) To direct you to the work of other bloggers who are contributing significant insights into the inside workings of the healthcare system.

That said, I bring your attention to this January 23 blog, http:///www.healthcareguy.com “Improving Patient Communication Often Leads to Improved Healthcare,” by Shadid N. Shah, CEO of Netpective, a software consultancy delivering in-house, outsourced, and offshore solutions.
Here’s an excerpt.

What I liked about Emmi was that it facilitates physician-patient communication by providing “prescription-strength” multimedia programs to help patients understand what to expect before, during, and after a surgical or invasive medical procedure. As most of us who’ve been in this industry for a while intuitively get, the more a patient knows and understands about their care providers, their diagnoses, and their procedures, the better the patient’s overall health is likely to be

And this January 22 bog, www://www.thehealthcarelblog.com by Matthew Holt, a noted healthcare analyst and astute observer operating out of San Francisco., This particular blog, “A Nice Conversation with Brent James,” features an interview with Brent James, M.D., Dr. Brent James at Intermountain Health Care in Salt Lake City, is a giant in health care, a physician who has provided national leadership on the quality, safety and industrial processes movements. He is executive directors of the Intermountain Institute for Health Delivery Research in Salt Lake City. He's been active at the Institute of Medicine, and recently served as a panelist on the Citizen's Working Group in Healthcare. At 11,956 words, this may be the longest blog on recent record, but it’s worth the read if you are a thoughtful observer of the American healthcare scene.

A Limerick Medical Blogging Challenge

A doctor turned literary critic
challenged me to blog a medical limerick.
I thought for a while,
Then with a smile,
A dozen limericks I blogged double quick.

A medical blogger thought his blogs bright,
He considered them faster than light,
Until he sent one out one day
in a relative way
and it returned the previous night.

John Donne said no man is an atoll,
Expression is the need of our soul,
Now we start blogs,
To better our nogs.
And sit atop the literary honor roll.

There once was a blogger named Reece
Who thought his blogs should be for lease.
A blog reader told him off,
with a sneer and a scoff,
But Reece still blogs on without surcease.

For years it has been an end of mine
To write a blog for a friend of mine.
This man is a medic
(a genus pathogenic)
Who else would be a friend of mine?

Your blogger is a bald-headed male
Who writes comic poems without fail.
This Prince of the Grin
To whom Fun is Next of Kin
Now grips the health system by the tale.

Among the computer cognoscenti
Especially those on EHRs hellbenti,
It is widely held
And often yelled
The future belongs to digital literati.

In these limericks every line has been clean
not a word that’s profane or obscene
Or spelled by four letters
That might pain my health betters
Or demean them – if you know what I mean.

There’s a old blogger in Old Saybrook,
Who believes the health world he has shook,
But, why do you think?
To his blogs they link,
It’s because they link by mistook.

A health blogger should cultivate brevity,
With a suitable leaven of levity.
In short, be terse,
For nothing is worse
Than interminable verbal longevity.

A blogger is like a rare old pelican
His bill holds more than his belican
He can take in his beak
Enough words for a week
I’m darned if I know how the helican.

Not all of these limericks are original,
Some may even strike you as aboriginal,
But whatever your take,
Whatever criticisms you make,
Blogging a dozen is not trivial.

Health Care Innovations for 2007 - Presentation before Comprehensive Health Solutions, Inc, Tuesday, January 23, 2007

A Coffee-Pot Theory of Health Care:
Boil It up from the Bottom Before
Percolating It Down from the Top

This talk will turn 180 degrees away from what other speakers are saying. These speakers are top health care lawyers, officials from the Department of Justice, the Office of Inspector General, the Centers of Medicare and Medicaid, and compliance experts. Other speakers work at the health care summit. I work in the trenches of care. I’m a bottom-up boiler, not a top-down percolator.

Government’s Role

In my view, the government’s should not only rule and regulate. Government should create a nourishing environment for health care innovators. The U.S. government doesn't create the health care economy. Entrepreneurs, innovators, and companies do. For the U.S. economic and physical health, we must balance the energy of entrepreneurs against the stagnation of regulation.

I champion private innovation and entrepreneurship. The U.S. health system’s success, and that of the economy as a whole, depends on vibrant innovation, health care decentralization and creative use of information technologies– not on government regulation. What happens in the field, not what occurs in Washington. D.C., is what matters.

Oh, I know government is the 800 pound gorilla at the Top of the Summit, the King Kong of Payers, and the Sheriff of the System. But government isn’t innovative. It makes the rules, but it doesn’t provide innovative tools.

If you provide care on the ground, innovation is within your control; policy decisions from the top-down aren’t.

One Workable Idea

If you carry away one workable idea from this talk, I will have succeeded, and you may further you success too. Here are four innovation examples.

• Create a Chief Innovation Officer for your organization.
• Delegate a nurse to manage a preventive program for uninsured ER “frequent fliers.”
• Install video and audio bedside modules for homebound patients.
• Organize an innovation team to brainstorm new ventures.

Action This Year

This year Democrats will push universal child coverage, government negotiation of Medicare drug prices, information technology incentives, and policies for covering the uninsured. Republican governors from Massachusetts and California have leaped upon the universal coverage bandwagon.

Not only government is engaged. On January 18, a broad coalition of business and consumer groups, doctors, hospitals, and drug companies unveiled a major proposal to provide health coverage to more than half of the nation’s 47 million uninsured. The coalition proposed expanding federal benefit programs and offering new tax credits to individuals and families.

The proposal, released after more than two years of work, was endorsed by 16 groups including AARP, the American Hospital Association, the American Medical Association, the Blue Cross and Blue Shield Association, Johnson & Johnson, Kaiser Permanente, Pfizer and the Chamber of Commerce of the United States.

“This is a proposal not for mandates but for incentives,” said Dr. Reed V. Tuckson, senior vice president of UnitedHealth Group, one of the nation’s largest insurers. “It’s a careful balance of public and private solutions.”The two key words here are “incentives’ and “balance.”

As we go through our political process, we should heed warnings from Europe. Stephen Pollard, Center for the New Europe Conference, says: “It would be the ultimate irony if the U.S. were to embrace single payer at the very time when Europeans are discovering competition and choice.”

As John Naisbitt points out in new book, Mind Set! in a chapter “Mutually Assured Decline,” Europe beats with two hearts – one offering comprehensive social welfare benefits and the other promising economic supremacy. You cannot have both. These two incompatible hearts, which beat in different rhythms, will likely result in mutually assured economic decline, and turn Europe into a historic theme park for well-off Americans.

My Purpose and Message Today

My purpose today is not so speak of universal coverage but to speak of incremental marketplace innovations you may see in 2007.

I define innovation as doing things better, quicker, differently, and more cost-effectively, even if it disrupts the usual way of doing things.

My message? Innovate and control your destiny, and someone else will.

Start of Road Show

Think of this talk as a road show. The show starts with my article in the August 2006 healthleadersmedia.com. There I described five major new directions for 2006.

1. Information technology tools for consumers to better manage and pay for care.
2. Consumer-driven healthcare.
3. Chronic care management.
4. Public-private partnerships to manage Medicare and Medicaid recipients’ care.
5. Customized ambulatory care centers and retail health chains.

In my healthleaders article, I outlined this consensus for 2006 of top ten innovations among 100 national health care experts whom I polled.

1) Pay-for-performance programs.
2) Introduction of electronic health records into medical practices.
3) Add-ons to EHRs--instant medical histories, coding devices, prescription-enabling modules, or Web sites that permit registration, virtual visits, prescription refills and open-access scheduling.
4) Software facilitating prescribing from office.
5) New practice business models (concierge, cash and retail).
6) High tech/high touch remote patient monitoring with patient interactive capacity.
7) Personal health records with and without EHRs.
8) Disease management programs.
9) Transparency as part of the consumer-driven care movement.
10) Software enabling self-care, self-service and self-empowerment of consumers.

Book

When asked to talk, I was writing the following book.

Innovation-Driven Health Care: 34 Key Concepts for Transformation
Richard L. Reece, MD,
ISBN 10: 0763746819
Price: $64.95 (Suggested US List Price)
Cover: Cloth
Pages: 400
Copyright: 2007
Bartlett and Jones will publish: 03/29/2007

2007 Expectations

From that book and other sources, here’s what I expect in 2007.

• Employer emphasis on HSAs, Consumer-Driven High Deductible Plans, consumerism, and workplace wellness.
• A web-based consumer revolution, Revolutionhealth.com backed by $500 million from Steve Case of AOL fame being a prime example.
• Call for government negotiation of Medicare drug costs and closure of the donut hole.
• Efforts to expand coverage at state and federal levels.
• A gradual policy shift will occur from illness to wellness– with greatest payments still on the disease side of the ledger.

Preventing disease and encouraging wellness is still more talk than action. Diseases are tangible and concrete; wellness is intangible and abstract.

At a more abstract level, we all know, or think we do, what the main lever for change will be – sweeping transparency and accountability reform through local, regional, and national data-sharing. This also is more rhetoric than reality.

Web-Based Innovations

Web-based innovations will flourish in 2007. For one thing, spreading the word by the Web is efficient. The Web lends itself to creativity and standardization across the enterprise and across the nation. For another, computers are becoming ubiquitous.
Web solutions will,

. help patients actively control their health;
• educate patients to understand their condition so they can comply with medical instructions;
• intervene at every medical interaction, communicate, and document exactly what to expect and what to do;
• aggregate and use captured documented exchange data to enhance care, improve outcomes, save time, and reduce risk.

Two countervailing realities, however, keep raising their heads.

• One, consumers lack real-time, relevant, and understandable information to comply with provider instructions or to change behavior.
• Two, many non-preventable diseases – Parkinsonism, Alzheimer's, ALS, MS, and non-smoking related cancers – are beyond consumer power to control.

What I Consider Innovative

What do I consider “innovative”?
• Emmi Solutions, Inc, Chicago, Ill: because it effectively educates patients with a pleasing voice, plain language, and precise illustrations of what to expect from the health system.
• Jewett Orthopedic Clinics, Orlando – because it has decentralized and gone out to patients by setting up seven outlets for minor orthopedic problems.
• MedAI, Inc, Orlando – because it has developed artificial intelligence techniques to help health care organizations make sound business decisions.
• Connextions, Inc, Orlando – because it has effectively used nurse callers and information technologies to manage health consumers in health plans of large corporations.
• Archimedes Project, Kaiser, Oakland, California – because it has used predictive modeling to manage major chronic disease decisions and to run drug clinical trials.
• Pavilion Healthcare, Wilmington, N.C. – because it has reached out to patients by setting up nine multispecialty ambulatory clinics in medically underserved North Carolina.
• Instant Medical History, Columbia, S.C.- because its founder has created easy-to-use software allowing patients to create their medical history before seeing their doctors.
• Bundled Bills, Oklahoma City, OK – because bundled bills combine hospital and physician costs for most hospital procedures and allow consumers to predict in advance what total procedural costs would be.
• SHAPE (Superior Heart and Pulmonary Evaluation), Mayo, Rochester, MN – because its developers modified existing cardiac and pulmonary tests to predict fitness and future chances of hospitalization and death.
• MinuteClinic, Inc, Minneapolis, MN, because it led the charge to bring affordable care for minor procedures in retail outlets.
• Big Boxes, Duluth, MN, and elsewhere – because it shows hospitals and doctors can work together and invest together in large one-stop facilities of benefit to all concerned.
• MedDirect, Inc., Grand Rapids, MI, a web-based company that offers convenient lines of credit and financing for patients and corporations at the point of care.

Five Road Stops

Now let’s visit five stops along the innovation road.

