Health Costs - Poverty, Poor Health, and Project Health

Filling in Information Gaps and Reducing Costs

Doctors have known two things for a long time.

One, costs skyrocket when you’re treating poor patients. When poor patients, who are sicker than most in the first place, go home, after being treated, they often return to their doctors sicker than ever because of miserable conditions at home. That’s why Medicare costs are highest in cities with poverty ghettos and in poor regions, such as the American South. Poverty is the main reason for regional cost spikes, not professional greed or overuse of resources.

Two, you may be able to treat diseases effectively and cost-efficiently , but once poor patients return to poverty-striken environments, with hopelessness, homeliness, domestic abuse, inferior education, lack of affordable care, malnutrition, high risk life styles, obesity, alcoholism, and diabetes run rampant, and their health suffers. all bets are off as far as controlling costs.

If you seek a graphic example of what can occur, I recommend you see the movie "Precious."

Dealing positively with poverty takes nimble thinking across multiple strata of society, cultures, and disciplines; leadership and keen sense of social responsibility; the art and science of new organization models; and, in some cases, imagination by someone young with originally thoughts who thinks anything is possible.

Enter Rebecca Onie. As a 19 year old sophomore at Harvard, she started visiting the Pediatrics Department at Boston Medical Center. She asked a doctor there,
“If you had unlimited resources, what would you do to help your patients?”

According to Onie, a pediatrician answered, “I have a kid who comes in with an ear infection, and I prescribe antibiotics, Meanwhile, the real issue is that there's no food at home, or the family is living in a car. It is that connection between health and poverty, all too often unaddressed.”

It is this connection that pushed Onie to found Project Health in 1996.

Project Health now serves 4000 families annually in Baltimore, Boston, Chicago, New York City, Providence, and Washington, D.C. Project Health recruits 600 undergraduate volunteers annually to partner with physicians and other health care professionals to connect families in pediatric clinics, newborn nurseries, adolescent clinics, ob-gyn clinics, pediatric emergency rooms, and community health centers with resources they need to stay healthy.

Doctors in participating clinics can write non-medical prescriptions for assisting patients with utilities, housing vouchers, and such things as child care. Patients then take their prescriptions to a Project Health Desk, where a college volunteer helps them find what they need. Young college students with energy to burn, idealism to exercise, and drive to serve society are wonderful embassadors for the medical profession and a great asset to the poor.

After founding Project Health, Onie became an assistant to a prominent federal judge, and a practicing attorney. After serving as Co-Chair for Project Health, she returned as CEO in 2006.

Onie, now 32, has won numerous awards. Among them are: The Kennedy Foundation Award to Americans under 40 who make a difference in their communities and the nation, the Time Magazine Gala 100 for 100 prominent young Americans , and the MacArthur Fellowship Award of $500,000, with no strings attached , for “exceptional creativity, promise of important future advances based on a track record of significant achievement, and potential to facilitate subsequent creative work.”

What Can Physicians Do? A Rallying Cry

What can physicians do to make American a better place to live, die, afford, and receive care ? What can we do to bring about practical reform? What can we contribute?

These may seem odd questions, After all, we deliver care. Care goes through us. But Medicare, Medicaid, and private third parties are big players. They dictate terms of engagement and payment. But the answers lie at the core of the physicians’ dilemma – how do we guide reform without being perceived as acting only in our self-interest?

Ineffective Nationally, Effective Locally

Independent practitioners in groups of six or less deliver 80 percent of care. But by and large physicians have not been effective in resolving national health care issues –such as tort reform, competition of health plans across state lines, and patient-driven care with HSAs.

Politicians and the media apparently believe health care at the national level is too important to be left to individual doctors. But people still admire their own doctors. People still believe , to paraphrase Tip O’Neil on politics, “all health care is local.”

Making an Impact – Three Keys

But how do we make an impact? How do we deliver more effective care without federal intervention? We need to be pragmatic about what works.

• The first key is practicing “virtual medicine.“ We must deploy the Internet to organize independent physicians. That way we can deliver quality, less-costly care. We can deliver it at the “point of care” – in our offices where patient meets doctor – but also in the homes. We can deliver it in detached diagnostic and treatment and rehab and rural facilities where telemedicine comes into play (see medinnovationblog, December 20, 2009. “Virtual Medicine: The Lever That Just Might Save Independent Practice.”)

Yes, virtual medicine has obstacles – malpractice, privacy, payment, and turf issues – but these barriers can be overcome. Given the growing adoption of broad band access in homes and businesses, indeed, in every segment of American society, overcoming these pitfalls is doable if we make patients “virtual partners.” We must make it convenient for them to enter their data, including their present complaints and past medical history, requests for refills and help for help for minor ailments.

• The second key is recognizing that hospitals remain the health care power and organizing center in most communities. This is because of brand name recognition and the tradition of hospitals as the places to go in times of urgent need, and as natural gathering sites for doctors. Hospitals need doctors. Without physicians, one wag noted, “hospitals are simply institutions with bad food.” Physician executives led the most powerful hospitals and integrated health systems.

It is probably inevitable that most “independent” hospitals and “independent” medical staffs will develop bundled payments, a mix of fee-for-service with capped budgets, for most episodes of hospital care. Based on my experience as chairman of a PHO, I believe hospitals and doctors can develop effective synergistic relationships without rancor or dominating one another. (J. Hawkins and R. Reece, Sailing the Seven “Cs” of Hospital-Physician Relationships – Competence, Convenience, Clarity, Continuity, Competition, Control, Cash,” PSR Publications, 2006).

• The third key is developing an overarching online communication source for independent physicians. This source must contain multidisplinary content. It must address the needs, strengths, opportunities, and innovations necessary to overcome fragmentation. It must serve a vast audience of independent physicians in a timely fashion. It must respond quickly and efficiently to their needs. It must bring together reliable content from multiple professional organization . And it must be online.

Because the Internet and search engines like Google and Yahoo ar efficient and low-cost means of delivering information, medical print publications, as well as newspaper organizations and publishing houses, are dropping by the wayside. Computer screens are replacing newsprint. Americans are doing their reading and gathering their information on countless websites. They are getting their daily news from blogs and from the Web. They are buying their books from Amazon.com and Barnesandnoble.com, They are do their book reading on Kindle and Nook (for background, see Sven Birkets, The Guttenberg Elegies:The Fate of Reading in an Electronic Age<, 1994). The transition from print to online is well underway and irreversible. Web publications like Modernmedicine.com, which has acquired Modern Medicine and Medical Economics, are rapidly evolving