Software City
Consumer City
Chronic Disease City
Retail City
Capital City

Destination One, IT City, Home of Software Developers

1) Emmi Solutions, Chicago, step-by-step, encounter-by-encounter, documented instructions of what’s about to expect and what to do.
2) Artificial intelligence and predictive modeling, MedAI (Orlando) Archimedes (Kaiser), SHAPE (Mayo).
3) “Transparent” health plan websites, e.g. doctors and hospital fees and Rx calculator, Aetna leading charge, United Health and Humana not far behind.
4) You Take Control, Inc, y-t-c.com, a company for consumers to protect sensitive information, Richard Dick, PhD.
5) Hospitals revealing prices in advance. St. Lukes Health System, Kansas City, Missouri,
6) Physician websites for scheduling, Rx refills, email messaging, patient education,
7) Medfusion, Inc., Raleigh, N.C
8) Connextions, Inc., a customer management company, headquartered right here in Orlando.
9) Hospital-physician bundled billing, particularly for elective high-tech procedures, personal experience.
10) Integrated community records aligning 7 hospitals and 4 doctor groups in Northwest and Alaska, PeaceHealth, Bellevue, Wa

Destination Two, Consumer City, Where Consumer Empowerment People Live

1) Health Savings Accounts and High Deductible Health Plans Growth, destined to capture ¼ to ½ of health plan markets by 2011.
2) Employers and their perception that consumer-driven care is only practical alternative short of single payer.
3) Health plans’ positive experiences (so far) with high deductible plans, e.g., Aetna’s report on first 1.6 million since 2001 12% preventive services growth, 70% rollover of unspent funds, cost rise,1% per year for HRA and HSA holders.
4) On economic front, Steve Case’s comprehensive website, Revolutionhealth.com and his acquisition of multiple health companies, backed by $500 million and his support, with intent of “revolutionizing” health care by empowering consumers.
5) On political front, Newt Gingrich, Center for Health Care Transformation, a feeding center of the media.

Destination Three, The Biggest Megapolis of Them All --Where Old Folks and Chronic Disease People Live

1) Aging population, “Demographics is destiny, a future that has already happened”
2) 150 million with chronic disease
3) 70 to 90 percent of present costs
4) Medicaid (53 million) and Medicare (42 million) populations
5) Private-public partnerships to handle problem, American Healthways, Pfizer Health Solutions, Medicaid HMOs with Medicare and Medicaid the prize markets up for grabs.
6) Shift to preventive side of market for the chronically ill -- in Medicare & Medicaid, in health plans, and among employers.

Destination Four, Mall City, Where You Can Get It Retail – and Wholesale

1. Walk-in specialty clinics, e.g. the Jewett Orthopedic Clinics here in greater Orlando area
2. MinuteClinics, acquisition by CVS with 6150 stores, acquisition of Red Clinics by Revolution Health, and other players, with plans for hundreds, probably thousands of retail clinics in Walgreens, Walmarts, and national drug stores, grocery chains, and national discount stores.
3) ProHealth Physicians, Inc., entry by physician into retail clinic market, a signal that doctors are ready and willing to join the competitive fray.
4) Urgent care centers, Urgent Care Association of America, 15,000 strong, expanding and ambitious
5) Onsitedocs.com, Teladoc.com. – doctor-led companies expanding outside physician offices
6) Big Boxes and Big MACCs, with and without hospital ties.
7) “Focused Factories,” Herzlinger, focusing on diseases like diabetes and AIDs, not yet viable because they lose money on sick patients.
8) “In-house clinics” in many national corporations.

Destination Five, Capital City, Where Money Lenders Reside

1) Venture capitalists have gravitated back to health care after physician management firm and dot.com collapses. They recognize health care is economic engine driving most communities, and nation as a whole.
2) Real estate developers and construction firms are providing capital because unprecedented hospital, outpatient, rehab, and other health facilities building boom underway – spurred in part by medical technology wars and by expanding population, 300 million +, 12.3% over 65.
3) Capital needed for large cancer and heart centers with two hospitals collaborating as partners in many communities. 50 heart centers in U.S, at least 5 two-hospital partnerships, Springfield, Ill., Waterbury, CT
4) Capital in the form of lines of credit for patients at the point of care, Meddirect, In, (meddirect.net) in Grand Rapids, MI
5) To repeat, new capital partners, e.g., construction firms and real estate developers, DeWitt Healthcare, Raleigh, N.C,
6) New practices and new startups capital sources, newpracticestartups.com ,primecareamerica.com, Cain brothers, and others.

Things to Watch for on Your Journey

On your journey, watch for:
• New practice vehicles
• Toll booths
• Big Ideas
• Speed Bumps
• Megatrends

As you tool along, watch for these new practice vehicles

1) New practice models, concierge, group visits, cash-only (direct pay) practices, retail clinics, SIMPD.com (Society for Innovative Practice Design) in search of physician satisfaction.
2) Consolidated large practice models – single and multispecialty – in search of infrastructure and efficiency.
3) Integration models based on Mayo model or other forms of integration, Carilion Clinic, Roanoke, in search of cutting cost.
4) Practices centered around Big Boxes, essentia.com, Daniel Zismer, in search hospital-physician joint equity.
5) Big MACCs (Multispecialty Ambulatory Care Centers), in search of new markets and more physician control.
6) Academic-Faculty joint ventures, Beth Israel, Boston, in search of new revenues (125 medical schools).
7) Competing hospital cancer and heart joint venture centers, too costly to go alone, in search of ½ a pie or none at all.
8) Remote care models, home-based, in search of patient independence, better outcomes, few re-admissions.
9) “Integrative” Care Centers, Duke University, and chains of cancer centers, in search of more holistic care and patient satisfaction

Smart Card Tollbooth and Big Ideas

To pass through the tollbooth, just swipe your smart card containing your HSA and personal history,

As you near your final destination, keep these big ideas in mind.

1) Predictive models based on large databases, watch for battles of databases.
2) Decentralization outside of hospitals, off-site ERs and clinics, and often in rehab facilities or home care, doctor-owned ambulatory care.
3) Going where paying consumers work, play, and retire – exurbs and rural areas,” “hit ‘em where they ain’t.”
4) Card-swiping of smart cards containing HSA and personal health information, with prompt payment at the point of care.
5) Aggregation of data to estimate costs of episodes of care, which may vary by factors of 5 to 20.
6) Consolidated consumer databases reflecting “wisdom of crowds,” the google-factor.
7) Consumers as free and willing data entry clerks– examples: ATM, gas stations, super markets, airports, instant medical histories, personal health records, HSA smart cards.

Really Big Ideas

“The Biggie,” Systems Engineering – “Science and process engineering will help bring health care per capita costs down before we reach the breaking point.” George Halvorson, CEO, Kaiser, Personal Communication.

A) SOP Care ( Systematic, Organized, and Purposeful Care) by big organizations (Kaiser, Mayo, VA, other integrated systems, health plans, and big IT companies)

B) SOAPWare for small practices (SOAP stands for Simple Object Access Protocol) , a computer communication platform that might be better called Systematic Organization of Assessments, and Plans (AllScripts, NexGen, GE, SOAPWARE, Inc, eclinicalworks, doctor notes, and 100 other vendors, large and small.

Speed Bumps along the Way

1) Viability and workability of Regional Health Organizations (RHIOs), competitors reluctant to share data.
2) EHRs and PHRs without subsidies, only 15-25 % of doctors now have EHRs, fierce resistance and skepticism by many doctors.
who see nothing to gain by radically changed practice flow and patterns without economic gain.
3) Pay-for-Performance without adequate bonuses, favor large practices, but 80% of docs in small practices.
4) Transparency across the system seems doubtful.
5) Pay-for-Performance as outcome-improving and cost-cutting tool.
6) Regulation reduction or elimination not easy, the Stark truths.
To Stay on the Road
1) Focus on health and consumers.
2) Create new consumer options.
3) Decentralize,
4) Partner with physicians.
5) Ramp up IT.
6) Explore transparency.
7) Seek new capital partners.
8) Combine health-focused with disease-focused care.
9) Innovate: it’s never too late.

Churchillian Conclusions

As Winston Churchill observed:

1) “The inherent vice of capitalism is the unequal sharing of blessings. The inherent virtue of socialism is the equal sharing of miseries.”

2) “In the end, Americans will always do the right thing, after they have exhausted all the other possibilities.”

The future system will not be perfect but it will be kinetic, free-flowing, and full of winners – and losers.

Next: Because you’ve been so patient slogging through this long blog, I will give you and me a rest for the next three days while I’m in Florida giving this presentation. I will resume blogging with an off-beat piece called “A Limerick Challenge.”

Digital Doubts -- More Perverse Verse

I have lingering deep-down digital doubts,
computers can storm all human redoubts.
can watch-over, make-over, and take-over
all patient-provider check-ups and fallouts.
No matter what the software rendition,
you cannot program the human condition.
In the end, I suppose you could say,
If dogmatic digital doggerel is okay,
You cannot out-google,
Every human boon-doogle.

Hickory Clickety Doc.
Hickory Clickety Doc.
The computer mouse ran up the clock.
The mouse rang up $’s on the clock.
Every step of the way,
every minute of every day,
the Doc had to pay,
despite practice flow disarrays,
staff training, and other delays,
and no clear or obvious
returns for financial outlays.

Next: Presentation before the National Summitt on Quality/Performance, Management& Compliance in Healthcare, Comprehensive Health Solutions, Inc., Orlando, Florida, January 23, 2007

Your Doctor and You - Seventh in a Series

Young, Healthy, Single, and Seeking a High
What Can Doctors Do?

What can doctors do about prescription drug “borrowing” and “prescribing” by one young person to another, or for that matter, obtaining these drugs over the Net?
Not much. But doctors can be alert to misuse symptoms – deterioration of school performance, lassitude, agitation, inappropriate behavior.

Multiple Drug Misuse in Heroine Users

They can also recognize that “doctor shopping” leads to “polypharmacy,” the use of multiple drugs. This is common among heroin users. In fatal deaths from heroin, multiple drug use is reported in 90 percent of toxicology reports. Prescription drugs were present in 80 percent of subjects. Subjects aged 14 to 24 years dying of overdoses use medical services six times more frequently than the general population. More than half of prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics.

A pattern of increasing drug -seeking behavior in the years before death was identified, with doctor-visitation rates, increased number of different doctors seen. Prescriptions peaked in the year before death (Data cited above from various Oregon studies, of heroin deaths, including Heroine Overdose Deaths --- Multnomah County, Oregon, 1993—1999).

Drug Access Techniques

Young adults trade unused prescription drugs, get medications without prescriptions from the Internet, and, in some cases, deceive doctors to obtain medications they think they need. It’s illegal to give prescription medication to another person, but the offense is rarely prosecuted.

Moving to the Beat of a Different Drug Drummer

Present practices of young adults giving mood-altering drugs to peers have a different goal than use of marijuana, cocaine, or powerful painkillers. These young adults don’t want to get high. They want to feel better - less depressed, less stressed out, more focused, better rested. The quickest route to this blissful happiness that end often seems to be medications for which they do not have a prescription.

A Pill for Regulating Every Mood

Some seek to regulate every minor mood; some want to enhance their performance at school or work; some simply want to find the best drug to treat a genuine mental illness.

Young people say many general practitioners, pressed for time and unfamiliar with the ever-growing inventory of psychiatric drugs, are happy to take their suggestions. Young prescription abusers have learned it pays to be informed. You can use your expertise to influence or manipulate primary care doctors.

Health Officials Worry
Health officials say they worry that as prescription pills get passed around in small batches, information about risks and dosage aren’t included. Even careful self-mediators, they say, may not realize the harmful interaction that drugs can have when used together or may react unpredictably to a drug.

Reflecting the Culture

Young people mirror America’s culture – a culture largely devoid of formal rites of passage and often unobservant of the few that exist.

Consequently, young people may make up their own rites of passage. These include feeling good at all times through drinking, drugging, and prescription drug use.

Contributing to Medicalization

These behaviors may well be a carry-over from the “medicalization” of untoward behaviors when young adults were going through school. Doctors may unwittingly contribute to this later behavior by prescribing mood-altering drugs to students referred to them by school authorities or parents. Drug prescriptions among the young meant to counter depression, anxiety, and mood or attention disorders went up 250 percent from 1994 to 2001 (Brandeis University Study).

Targeting Boys

Prescriptions for hyperactivity, attention deficit syndrome, and bad behavior most often target boys. One of every ten boys who visited a doctor during this time period left the doctor’s office with a prescription.

Of this phenomenon, conservative commentator Thomas Sowell commented,

“The motto used to be ‘Boys will be boys.’ Now it is ‘Boys will be medicated.’ The 3Rs have become Repression, Re-education, and Ritalin.”
The doctor culture may have created a counter-culture.

Wrapping Up

Doctors can't control swapping of information on prescription drugs or giving of these drugs to friends. The Internet has changed our culture. The young can now go directly to the Internet to learn about the psychopharmacology of these drugs. Many feel they know just as much as doctors, who are hard pressed to keep up with new drugs pouring out of pharmaceutical company pipelines. Also these young people can learn from Internet support groups, like CrazyBoards.org, and they are perfectly capable and competent of using the Internet to order drugs from Canadian pharmacies and other sites. Also, through email and one-to-one relationships, the young are accustomed to exchanging highly personal information, an unthinkable behavior in previous generations.

Your Doctor and You - Sixth in a Series

YOUNG, HEALTHY, SINGLE, AND SEEKING A HIGH: CONFESSIONS OF A USER

”The weller you are the more drugs you can take without getting sick.”

Eugene Stead, MD, “Aphorisms from Eugene Stead, Jr.,” Annals of Internal Medicine, 1968

You’re under 25. You’ve rarely been sick in your life, except for a bad cold or perhaps a bout of mononucleosis or an athletic injury.

You don’t worry much about health insurance. Why spend money on health care premiums, when you have electronic toys, clothes, and cars to buy; boys or girls to chase; places to travel; events to attend, parties to go to; and pleasures to pursue.

Speaking of pleasures, you’re in the fun phase of your life. You’re healthy. The world’s your oyster. You have new things to try, new things to do, new experiments to undertake– before age and reality force you to settle down.

Occasionally, at parties with your friends, you try a drug or two, a new drink, a drag of marijuana, or a street drug.

You’ve heard prescription drugs alter your mood and give you a high. You can get prescription drugs and don’t ever have to see a doctor. You have friends whose parents are addicted to pills, and you borrow from them. You have other friends who take drugs for their ailments. They get lots of pills and sell them cheap. You don’t worry. As long as prescription drugs are taken right, they’re much safer than street drugs.

You’re an Internet browser. There you learn about mood and mind altering drugs and their main and side effects. You can even order drugs online.

In a democracy, you’re free to exercise choices, to do what you want to do. You’re bent on pursuing happiness, no matter what the risks. Life, Liberty, and the Pursuit of Happiness. Isn’t that what it’s all about?

The Doctor’s Role

Doctors are the only ones who can legally prescribe drugs. They tend to think you’ll follow their directions. You know better. In fact, you may know more about these drugs than they do. Besides, you can always google and bring up this kind of information from the Boston Consulting Group and Harris Interactive.

Imperfect Patients

Many patients say they do not follow doctors’ orders. They cite a number of reasons for not taking their prescribed drugs.

In the past 12 months have you…

not filled a prescription 18 percent

sometimes forgot to use or refill 24 percent

delayed filling a prescription 26 percent

didn’t want the side effects 20 percent

taken a medication in smaller doses than prescribed 14 percent

the drug costs too much
17 percent

taken a medication less often 30 percent

don’t think you need the drug 14 percent

stopped taking a medication sooner than prescribed 21 percent

couldn’t get the prescription 1o percent
filled, picked up, or delivered

If doctors can’t control how their own patients follow prescriptions, how can they expect young people like you to follow doctors' instructions? Doctors can’t. That’s why you experiment. You occasionally use drugs like Vicodin and Ritalin. Why not? They’re easy to get. And you can mix them with alcohol or marijuana – anything for a high.

Sure, you hear occasionally about overdoses, even deaths, but that’s what happens to others – not to you. After all, you’re young and healthy. You have no where to go but up.

Your Doctor and You - Fifth in a Series

Fending for Yourself with Help

Most seniors, even those with chronic disease, are independent. You prefer to fend for themselves. But if you’re 75 or older, chances are you will need help. According to the National Council on Aging, most communities have centers for the aging offering help to improve the quality life, involve seniors in the community, and offer resources to aid independent living.

Senior Center with Expanding Services

Most seniors, given their druthers, prefer to remain in their homes. In Old Saybrook, Connecticut, where I live, the Estuary Council of Seniors, Inc. serves nine communities along the Connecticut shoreline.

Among other things, the Estuary provides nutritional counseling and low cost meals at its headquarters, has nutritionists who visit homes, and sponsors active daily meals-on-wheels programs staffed by volunteers.

The Estuary also offers health and support services, including talks by visiting doctors and other health professionals and other program for patients and caregivers of victims of emphysema, diabetes, Alzheimer’s, and spousal loss.

Senior services support exercise classes, weight lifting programs, book clubs, income tax preparation, and computers. Most recently, the Estuary has expanded its transportation services to include ferrying patients to doctors, hospitals, radiation and chemotherapy sites, in the immediate community and throughout the state.

The Estuary prides itself as a center where you can meet, greet, socialize, and learn. If you’re ill, of course, you may need medical services in your home. This is often supplied by home care providers or by visiting nurses associations. There are also agencies that will supply caregivers to stay in homes during the day or 24 hours a day.

Best Care by Doctors Who Know You

Many doctors feel the best care is care provided by a doctor familiar with the patient’s history. This is the position of the American Board of Clinical Medicine and an organization called Bridges to Excellence, a bonus program for doctors supported by multiple businesses including GE.

Francois de Brantes, who oversees Bridges to Excellence and who manages GE health programs, says, “We pay disease managers to coordinate care because no one else is doing it, but all the evidence says care coordination is better if done by a doctor. “

Doctors Feeling Less Chained to Offices

This may be, for many doctors feel chained to their offices. That’s where they receive their income, keep their equipment, provide ancillary services, and maintain their staff. Those are among the many reasons; they don’t make house calls anymore. But that is changing. A survey by the American Association of Family Physicians indicate 19 percent of their active members make house calls.

Doctors are feeling a financial pinch. They’re now less reluctant to venture outside their offices into homes and workplaces for disease management. Reimbursement is low, and they’re losing money in their offices. They're beginning to welcome information systems linking them to home-bound patients and to employees in the workplace and to nurses. Additional compensation for coordinating care would also be appreciated.

Gray Panther Political Power

Seniors vote. They swing elections. Therein lies the power of the over 65 crowd. If you doubt this power, I invite you to look at the Medicare Prescription drug bill passed in December of 2004. Senior anger forced Republicans and Democrats to pass “some bill” – even though it meant an unprecedented increase in Medicare spending, from $300 billion to $400 billion in 2006. With 78 million baby boomers starting to turn 60 this year, gray panther power will intensify.

Summing Up

It isn’t a bowl of cherries to be elderly, sick, and alone. But there is help out there.

• Senior centers are expanding transportation, educational, food, and educational services.
• Caregivers are going to homes.
• Doctors are devoting their time exclusively to the elderly.
• Health plans, independent firms, and health systems are developing disease management services.
• Companies are creating and installing remote technologies, i.e., telemedicine devices your home to keep you constantly in touch with the outside world.

If you’re still unhappy with the system, you always have the option of exercising your political power. When AARP (The American Association of Retired People), 40 million strong, speaks, politicians listen.

Your Doctor and You -- Fourth in a Series

OLD, SICK AND ALONE

“Old age is not for sissies.”

Betty Davis

You’re over 75. Your friends are dying off. You’re divorced or widowed. You live alone. You’re one of 150 million Americans with one or more chronic diseases – arthritis, depression, hypertension, diabetes, coronary artery disease, heart failure, emphysema, Alzheimer’s.

You're frightened and confused about the new Medicare drug plan. Will you fall in the dreaded “Donut Hole,” or won’t you?

Your kids have moved and live in a distant warm weather state, most likely Florida, California, Texas, or a Southeastern state with a moderate climate. People are questioning your ability to drive, your last vestige of independence (“Older Drivers Fight to Stay on the Road,” Wall Street Journal, March 25, 2006).

You do not know quite what to do with the time you have left.

Should You or Shouldn’t You

Should you try to stay in your current home? That would be best. You want to maintain your dignity and independence. But it isn’t easy. It’s the simple things that are hard to do – cooking, shopping, and doing the laundry. Sometimes you need help dressing, bathing, and even doing ordinary toiletry. Where can you turn for help for these seemingly simple chores?

Should you sell the big house? Should you move into a condo? Should you consider an assisted living facility? Should you move closer to your children for family support? Should you get rid of your assets so you can qualify for Medicaid-assisted nursing homes?

These are scenarios and questions you face everyday. Doctors qualified to address problems of the elderly may not be available. A huge shortage of geriatricians exists in this country. The government is concerned. Chronic disease and long term care is costing a lot of money. Twenty percent of patients with chronic disease generate 80 percent of all health costs (in the management and economic worlds, this is known as Pareto’s Law – 20 percent of problems cause 80 percent of results).

Patients with Five or More Chronic Diseases

The Centers for Medicare and Medicare Services, says patients with five or more chronic conditions accounts for 23 percent of its beneficiaries but 68 percent of spending. These patients see an average of 13 different doctors each year and fill 50 prescriptions. By 2020, 25 percent of Americans will be living with multiple chronic conditions, and costs for managing them will reach $1.07 trillion (Source: Center for Medicare and Medicaid Services)

Medical Records, Medical Homes, and Home Monitoring

Some health plans are offering financial incentives to primary care doctors to invest in electronic medical records to improve care for patients with multiple ailments. With these records, doctors can coordinate care among multiple doctors and nurses.

The American College of Physicians, representing internists, the American Association of Family Practice, and the Academy of Pediatrics are asking to be paid more to establish a “medical home” in their offices.

The Centers of Medicare and Medicaid (CMS) have launched a pilot program covering 100,000 beneficiaries. CMS will pay eight companies, including Healthways, Aetna, CIGNA, and Health Dialogue to coordinate care.

Electronic Monitoring of Home-Bound Patients

One rapidly evolving trend is remote electronic monitoring of home-bound patients with small bedside video and audio units though. Through these units, chronically ill patients can initiate conversations with nurses and doctors and signal distress. Doctors and nurses, in turn, can see you, talk to you, listen to your heart and lungs through a remote stethoscope, and monitor your vital signs, your weight, and even your blood oxygen.

Next Episode of Your Doctor and You. Old, Sick and Alone. Fending for Yourself.

Your Doctor and You -- A Poetic Interlude

My recent outburst of three episodes of Your Doctor and You, you deserve a break. As John Asberry, the Pulitzer Prize winning poet observed in last Sunday's New York Time Magazine, "It doesn’t take so long to read a poem, and if you need a quick fix or consolation, you can get it. ”You will be interested to know that KevinMD.com, the most popular physician blog, and Revolutionhealth.com, destined to be the be the world's most comprehensive health are website, will mention my blog.

Prose and Cons of Blog Poetry:
More Pros than Cons, I Trust

To my astonishment and conceited great satisfaction,
My blog is finally gaining much needed gratis traction.
Traction is coming in the form of complimentary e-mails.
More often emails come from males rather than females.

As examples of these responses, still too few,
I offer as evidence these recent precious two.
One comes from one of America’s top health leaders,
The other comes from one of my anonymous readers.

From George Halvorson, Kaiser’s Chief Executive,
came this message in a series of sentences consecutive.
He is giving me personal thanks,
And saying with him rhyme ranks.

“Thanks for the blog.
Are you getting responses?
Hits?
Impact?
I love the idea of rhyme.
I wrote a few rhyming pieces in college.
We could be the Twin Poet Laureates
of health care blogging.
Just a thought.”

George, please note, chose to converse
in a poetic medium known as blank verse,
His mind is not blank, just his poetic prose.
He’s a frustrated poet to the tips of his toes.
Let us hope in rhyme he will now compose.

The other comment sprang from an unknown source,
too shy to let his or her identity be known, of course.
He or she has his or her likes and dislikes,
It depends on which gender mood strikes.

“Twas a dual of two poets..
I personally liked Richard Reece's poem
over Richard Brautigan's piece.”

Mame or Sir, whoever, you have your opinion,
even if it falls outside your literary dominion.
Choosing my poem over Brautigan’s piece,
is an amusing case of undeserved noblesse.

Now I am no Ogden Nash,
But I am making a splash.
Before you know it,
I will be a real poet.

It was the late poet Ogden Nash,
for those old enough to remember,
with a still intact memory cache,
who said one frigid day in December.

“I test my bath before I sit,
and I'm always moved to wonderment
that what chills the finger not a bit,
is so frigid upon the fundament.”

There you have it,
Before you know it,
I will be a poetic dandelion,
a widely known literary lion.

The following verse was written
For my fans who are poetically smitten.
Some call this dogmatic doggerel,
I proclaim it as fulsome folderol.

Roses are red.
Violets are blue.
Dandelions do,
what they want to do.

Your Doctor and You - Third in a Series

Ending Information Limbo

Here are your options for ending information limbo.

• Simply seek out a doctor with credentials on the wall with whom you feel comfortable and trust.

• Find your doctor through word of mouth, referrals from other doctors, asking your friends and relatives, calling your local hospital or medical society, or by leafing through the yellow pages.

• Go to healthgrades.com to find if doctors have been disciplined.

• Visit www.hospitalscompare.gov to see how the federal government rates hospitals for their treatments and outcomes of certain common diseases.

• Call your local hospital to see how many nurses they have on staff, and what the nurse/patient ratio is (the ideal NPR ratio varies from 1:1 in trauma units and operating rooms to 1:5 on general medical or surgical wards)

• Go right to the top by consulting America’s Top Doctors book or a referral service like America’s Best Doctors (www.bestdoctor.com).

• Proceed directly to a nearby well-known clinic or hospital with a good reputation. Hospital systems and academic medical centers pride themselves on having the best doctors and providing the best care.

• Look at your health plan’s website. It will have information on doctors and hospitals in its network, the website may compare costs of brand name and generic drugs, and it may even list the prices charged by its participating physicians.

• Gravitate to doctors who have practice websites. Most businesses across America now have websites. Why not doctors, too? Ideally practice websites will tell you how to get to the doctor’s office, the hours of operation, the credentials of the doctors, and will help you refill prescriptions, schedule appointments, educate you about disease, and allow you to consult with your doctor by email for minor non-emergency illnesses.

• Study your disease over the Internet, download relevant references, compile your questions, and then go to the doctor with your concerns. Doctors vary in how they react to Internet-savvy patients. Some doctors welcome well-informed patients; others regard them as misinformed. You may want to call ahead to see how the doctor might react.

• Tell your doctor you want to create an equal partnership with equal sharing of information, guidance to the best evidence, open-ended access, and economic mentoring about best values in health care.

Another Possibility

Another possibility is slowly evolving – patronizing doctors whose offices have electronic health record systems. Government, corporations, health plans, and consumers are pressuring doctors to install computer systems to generate electronic medical and health records. These electronic records, it is said, will make you safer, separate good doctors from mediocre doctors, and coordinate your care as you go from doctors’ offices to another, to hospitals, to rehab units, to your home.

Another Tack - Interviewing the Doctor

You may want to interview doctors before considering their services. That way, you can judge the personal chemistry and see if you can work with this person. You can ask them about their results, how many procedures they have done, and how their quality ranks among their peers.

This approach may work best if you are considering undergoing a major operative procedure. It may require confidence and an assertive personality.
I have a friend, the former CEO of a major company. He knew he had to have both knees replaced. He did not go to the Internet to find the best doctor.

Instead he personally visited four orthopedic surgeons, assessed the compatibility of their personalities, and asked how many bilateral knees that had done and what their results had been. The operation succeeded, and he is now walking without pain.

My friend says if had he had it to do over again, he would still go the interview route. Nothing, he says, can replace talking to a doctor in person before what needs to be done is done.

Your Doctor and You - Second in a Series

Information Limbo

“Limbo is not a good place to be.”

Bill Joy (1954- ), Chief Scientist and Co-Founder in 1982 of Sun Microsystems

• You’re confused.

• You have a chronic disease, not curable but controllable.

• You’re taking a drug to treat the diseas.and you have read the long list of side effects.

• You have seen the drug advertised on TV.

• You have googled the disease and the drug.

• You have joined an Internet disease support chat group.

• You remain befuddled about what to do.

Things aren’t going well. You’re still feeling ill. You’ve seen multiple doctors, each of whom has a slightly different opinion and who may have prescribed another drug. You’ve obtained a second, third, and fourth opinion.

You’re in disease information limbo.

Information Overload

You’re suffering from information overload. It’s nobody’s fault in particular. You’re doing the best you can to find straight answers. You want to understand the options. Your friends, spouses, and relatives are trying to help, but there is simply too much information to absorb and digest.

You’d like to trust the drug companies, but those long lists of side effects frighten you, and drug costs are becoming prohibitive. And even though drugs are field-tested and marketed at considerable expense and are Federal Drug Administration approved, you’re aware drugs like Vioxx harbor unexpected complications.

Your doctors are doing their best to prescribe the right drug, which to the best of their knowledge, works. But the media is telling you drug companies are unduly influencing doctors with luncheons, gifts, and consulting fees.

The Internet web sites – some containing neutral information, some biased with information relating to their product, much of it unfiltered by editors or experts – are trying to keep you informed – or to sell you something.

Parts of the Information Limbo Problem

Parts of your limbo problem are,

• No precise “scientific” answer exists for each individual patient for every problem. Everybody has a different set of genes and reacts differently.

• Much medical knowledge lies in the “gray zone.” Anecdotal stories may say something works, but solid unequivocal scientific evidence is lacking or conflicting.

• A subtle and sometime profound interaction exists between mind, body and spirit. This is the “placebo effect.” If you trust doctors, you respond better. If you believe a drug is helping, it will. Prayer may work but sometimes not(“Long-Awaited Medical Study Questions the Power of Prayer, New York Times, March 31, 2006).

• Then there is Internet misinformation. Internet vendors have a product to sell an ax to grind, and they grind it – whether it holds scientific weight or not. Infomercials hype products with “antioxidant” powers to destroy those “dangerous free radicals,” and you wonder if this is too good to be true.

• The “fragmentation” of the system contributes to your problem. Medicine is divided into 50 or so different specialties. Many specialties function apart from one another, and some specialists do not know what other specialists are recommending or prescribing. Presently no common patient record is accessible to all doctors that keeps all caregivers across the health care spectrum coordinated and informed.

• You may not be complying with the doctors’ instructions. As many as 30 percent of patients never fill their prescriptions, stop taking the medicine, fail to follow the dosage schedule, or randomly take the pills of spouses.

Next blog -- Ending information limbo

Tour Doctor and You - First of a Series

Navigating the System

This series will consist of excerpts of chapters from my unpublished book Your Doctor and You. These entries may be a trifle long for instant news-seeking and quick-reacting blog readers. Forgive me. I prefer depth to one-liners and balance to sensational revelations or late-breaking news. I am not the Jack be Nimble, Jack be Quick, Jack Jump over the Candlestick type. I don’t look for current greedy villains. I prefer quiet innovative heroes, many of whom I describe in my upcoming book, Innovation-Driven Care: 34 Key Transformations (Jones and Bartlett, 2007). I will occasionally break up the longevity by inserting a poem or two.

For many of you patients navigating the health system – finding the best specialists, avoiding the worst, selecting the right cosmetic surgeon, choosing a cancer doctor who knows most about your particular malignancy, picking the right health coverage, unearthing care you can afford, and finding help in settling disputed claims – has become an exercise in futility because of the overwhelming complexity of the system.

To whom can you turn? Your employer, your insurance agent, your doctor, your local hospital, your local medical society, or, Internet search engines, such as Google, Yahoo, Netstar, or soon, Revolutionhealth.com? These sources may help, but in the end you must help yourself as an informed consumer. In desperation, you may even want to turn to this blog.

Human Help Needed\

As good as the Web is for ferreting out health information, it is not enough. Human help is needed. I have tried to provide that help by writing this book for patients in different, sometimes difficult, economic, disease, and cultural circumstances.

This book seeks to instruct patients how to get the best care depending on your situation. i.e., whether you are healthy, sick, old, young, wealthy, foreign-speaking, poor, insured, uninsured, happy, unhappy, neglected by doctors, cultivated by doctors, afflicted with cancer or other dread disease, going to alternative practitioners, or just plain frustrated with the system.

Americans Generally Satisfied with Quality of Doctors, Nurses, and Hospitals

Surveys indicate most Americans are satisfied with quality of their health care: 86 percent are happy with their doctors and nurses, and 74 percent rate the quality of their local hospital as good or excellent.1

Furthermore, Americans are living longer than ever and are approaching an overall longevity of 80 years. Cardiovascular death rates have dropped by two-thirds since 1960.
We have the most advanced medical technology and medial science in the world.

• America has more Nobel Prize winners in medicine than the rest of the world combined.

• Eight of the ten of the world’s most important medical innovations over the last thirty years have been from America.2

• Companies selling eight of ten of the world’s top selling drugs are headquartered in the United States.3

Americans Dissatisfied with Costs, Uninsurance, and Inefficiencies

While Americans like their doctors and approve of the quality of care, they are not happy with the cost. In 2001, 71 percent said they unhappy with health care costs.1

This was higher than your dissatisfaction with crime or poor education. Moreover, according to a recent New York Times series, many of you are unhappy with various pitfalls, bear traps, and potholes in the system (see www.nytimes.com/health/ref/patient-series/html).

Health care defects include high prescription drug costs, long waiting lines, growing uninsurance, information overload, inefficiencies, and spotty quality. A host of critics have suggested how to reform the system. Some recommend government take-over. Others advocate a shift to a consumer-driven, market based system. 4-6

Credentials

I am a pathologist, writer, editor, speaker, and author of nine books, eight on health care, and one on my beloved French bulldog, Paris
.
This current book consists of my opinions and observations, refined and cultivated over the last 40 years, on patients and their doctors.

For the last seven years, I have served at historian for The Center for Practical Health Reform in Jacksonville, Florida. The Center espouses structural reform with private-public partnerships and wider coverage.

For the last decade, I have been on the Advisory Board of America’s Top Doctors (A Castle-Connolly Guide, New York City, 2005). America’s Top Doctors is an 1133 page volume containing lists, addresses, phone numbers, and credentials of more than 3000 top specialists nominated by peers and investigated by the Top Doctors staff.

Emmi Solutions, Inc

More recently, I have served on the industrial advisory board of a company called Emmi Solutions, Inc, in Chicago. Emmi stands for Expectation Medical Management Information. Emmi is in the business of educating patients about what to teaching patient what to expect from surgical procedures and chronic disease.

Emmi has come up with an elegant solution, - web-based programs featuring vivid videos guiding people through a soothing empathic conversational voice, plain language, and beautiful medical illustrations. A big part of our health system’s problem is that doctors and others have not taken the time to look and listen and teach – from the patient’s point of view with the right information patients understand at the right time presented in the right way.

Americans need to be more informed health consumers. But is up to we doctors to provide the information you need -- relevant, real time, at the right time when you need it the most.

References

1. “Survey Results on the Cost of Health Care and Health Insurance,“Market Strategies,: Livonia, Michigan, 2004.
2. Victor Fuchs and Harold Sox, “Physicians Views of the Relative Importance of Thirty Medical Innovations, “Health Affairs, 20 (2001), pages 30 to 42.
3. U.S. Council of Economic Advisors, Economic Report of the President, Washington, D.C., U.S. Government Printing Office, 2004.
4. John F. Cogan, R. Glenn Hubbard, Daniel P; Kessler, Healthy, Wealthy, & Wise: Five Steps to a Better Health System, The AEI Press, Publisher for the American Enterprise Institute, Washington, D.C, and the Hoover Institute, Stanford University, Stanford, California.
5. Richard L. Reece, MD, Voices of Health Reform, Interviews of Leading Health Care Stakeholders at Work, Options for Repackage American Health Care, Practice Support Resources, Inc, Independence, Missouri, 2005.
6. Rashid Fein and Julius Richmond, The Health Care Mess: How We Got Into It and How We Get Out, Harvard University Press, Cambridge, Massachusetts, 2005.

What It's All About

For those of you who remain in doubt,
Of what this health blog is all about,
In my next blog, I shall launch a new series,
to support and add to my health care theories.

I shall quote from my unpublished text,
“Your Doctor and You.”
This unknown volume, for better or worse,
has something borrowed, something blue.

This is how I will publish my book,
Even if by blog, hook, and crook.
The book tells of errors of commissions and omissions,
hospital admissions, and less than optimal conditions.

I will talk,
and I will not balk,
about what is, could be, and should be,
what patient-doctor relationships can be,

What the U.S. health system has wrought,
why patients and doctors are distraught,
how patients to doctors might ruefully relate,
about special circumstances and mutual fate.

About those vulnerable venrables called patients,
their different and difficult physician relations.
keeping patients well,
making them feel swell.

About heeding different patient circumstances,
talk of medical bankruptcies and low finances.
terrors of waiting,
fears of time abating.

About those who with cancer suffer,
the need for a holistic buffer,
unraveling clinical mysteries
listening to medical histories,

About how patients can relate,
faith and fate,
connecting,
resurrecting.

About patient-doctor fundamentals,
not accidentals or incidentals.
Patients and doctors are the backbone.
Their importance cannot be overblown.

In composing these chapters to follow,
I tried to make them easy to swallow.
I have followed this famous poetic advice ,
created by Kipling as a journalistic device

“I keep six honest
Serving men
(They taught me all I knew)
Their names are What and
Why and When
And How and Where and Who.”

Twelve Health Care Predictions for 2007

Thoughts from the Edge

Here are my top ten health care predictions for 2007. These are thoughts from the edge. From Megatrends, I learned trends start out there at the edge, away from Washington, D.C. From Edge Cities, I learned cities at the edge of major metropolitan areas are where the action and population growth are. From Edgeware: Insights from Complexity Science for Health Care Leaders, a VHA, Inc publication, I learned to heed these maxims.

•“When life is far from certain, lead from the edge.”

•“Tune your place to the edge.”

•“Go for multiple actions at the fringes.”

•“Listen to the shadow system, realizing that informal relationships, gossip, rumor, and hallway conversations contribute significantly to mental models and subsequent actions.”

So to the edge I go.

1.Home care will boom. A friend of mine started an edge business focusing on maintaining “dignity and independence” for the elderly in their homes by offering cleaning, transportation, and home care services. She can’t keep up with business. Home care, long thought to be at the edge of health care, is booming. It’s growing faster than any other health care sector. Home care is decentralization or, as the feds like to say “the declining concentration of health care,” at work. When people are old, sick, or dying, they want to be home. That is why home health agencies, visiting nurse associations, home hospice care, durable home good companies, and home monitoring technology firms, are growing fast – at the edge of the system.

2.The Universal Health Care movement will take shallow roots in states at the edge of the continent – California, Massachusetts, Maine, and Vermont. These edge states are where progressives hang out, and in the case of California, where legal and illegal immigrants flock and where big health care problems-- the uninsured, hospital bad debt, and untreated chronic disease—are huge. The California proposal may be in for heavy sledding. It drew this response from the San Francisco-based Pacific Research Institute.

"The idea that taxing physicians' revenue will cause them to provide more care of higher quality defies understanding," said John R. Graham, director of Health Care Studies at the Pacific Research Institute. "Instead they'll spend more time with accountants figuring out how to hide their incomes, or prospecting for new practices next door in Nevada or Arizona."

3.Consumer-driven high deductible health plans (CDHPs), powered by HSAs, have reached the tipping point and will explode in growth. This will occur because more employers will completely replace HMOs and PPOs with these new plans. Critics of CDHPs, such as the Commonwealth Fund and similar think tanks, say these consumer-based plans are an edge phenomenon, a cosmetic but not a real solution. But they may be wrong. Congress has just passed legislation to make HSAs easier to offer and to acquire, and more plans have low cost or free preventive services as incentives to join these plans. These three things – complete replacement by employers, Congressional easing of HSA entry and acquisition, and low cost of free preventive services – will tip CDHPs over the edge.

4.Workplace wellness and preventive programs will escalate as employers seek to prevent “presenteeism” (the feeling that one must show up for work even if one is too sick , stressed or distracted or disturbed to be productive), and to reduce absenteeism from work. In employers’ eyes, a healthy employee is more likely to be a working and productive employee, adding not subtracting from the bottom line. So far evidence indicates this may be true. Returns on investment in employee wellness and prevention programs have been in the 2:1 to 3:1 range. The development of sophisticated software to document this return and its bottom line impact is persuading employers to adopt these programs. With continually rising costs, many employers feel they have no other choice.

5.Taking care of health problems of employees, both on an acute and chronic basis, at the worksite will become a growth industry. American HealthWays has made a science of reaching chronically ill clients both at home and work with protocol-bearing nurse extenders. Their evidence-based programs provide specific and personalized interventions for each individual in a population, irrespective of age or health status, and are delivered to consumers by phone, mail, Internet and face-to-face interactions. American HealthWays is contracting with a number of Blues plans and large employer grous. Niche companies, led by physicians and often using Internet technologies, are springing up at the edge to supply workplace health services... These include onsitedoctor.com and teladoc.com. These various efforts could be characterized as disease management at work.

6.Web-based companies offering the right information at the right time, real time, at the point of care will create their own demand. These include companies like Emmi Solutions, offering relevant, timely, easy-to-comprehend patient education at every health care interaction; Medical Dialogue, offering automated and standardized informed consent forms; Meddirect offering credit lines at the point of care; and Active Health Management, which puts together all sorts of data from many sources, to help doctors and patients make clinical and financial decisions. The idea behind all of these smart, small, and swift-acting companies is to bring the creative potential of the computer to bear in a timely, time-saving, and time-enhancing as human support systems- real time at the right time.

7.As drug patents expire at an accelerating rate and costs rise, generics will grow, and pharmaceutical profits will drop, causing drug company lay-offs of sales reps, diversification, and expansion into other health sectors, such as chronic disease management. The public is sensitive to drug prices. Three quarters of consumers are willing to take a generic rather than a brand--name prescription drug. Trends driving the pharmaceutical industry include merger and acquisition activities, licensing barriers, government and payer cost constraints, patent expiration and generic competition, biotechnology-driven drugs, and aging populations

One new source of revenue for drugstores, but not necessarily drug company sales, may be fast-growing retail clinics – MinuteClinics, Rediclinics, and others – strategically located in Walgreens, Walmarts, drugstores, and grocery chains near prescription counters. Retail clinics, in which nurse practitioners and physician assistants can write prescriptions, are prospering at the edge of the health system. Their number will grow to 10,000 by the end of the decade.

8.Obesity will replace smoking as a social ‘no-no” and as the poster child for prevention and symbol of bad behavior. The prevalence of obesity (65 percent with BMIs of over 25, and 31 percent with BMIs of greater thn 31 percent) now far surpasses that of smoking (20 percent).Transfat bans will proliferate across the nation, employers will institute fat-control and fitness programs. Fat-loss drugs will become the Holy Grail, and the diet industry will continue to explode – and fail. Diabetic disease management will become a full-time industry. Technological devices to measure the precise adverse effects on cardiac and pulmonary function and loss of fitness, such as the Mayo-sponsored SHAPE (Superior Health and Pulmonary Evaluation) will become commonplace in health and fitness centers.

9.The “small is big” school of management, which preaches decentralization into smaller more manageable and productive units will spawn a whole new generation of consultants. Here is how John Naisbitt explains what is happening in Mind Set! “It is a shift to a new appropriate scale, right down to the individual, interplay among millions of individuals and companies, economic domains acting in there own interest. Growth and stability is the world is wholly dependent on the degree to which the world decentralizes. The bigger the entity of any kind, the more it must be made up of smaller and smaller, more efficient parts to be successful, The decentralization of companies mirrors the increased success of small, swift-acting entrepreneurial companies.

10.Web-based patient education will explode, for the simple reason that physician-patient partnership and understanding will be necessary to make a consumer-based health system work. Patients must know what is of value and what is not and what to expect and what not to expect at each health are interaction. Giant strides forward will occur as Internet companies seek to cut through the information glut and to reduce it to manageable size. The health care will be watching to see if Revolution Health’s website, revolutionhealth.com, Steve Case’s go at transforming the health care industry as his former company, American Online, transformed the dot.com industry. Case is betting that the growing ubiquity of computers – in homes, offices, kiosks, cafes, and libraries – will transform consumer-driven health care by making health information universally accessible, understandable, and actionable.

11.Baby boomers, 76 million strong and turning 60 every 7 seconds, and accustomed to having things their way, will severely stress the system. Part of the stress will come from “weekend warriors” undergoing knee and hip replacement for those joints, muscles, and tendons worn out or injured from incessant exercise and self-imposed sporting events. Another part will emanate from the perpetual young crowd who feel they need cosmetic procedures to remain looking and functioning in a forever young fashion. And the final part will come from genuine diseases of aging, which now afflict 150 million Americans.

12. There will be much talk but little action about “personalized” and “individualistic” health care as genomic research advances and individualized treatments based on predictive modeling mature. We’re still five years out on making this type of care a reality. Personal health records are much closer and are being subsidized by many companies for their employees. These personal health records may contain individual histories, allergy information, medications, lab data, even images of x-rays, CT scans, and MRIs, cardiograms, HSA and CDHP financial information. The next step will be genetic information and life style cues. Within two years, health consumers will be swiping smart cards at the entry and exit doors at doctors’ offices, ambulatory surgery units, and hospitals.

Cosmic Relief

Confessions of a Blighted Blogger

Believe me, it is gratifying to be considered cosmic,
but nettlesome typos can quickly render you comic.
Why not, you say, use spellcheck as a corrective cog?
Sounds good, but spellcheck changes “blog” to “bog.”
It is wonderful to be considered telepathic,
but what kills you is still the typographic.
Some astute readers of this daily blog,
say I must work in an acute pea soup fog.
Others point a finger at my mistakes.
and say I ought to do second takes.
You close readers are quite correct.
With spelling I may fail to connect.
Misplaced colons and commas I may miss.
For your diligence, I throw you a kiss.
As I write this Internet diary,
I may become lazy and tirey.
I strive too hard, as I just did, to rhyme.
In the process, I commit a verbal crime.
He who strives to be his own editor,
has a fallible fool for a word doctor.
When you’re close to the material,
your errors tend to become serial.
Nevertheless I thank you error pickers.
I need more people like you sticklers.
Without you and those of your kind,
I might become a legend in my mind.
This business of a daily bloggery,
is an open invitation to pettifoggery,
Readers are right about the small stuff,
But they have yet my big ideas to rebuff.
By the way, in closing,
just in case you’re dozing,
have you heard about the expert in punctuation?
He developed an acute intestinal obstruction.
He feared as a common period, life might end,
But a skilled surgeon came around the bend,
And instead of the expert’s life being stolen,
he survived and thrived as a semicolon.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Twentieth and Last in a Series.

Prospects for Universal Coverage

I will end this 20 part series on clinical innovation to build patient-doctor trust by addressing the issue of universal coverage. After a brief interlude of several days, I will resume blogging by publishing a 16 parts series consisting of chapters from an unpublished book of mine addressed to patients, The book was called You and Your Doctor.I

I don't believe single payer coverage from the federal government is in the immediate cards, but universal coverage in a few states may take place over the next two years. The coverage will be very much a trial and error thing, and it will evolve. The states will be the experimental laboratory.

Universal coverage might enhance the patient trust of doctors, since doctors would have less personal skin in the economic game, and patients would worry less about health bills. But this is sheer speculation, since most Americans or medical professionals have no direct experience with universal coverage.

I am familiar with the different mindsets shaping the universal coverage debate. I published Voices of Health Reform (Practice Support Resources, Inc, 2005). In that book, I interviewed 41 national healthcare stakeholders. These stakeholders came from across the ideological spectrum from conservative to liberal.

Any universal proposal gores somebody’s ox or adorns someone’s ideology or digs into someone's pocketbook. In interviews in Voices of Health Reform, conservatives said universal coverage would never happen because Americans deeply distrust government and the bureaucratic baggage that comes with it. Liberals said universal coverage had to happen if America is to have a moral, equitable, and compassionate society. From the interviews, I predicted gridlock would continue for the short term, and adjustments would be made to cut costs.

Short Term Adjustments

Over the short term, these adjustments are occurring. The latest federal data available (2005) shows U.S. health spending increased at the slowest pace in six years at 6.9 percent, the lowest rate since 1999. Prescription drugs costs decelerated, down to 5.8 percent, thanks in large part to drops in Medicaid drug costs, which rose only 2.8 percent. By far, home health costs grew the fastest, by 11 percent, a sure sign the healthcare industry is decentralizing, with services diffusing out to where patients live. Hospital spending (up 7.9 percent) and physician spending (up 7.0 percent) held steady over previous years.

Breaking Up of Gridlock?

The gridlock I predicted in my book may be breaking up. The Democrats, long champions of government-supported care, control Congress, and Blue States like Massachusetts, Vermont, Maine, and now California have universal plans on the table. I find the California plan, announced yesterday, January 8, which will cost $12 billion, the most interesting. It will cover 6.5 million uninsured, at least one million of whom are illegal aliens. It is a much bigger deal than in Masachusetts, which has only 550,000 uninsured.

I find he California plan intriguing. Why? Becasue many of those in the healthcare paying “buckets” I mentioned in the last blog supposedly will be enlisted to help the California state government pay for the coverage

•Businesses of 10 or more not currently offering coverage would pay 4 percent of their total social security wages to a state fund.

•Doctors would pay 2 percent of their revenues, and hospitals 4 percent of their revenues.

•Health plans would be forbidden from denying coverage because of age and health status and would be compelled to put 85 percent of their profits into health services, rather than marketing or administration. In other words, California plans to spread the economic pain; seeking “by-in” from all health care players, for the good of everyone.

Conventional Wisdom

These various state-based plans feed conventional wishful thinking that national universal coverage will start in the states, and then gain national momentum. This may be. State legislatures are growing weary of diverting costs from education and other state obligations to pay for health care. Employers are showing signs they want to get out of the health coverage business.

Whatever happens, and I am not smart or prescient enough to know what that might be, I believe we’re now about to engage in a great debate about universal coverage leading up to the 2008 election.

If this coverage can strike a reasonable balance between the forces for centralization in D.C, and forces for decentralization in the states, and if universal care can be pulled off by not dramatically increasing state taxes, such care might be achieved in selected Blue States, not yet in the nation as a whole.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Nineteenth in a Series

Health Care Mindsets and Health Care Buckets

I am slated to give the keynote address at a “comprehensive national summit meeting on quality/performance, management, and compliance in healthcare” in late January.

Most other speakers hail from the health care summit. They include government officials, compliance experts,Joint Commission surveyors, leaders of various health care organizations, business CEOs, consultants, and health care lawyers.

These bona fide experts look down from above. They oversee, regulate, enforce the rules, make sure federal mandates are met, manage the system, and otherwise strive to improve health care. On the other hand, I am speaking of innovations from the “bottom-up” – from the clinical trenches. Like other speakers, I too seek to improve the system, but from a different vantage point – through innovation to enhance the patient-doctor relationship.

At the meeting, I will introduce my coffee-pot theory of health care, as set forth in this title and subtitle for the talk.

Key Innovations for 2007

A Coffee-Pot Theory for the Health Care System
Boil it up from the Bottom,
Before Letting it Percolate down from the Top

One’s mindset about what is taking place depends on one’s point of view. If your mindset tells you health care needs to be seamlessly integrated for the common good under one national umbrella, you think a certain way. If your mindset says health care is running amuck, about to plunge over the economic cliff, taking the nation’s economy with it, you think another way. If you think health care is self-correcting, based on market-based feedback and smart health care consumers capable of judging and choosing quality care, your thinking framework differs.

Health Care as a Series of Buckets

I recently ran across this arresting statement by Clayton Christensen, a professor at Harvard Business School and author of such books at The Innovator’s Dilemma (1997) and The Innovator’s Solution (2003),

“The current health care system is divided into buckets. You have the insurers, the employers who put up the money, the providers such as doctors and nurses, and the hospitals. Because they exist as independent companies, they can each improve themselves, but they can’t re-architect the system in the way it needs to be changed.”

Christensen praises integrated systems, such as Intermountain Healthcare in Utah and Kaiser Permanente in California. He argues these systems work efficiently because they integrate buckets across the system. He says integrated systems are effective business models because they enforce “rule-based diagnosis and therapy.”

As an example of the power of “rules-based diagnosis and therapy,” he cites MinuteClinics, where this sign appears on clinic doors,”We treat these 16 rules-based disorders,” which include strep throat, pink eye, urinary tract infection, earaches, and sinus infections,” for $39 each with no waiting.

Christensen is persuasive. but I would point out three things:

1) Physicians delivering care at integrated systems like Intermountain and Kaiser currently comprise only about 10 – 12 % of America’s doctors;

2) MediClinics and other retail outlets aren’t usually part of integrated systems;

3) Patients fall into “buckets” too.

Patient Buckets

Patient “buckets” includes:

1)Patients seeking beauty enhancements – facelifts, tummy tucks, breast augmentation or reduction, nearsightedness correction by Lasers, hair transplants, cosmetic surgery, liposuction, varicose veins erasure, and Botox injections. For the most part, health plans do not pay for these treatments. The treatments have become subject to market forces and have shown dropping prices because of competitive forces..

2)Weekend warriors, mostly aging baby boomers, seeking lifestyle improvements - knee and hip replacements – so they can return to full-function. Health plans pay for these procedures, the costs of which remain high because they are performed mostly in separate hospitals’ and specialists’ buckets.

3)Patients suffering from life-style abuses - coronary artery disease, lung cancer, chronic obstructive lung disease, other smoking related diseases, obesity connected diseases (heart disease, congestive heart failure, diabetes, hypertension, dyslipidemias, and metabolic syndromes), cirrhosis, and esophageal varices. Insurers pay for treating these problems, as they should, but many patients may have a hard time getting insurance because of “pre-existing disease.”

4)Non-compliant patients – who do not follow doctor’s orders, do not fill their prescriptions, do not lose weight, do not exercise, and who resist doing what is good for them. Again insurers pay. In a capitalistic democracy, after all, individual freedom to do what one wants comes with the system. Part of the problem here may be that doctors do not clearly or effectively educate patients to the consequences of their noncompliance. Part of the problem is lack of money. Part of the problem is, well, people will be people.


5)Gravely ill patients with degenerative or fatal diseases of genetic, environmental, or unknown cause – childhood malignancies, cystic fibrosis, autism, most cancers, rheumatoid arthritis, rare diseases, or diseases of the nervous system (multiple sclerosis, Parkinsonism, amyotrophic sclerosis, Alzheimer’s). As a compassionate society, we are obligated to take care of these folks, no matter what the cost, no matter what bucket is involved..

6)Inevitable diseases of old age as our biological clocks tick down, and we end our life spans before five score years, no matter what we do or how we live. Death from old age is an inevitable outcome for us all. None of us are going to get out of this alive. We all fall into the same bucket.

Self-Evident Truths and Countervailing Realities

In my talk, I outlined these “self-evident truths,” many of which may smack of political incorrectness because they show some diseases are beyond the physician’s control, whether these diseases are “rules-based” or not. Although it is heresy to say so, many diseases are culturally-based and have little to do with the health system.

•People spend 99.9% of their time outside of doctors’ offices and hospitals, and many do what they want to do, no matter what the doctor says.

•Many patients do not follow doctors’ orders – 30% never fill prescriptions, 25% don’t get needed refills, and an estimated 90% avoid exercise.

•Many chronic diseases– heart ailments, COPD, cirrhosis, alcoholism, hypertension, diabetes, to name a prominent few-- are life-style related.

•Half-way technologies – stints, coronary bypasses, joint replacements, and statins –don’t eliminate underlying diseases or change their basic pathophysiology. In other words, physicians can’t save many patients once the disease horse is out of the barn.

•Many people dig their graves with their own teeth, hence, the obesity epidemic.

•The cultural environment and society’s habits limit what can do: modern technologies. For example, the love of cars, lack of sidewalks and footpaths, and the explosive growth of computers, video-games, TVs, and home computers – foster obesity.

•Gaps between expectations and results are inevitable and lead to disappointments, dashed expectations, and law suits.

Then I set forth two “countervailing realities” that make a huge new health system “bucket” -- consumer-driven market-based health care – impossible to apply across the health care spectrum.

•One, consumers lack real-time, relevant, and understandable information to comply with provider instructions or to change behavior.

•Two, many non-preventable diseases – Parkinsonism, Alzheimer's, ALS, MS, and non-smoking related cancers, or more simply, the ravages of old age and multiple organ failure – are beyond consumer power to control.

These “self-evident truths” and “countervailing realities” make health care what it is. It is personal and emotional. It is heterogeneous humankind in action and in decline.

It is difficult to apply rules in all circumstances and to set up a bucket brigade that covers all eventualities and to put out every fire ignited by dysfunctional separate economic entities, human misbehavior, and illnesses that strike for no apparent reason, “Acts of God, ” as they are called.

But do not despair.It is never too late to innovate, whether at the summit or in the valleys, to improve access, convenience, affordability, and to work to prevent early death.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Eigthteenth in a Series

Automating, Standardizing, Customizing, and Documenting the Informed Consent Process

For those of you not in the know, informed consent is communication between patients and doctors culminating in patients’ agreeing to undergo a medical procedure or treatment. The requirement for informed consent is embedded in statutes and case law in 50 states.

For the most part, informed consent relies solely on traditional written consent forms. These forms are often incomplete and may not fully explain a particular treatment or procedure to a given patient. Furthermore, doctor explanations vary from one doctor to the next, and patients tend to forget what was explained. These problems may lead to misunderstandings, patient safety lapses, and malpractice actions.

One web company, Dialog Medical, Inc., in Duluth, Georgia, has standardized clinical communication with an automated informed consent form customizable to the procedure. This novel solution standardizes communication across the enterprise, manages risk, complies with regulatory requirements, and documents informed consent encounters. Its automated informed consent form is now used in the Veterans Administration system, in many hospitals, and by 15,000 physicians.

Dr. Neil Baum, a New Orleans urologist, has written of the importance of automating informed consent in Patient Safety and Quality Healthcare, May/June, 2006.

“Hospitals and physicians are going to be challenged to improve the informed consent process. The government, the AMA, and other organizations of stature are demanding that the informed consent process meet all of the guidelines for truly informing the patient about procedures and tests. The automated informed consent is able to accomplish this previously daunting task. Not only are patients well informed but the risk of malpractice will be significantly decreased. As a result patients will be better informed and more compliant as they will not only be adequately informed but will also understand what is going to be done. The future of medicine will depend on hospitals and doctors making changes and adapting new technology that improve the quality of healthcare and the automated consent is just one example.”

Two Big Things Taking Place in Economic World

Two big things are simultaneously taking place in the economic world today – decentralization and globalization. Thanks to the Web, which transcends health care, business, and national boundaries, complexity is being reduced to simplicity at breakneck speed.

The Web lends itself to greater flexibility, creativity, customization, and individual freedom. In health care. computers make it possible to organize complexity into smaller and smaller units, and to automate solutions to complex problems for individual companies and individuals themselves.

Twenty Clinical Innovations to Build-Patient Trust: Seventeenth in a Series

Future Patient Education Will Need To Be Visual to Build Doctor Patient-Trust

“Both word and image will remain. But in many cases the written word will be replaced by visual representation, and literary narrative will be displaced by illustration. Within the changing communication mix of word and visual, the visual will dominate. The challenge is to ascertain the optimal mix of word and visual in each field of endeavor.”

John Naisbitt, Mind Set! Collins, An Imprint of HarperCollins Publishers, 2006

A picture, it is said, is worth a thousand words. In the future, it may be worth 10,000 words. Visualizing is simply quicker and more effective than verbalizing, though you need the right combination of the two.

This already holds true in physician education. For more than 20 years, The American College of Surgeons has contracted with Cine-Med, a company in Woodbury, Connecticut, which has produced more than 1000 videos for the College of Surgeons for training surgeons.

With widespread broad band Web access, other companies are producing visual web-based programs to educate patients. When it comes to the language of medicine, and medical jargon, and new medical procedures, web-based pictorial video programs may be worth more than a thousand words, for these interactive video programs can answer questions and teach patients with simple language and clear illustrations what surgery and disease portends, what patients can expect, and how patients can avoid complications.

Bariatric Surgery

Consider bariatric surgery, that field of medicine dealing with weight reduction procedures to treat morbid obesity (defined as being more than 100 pounds overweight). For every surgeon to give every patient an anatomy lesson in what will be done at surgery is difficult. But a simple picture, drawn by medical artists, and approved by surgeons, can help enormously in simplifying understanding of the surgical process. On Google, for example, you can images of almost any surgical procedure you can conceive.


Laporoscopic Surgery

Take laporoscopic gallbladder removal (now about 15 years in existence). With pictures, surgeons can explain why a “closed” gallbladder removal through the navel is much safer and less debilitating than “open” gallbladder removal.


Heart Bypass Surgery

What about coronary artery bypass, now performed on as many as 300,000 Americans each year. With pictures you can explain what is being done and the difference, for example, the reasons for a single coronary artery versus a five coronary artery bypass.



What about the two most common joint replacements done today – hip replacements and total knee replacements?

Hip Replacements



Total Knee Replacements




Graphics need not be restricted to procedures. They can be extended to include complications of procedures; what to expect during normal recoveries, and how to deal with doctor treatment and self-treatment of chronic disease.

Graphics can be downloaded to patients and families to view at their leisure. This is important because research has shown patients forget 85% of what they have been told 10 minutes after leaving a surgeon’s office. Graphics can be downloaded to become part of the medical record, should future misunderstandings about what was said and what was done conflict.

The Power of the Visual

If you doubt the power of the visual, I invite you to visit Google. Type in your search on any health care subject, and click on images. You will immediately get a series of images, without video or voice, of course.

Or go to YouTube.com, a popular free video sharing Website. YouTube lets users upload, view, or share video clips. Youtube.com was founded by three employees of PayPal, using Adobe Flash technology to display video. It is now staffed by 67 employees and on the 13th of November, sold to Google, Inc, for $1.65 billion. The YouTube site contains the following number of videos for these surgical procedures: bariatric surgery (56), laparoscopic surgery (65), heart bypass (23), knee replacement (35), and hip replacement (45).

Most of these videos are from surgeons, hospitals, ambulatory surgical centers performing the procedures. A few describe the patients’ experiences before and after surgery. The videos vary in quality and are not necessarily consistent, but they demonstrate beyond any doubt that a universally accessible visual world has arrived.

The visual, combined with the verbal, is powerful and will become an information and marketing staple of the health care industry.

.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Sixteenth in a Series

Health Care is Not a Business, or is It?

A doctor reader recently responded to one of my blogs, where I spoke of medicine as a market-driven enterprise that must respond to consumers. I used the success of retail-clinics as one example.

The reader commented,

“Health care is not a traditional market because the consumer feedbacks can take decades to emerge. A poor bypass operation looks like a good deal until it doesn't. How can a ‘consumer’ know that choice's value when the result isn't immediate? This is why treating health care as a free-market business isn't working. It's not a business. It's making people well and keeping them there. You can make money at it, but it is NOT a classic free market precisely because of the long lag in market information.”

I agree “health care” is NOT a “traditional market”, but I do not agree the reason is the “long lag in market information.” Sure, in some instances, health care can be a life and death matter where money is no object and the end is nowhere in sight.

On the other hand, in the case of retail clinic outlets, health care consumers are perfectly capable of judging value in terms of convenience, cost, and access. Consumers can judge waiting times, pain relief, symptom relief, and the ability to return to normal functioning in their job or in their life. These benefits can be immediate, and there is no “lag time.” My greatest fear is that nurse practitioners in these clinics will mistake a major emergency as a minor illness with tragic results.

The test of innovation in any business is: Do consumers want it, and are they willing to pay for it? That is true in health care, as well, and it is increasingly apparent consumers are willing to pay a $39 flat fee for treating minor conditions such as strept throat, pink eye, and urinary tract infections.
According to the 2007 predictions of Fierce Healthcare, a Washington, D.C. based newsletter:

“Though retail clinics may not become a household word among consumers this year, players in this niche will make dramatic progress in 2007. This year retail clinics will move from novelties to strategic business extensions of major health players. Specifically, integrated health systems will begin setting up retail clinics as a new form of satellite feeder site. Also, emergency departments building primary care diversion programs might consider it wise to set up on-site ‘retail’ style clinics. For simplicity, hospitals may still go to existing retail clinic providers like MinuteClinic with a strong connection to pharmacy dispensing and digital patient health records. If they don't, they still have the opportunity to avoid unneeded ED visits by situating a low-fee, physically attractive retail-inspired clinic which sees patients at rates EDs couldn't possibly match. What's more, the form of the retail clinic model should evolve, providing such additional services as laboratory testing, basic diagnostic imaging and small, integrated pharmacy inventories.”
Health care may not be a “traditional market” for major procedures such as coronary bypass, although increasing numbers of “medical tourists” are going abroad for heart bypass surgery. In the case of minor illnesses, consumers are responding like they are in a traditional market.

We doctors tend to use “business” in a pejorative sense and assume that businessmen are always “out for the buck.” I do not believe it, nor do I believe economics decisions do not occasionally influence physicians acting in their own economic best interest.

Indeed, newspapers have been running a recent spate of articles on the influence of economic incentives on doctors (“More Doctors Turning to the Business of Beauty,” New York Times, November 30, 2006, “Sales Pitch for Treatment,” New York Times, December 1, 2006; “Surgeon Kept Quiet about Stake in Company,” Cleveland Plain Dealer, December 10); “Spine as Profit Center: Surgeons Invest in Makers of Hardware,” New York Times, December 30, 2006).

These isolated examples do not reflect most physicians’ business behavior, but the stories highlight that doctors, to a greater degree than other professionals, must be perceived to purer than Caesar’s wife.

Like businessmen, physicians must make a certain amount of money to pay off debts, compensate staff, meet overhead, provide for family, and plan for a rainy day or retirement. As physicians and businessmen, doctors invest in ancillary technologies -- CT scans, MRIs, nuclear cameras, labs – and in health facilities – ambulatory surgical centers and specialty hospitals -- to increase economic efficiency – and to help keep people well and keep them there. These ends can sometimes only be efficiently achieved through superior technologies and specialized facilities managed by physicians.

Medicine is a business, albeit not a traditional free-market one, if the following authorities are to be believed.

First, J.K. Silver, MD, Physiatrist, Clinical Consultant in Physiatry at Massachusetts General Hospital, writing in The Business of Medicine, Hanley & Belfast, Philadelphia, 1998. She says,

“The field of medicine is drastically changing, and like it or not, business influences are dominating how we deliver health care services. While it is imperative to learn and maintain superb clinical skills, it is also important to learn the business of medicine. Without this knowledge, health care providers are unable to negotiate managed care and capitated care contracts, understand billing procedures in order to avoid government audits, advocate for patients negotiate with insurers, increase productivity an decrease expenses in the office and hospital environments, or decide which practice opportunism are financially viable, and the list goes on.”

Next, David Dranove, Professor of Management and Strategy at Northwestern School of Management, writing in The Economic Evolution of American Health Care, Princeton University Press, 2000. He says,

“Many physicians have embraced the business side of medicine. Nowhere is this more apparent than in ongoing educational programs. Not so long ago, a physician’s ongoing education consisted of attending seminars on the latest clinical developments and reading medical journals... Now it is not unusual for physicians to attend management seminars and read medical management journals. A small but growing number of young physicians have taken the need for management training seriously and are pursuing M.B.A degrees either concurrently or with or after their M.D. training. The ongoing business education of physicians is a rapidly growing industry.”

With the advent of HSA-driven consumer health care, development of smart cards containing HSA and personal health information, and entry of banks in the health care transaction arena, medicine may become even more like a retail business. Patients will swipe a card at the point of care, and doctors will be paid promptly – just like in any other retail business. Health care may not be a traditional market-driven business, but it will feel and act like one, and overhead and creditors will always be out there.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Fifteenth in a Series

KISS (Keep It Simple Stupid): Or, Of Time, Templates, and Technology

Clinical innovations need not be complex. Indeed, they can be devastatingly simple. Nothing, for example, could be simpler than a video explaining in plain language with simple pictures showing exactly what to expect from surgery and what to do about your chronic disease.

Not many people realize it, but the acronym KISS (Kiss It Simple, Stupid) is a favorite expression of computer technologists. The KISS principle is a colloquial name for the empirical principle that simplicity is an essential asset and goal in systems and (industrial) processes. The use of KISS is common in software and engineering circles.

KISS is the basic thought behind “disruptive technologies,” a term for simple, convenient, less costly technologies that “disrupt” markets by replacing more complex, inconvenient, and costly technologies.

Disruptive technologies are a term popularized by Clayton M. Christensen in The Innovator’s Dilemma (Harvard Business School Press, 1997). Later Dr. John Kenagy, a vascular surgeon and a visiting scholar at Harvard Business School, applied the notion to health care “Will Disruptive Innovations Cure Health Care?” (Harvard Business Review, Volume 6, pages 102-122, September 1, 2000).

Kenagy and colleagues at Harvard Business School give these examples of disruptive innovations in health care.

•Minute Clinics – clinics in retail outlets where services are delivered by nurse practitioners rather than doctors.

•Balloon angioplasties – where coronary arteries are unplugged by balloon catheters rather than open-heart surgery.


•Nurse practitioners and physician assistants assisting, delivering services, and prescribing.

•Outpatient surgeries. Labs and imaging centers delivered in ambulatory settings rather than hospitals.


•Non-invasive vascular diagnosis by ultrasound and radiographic technologies.

Disruptive Technologies as Time-Savers

I think of disruptive technologies in a simpler way – as something that saves time for physicians and patients, thus allowing them to spend more time with one another.

That the shortage of time for patient-doctor interaction and a waste of time for reaching that interaction are major sources of doctor and patient dissatisfaction and distrust is obvious to many observers.

•In a 2004 New England Journal of Medicine article (“Dissatisfaction with Medical Practice,” volume 350,. pages 69-75, January 1, 2004), Dr. Abigail Zuger writes,

“Among the aspects of practicing medicine that particularly frustrate conscientious physicians around the world is the lack of time to accomplish necessary tasks. ‘Indicated’ tests and treatments must be scheduled, checked, and paid for; administrative and regulatory requirements mount; and financial considerations demand an emphasis on volume and turnover. E-mail and the Internet have conditioned many patients to expect instant responses to all concerns. ‘The single greatest problem in medicine today is the disrespect of time,’ said Kenneth Ludmerer, a physician and medical historian at Washington University in St. Louis, in an interview. ‘One cannot do anything in medicine well on the fly.’

•Lack of time is the driving force behind the concierge and cash-only practice movements. By supplementing their income with retainer fees and eliminating third party administrative hassles, doctors are able to spend more time with patients and to use their time for what they were trained to do – listening, treating, and spending time with patients.

In an unpublished book, You and Your Doctor, I described the patient’s dissatisfaction with time wasted before seeing a doctor with these words,
“You’re sick and tired of waiting -- waiting to get an appointment, waiting in the doctor’s waiting room, waiting to get the procedure done, waiting to get test results, waiting to see the specialist to whom you were referred, waiting in the hospital admitting suite, waiting in the emergency room, waiting to have your operation. Why can’t doctors and hospital be more efficient? Don’t they understand your time is just as valuable as theirs?”

The title of an August 20, 2005 New York Times article captures patient’s frustrations over wasted time, “Sick and Scare, and Waiting, Waiting, Waiting.”
Now, to return to my subtitle, “Of Time, Templates, and Technology.” I believe the simplest of ideas, a template, can save time for doctors and patients. A template is nothing more or less than a master, or a pattern, from which similar things can be made and which can serve as a repeated reminder of what needs to be thought of or done. A computer-generated template saves time for everyone. Re-inventing a constantly rotating wheel is of little use to anyone.

One of the biggest time wasters in health care is the need to re-document dialogue for repetitive or duplicative tasks that doctors do every practice day. To be paid doctors must document by writing or dictating in essentially the same words. What they have done a thousand times before.

•An example would be the medical history and physical exam, which consists of documenting the following: chief complaint, present history, past history, review of organ systems, physical examination, and treatment plan. A physician can document this through handwriting (30 words a minute), dictating (150 words a minute), or by downloading a template of the complaint, present and past history, review of symptoms created by the patient (which can eliminate the need for handwriting or dictation, leaving only physical findings and treatment plan to be recorded,) Other than physical findings and treatment plan, patients can generate most of this information using an interactive template consisting of a “ye” or “no” algorithm based on the patient’s complaint, age, and gender. Add physical findings and treatment plan, and you have a complete medical record that can be presented to the patient, as a template, if you will, of the patient’s complete electronic health record.

•Another example is the informed consent process, which involves telling the patients the risks and options of a given procedure and reaching an agreement signed by the patient that this or that can be done. As I have indicated in previous blogs, these consent firms can be automated and clarified by computer templates that document what to expect and what the risks. Having a computer creates this paper or video “templates” saves doctors’ time, achieves consistency, and educates patients.

•Yet another example is templates of procedures done in doctors’ offices, outpatient settings, emergency rooms, and hospitals. Templates can describe and document writing of a prescription, applying a cast, taping an ankle, using a needle to remove fluid from the chest or abdomen, draining an abscess, treating a wound, performing a tracheotomy or performing any other surgical procedure. These procedures are something the doctor does everyday in much the same way. Rather than spending hours dictating what was done, why not create templates, blocks of print or canned descriptions, varying only with the name of the patient, or any complications that may have occurred, and download the computerized template for the record – thus saving time for the doctor and allowing him or her more time for the next patient?

•The final example is templates for the whole field known as diagnostic support services. In the course of seeing and examining patients, interpreting findings, conducting a differential diagnosis, or reminding patients they need to be seen again, why not simple generate templates that serve as reminders for doctors what to look for and to think of as diagnostic possibilities, what tests to do diagnose these possibilities, and what steps to take to remind patients that some test is askew and that they need to be seen by a physician.

Maybe this blog has been a template in a teapot, but it seems to me we sometimes make health care more complex than it need be, and we can “disrupt,” i.e. simplify, the process by adroit use of existing template technologies.

The computer, after all, is matchless at instantly replicating repetitive tasks which may otherwise consume vast chunks of human time. Computer templates can free up more time for patients and doctors to spend together, building a more solid and trusting relationship.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Fourteenth in a Series

Start-Ups: “In the final analysis, it is implementation, not ideas that count”

In the title, I am quoting Norbert Goldfield, MD, a practicing physician in Springfield, Massachusetts. Norbert is also medical director of 3M’s Medical Information Systems in Wallingford, Connecticut. He is considered an expert in analyzing physicians’ practice patterns and in how to best implement Payment for Performance Programs (P-4-P).

Over the years, I have been involved in a number of health care start-up companies. I have watched some fail, some succeed. I have formed ideas what works, and what doesn’t. I have met entrepreneurs, angel investors, and venture capitalists.

Entrepreneurship and innovations are the life-blood of the American health economy, the central theme of my book Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007).

I agree with Dr. Goldfield it is implementation, not bright ideas, that count. Giving substance to a start-up, turning to seasoned entrepreneurs, growing it, building a management team, taking it to market, listening to customers, learning when to turn it over to managers, assembling an advisory board, accessing capital, and deciding when to be acquired, takes a disciplined and risk-aware team.

After the physician practice acquiring debacles by MedPartners and PhyCor in the late 1990s and the dot-com collapse during that same period, venture capital interest is returning to the health care field.

This is fed by the realization that health care may be a central engine that may ultimately drives 25 percent of the U,S economy (Gina Koala, “Making Health Care the Engine That Drives the Economy,” New York Times, August 28, 2006). The fact that the U.S. government, which isn’t going out of business soon, despite political rhetoric to the contrary, funds 1/2 to 2/3 of U.S. health care hasn’t escaped the attention of venture capitalists (Daniel Gross, “National Health Care? We’re Halfway There, New York Times, December 3, 2006).

According to Peter F. Ducker in Innovation and Entrepreneurship: Practice and Principles (Harper and Row, 1986), a new venture or startup requires.

1.A focus on the market – What is the opportunity? How can the new venture organize itself to best take advantage of new and unexpected markets, quickly and efficiently, before a competitor does?
2.Financial foresight and planning for cash flow and capital needs ahead. New ventures tend to “burn cash” quicker than originally thought because quick growth demands cash.
3.Building a top management team before the start-up needs one and before it can afford one. This requires experience in the field, belief in the ideas, and relationships.
4.A founding entrepreneur who must decide his or her role, area of work, and position within the company.

These four requirements are old hat to seasoned start-up entrepreneurs but not to doctors with bright ideas. To begin with, doctors may not have the $10 million in assets usually required by banks for a loan for a high-risk startup. Doctors may not know where the various sources of capital, which may include:

•Private equity
•Regular banks
•Investment banks
•Business valuation
•Corporate Finance
•Venture capital
•Open source funding
•Angel investors

Venture capital

Because of strict requirements venture capitalists have for potential investments, many entrepreneurs seek initial funding from angel investors, or family members, who may be more willing to invest in highly speculative opportunities. In addition, concern among venture capitalists has grown since the dot.com boom collapse. Also there is a "funding gap" between friends and family investments, typically in the $10,000 to $250,000 range, and amounts most Venture Capital Funds prefer to invest, generally in the $2 to $5 million range.

Health care now represents 16 percent of US GDP and is a major market of new venture investing. In recent years, biotechnology, medical device, and health care service investments have represented between 25 to 30 percent of all venture capital funding.

You may be asking: what does the foregoing have to do with building patient-doctor trust? To begin with, doctors are closer to patients than anyone else in the health care sector. It is doctors who may be the first to recognize what patients need most. Doctors may be ones with the “bright idea” – a surgical tape or staple, thermometers inside the ear or on the forehead, an orthopedic screw or device -- that may lead to a start-up, to a new venture, a new investment opportunity that makes a difference in quality of patients’ lives.

If you are an entrepreneurial doctor out there, I would concentrate on ideas that lower costs, offer more convenience, provide greater comfort, or more consistent and documented quality, or effective patient education about procedures or chronic conditions, or on devices or drugs that promise relief of symptoms or even cure of common chronic diseases.

Examples might be:

•establishing cutting-edge clinics in underserved areas;

•creating two-way wireless communication units between doctors and their home-bound patients;

•setting up physician-franchises in retail outlets, inventing implantable devices to relieve or monitoring diabetes, Alzheimer’s, or Parkinsonism; rerouting nerves to correct erectile dysfunction, loss of bladder control, neuropathies, or even quadriplegia;

•“unbundling” hospital services into separate decentralized free-standing specialized facilities;

•“bundling” bills to cover all services – hospital, physicians, and rehab – for a given disease episode so consumers know in advance exactly what they are paying for;

•developing “smart cards” containing patients personal health information, x-ray and scanning images, electrocardiogram image, that can be “swiped” at the point of care;

•small mobile heart and pulmonary units containing databases for precisely evaluating fitness, disease status, response to therapy, and prognosis information such a chances of hospitalization and even sudden death.

•any mechanical or electrical device that makes the work of physicians easier or solves some common clinical problem.

Possibilities are endless, but they will all require entrepreneurial and innovative discipline and know-how to take advantage and organizations or individual customers who are willing to pay

Twenty Clinical Innovatiions to Build Patient-Doctor Trust: Thirteenth in a Series

Twelve Ways for Physicians to Help Patients Decrease Drug Costs

Hang around 65 year olds long enough, and the subject of prescription drug costs will surface. Some sexagenarians tell me they are asking doctors, “Can’t you prescribe something a little cheaper?” Doctors usually can, and they can offer other advice too. Give it. Trust me, they will trust you more.

1. Prescribe generic drugs when appropriate.

2. Offer free drug samples but point out brand name refills may be expensive.

3. Encourage patients to order drugs in bulk by mail.

4. Consider dispensing from the office in states where office dispensing is permitted. Four side benefit are: one, when you are buying drug inventory, you will learn costs of drugs; two, you will be paid for time and knowledge needed in writing prescriptions; three, drugs you dispense will be less expensive than at pharmacies; four, patients are more likely to comply with your instructions when you personally hand them the drug you prescribed.

5. Explain to eligible veterans that many prescriptions are available for $7 at their local VA if they qualify for the benefit.

6. Make patients aware Wal-Mart sells some prescription drugs for $4. Target stores are offering a similar service.

7. Delegate to a member of your staff the duty of explaining the best Medicare drug benefit.

8. Learn the cost of drugs from a local pharmacy or pharmacies to which you refer your patients.

9. Recommend effective OTC (Over the Counter) drugs when appropriate.

10. Consult sources such at Consumer Reports, MedicalGuide.org to see what they recommend as most cost-effective drugs.

11. Suggest to patients that they visit their health plan’s website: some of these websites contain information on the comparative costs of brand name drugs and generic-equivalents.

12. Make friends with pharmacists. They may be you and your patients’ best friends in threading the way through the drug cost world.

Remember: To gain trust of your patients in the future, you may find yourself serving as their mentor and navigator through the medical cost maze.

Twenty Clinical Innovations to Build Patient-Doctor Trust: Twelfth in a Series

A Change of Pace

In this amateurish poem, my first 2007 blog, I contend health care needs poets and artists just as much as we need computers. This may be because my son, Spencer Reece, is a poet. My other son, Carter, has the tastes and soul of an artist. Fathers become doctors so their sons can become artists.

I’m no poet, but in this blog you shall see,
I have carried out a poetic change of pace.
When we talk of what medicine should be,
We prattle on about the technological race.

We praise computers’ many advantages to the skies,
But computers aren’t the only kind of bio-enterprise.
Too often we forget the basic ecology of technology.
That computers can fix anything is pure mythology.

For every conceivable highly technical advancement,
There is a separate but equal high touch enhancement.
For every biotechnology-developed anti-cancer drug,
There surely will be a counterbalancing emotional hug.

The hug might come from a support group,
Or from drinking a hot cup of chicken soup,
Or from a soothing massage by a skilled masseuse,
Or from being subjected to skilled acupuncture use.

With every single ounce of technological passion,
There must be a corresponding pound of compassion.
The Web and wireless phones not only concern technology,
They’re about communicating, connecting, and psychology.

Computers may turn on a dime and save time,
But they don’t replace a sublime artistic mime.
In medicine computers have a role.
but they have yet to save one soul.

That the computer will be the do-all and cure-all,
is a message resonating with blind technophiles?
Techies believe computers will solve every shortfall,
but computers can’t mimic human styles or wiles.

We may suffer from hardening of digital categories,
Similar in some ways to hardening of human arteries,
People take pleasure from the creative, verbal and visual,
Above all else, we humankind treasure the truly original.

Do payers and managers rely too much on data?
Is data for health care providers the true intifata?
Ordinary mortals may say, in God we trust,
but managers say, show me data or go bust.

I say: high tech health care’s computers and scanners,
must be softened through interactive human manners.
So wake up! You computer geeks!
Give more of what humanity seeks!

What patients seek are accessible understandable clear facts,
Explained for ordinary mortals, something the system lacks,
So automate facts, add simple words and pictures, stir, mix, and serve on the Net.
Patients, and doctors who care for them, will be forever in your everlasting debt.

Here’s a more upbeat take on technology ecology by a real poet – Richard Brautigan

All Watched Over By Machines of Loving Grace

I like to think (and
The sooner the better!)
of a cybernetic meadow
where mammals and
computers
live together in mutual
programming harmony
like pure water
touching clear sky.

I like to think
(right now please!)
of a cybernetic forest
filled with pines and
electronics
where deer stroll peacefully
past computers
as if they were flowers
with spinning blossoms.

I like to think
(it has to be)
of a cybernetic ecology
where we are free of our
labor
and joined back to nature
returned to our mammal
brothers and sisters
and all watched over
by machines of loving grace.

Richard Brautigan, 1968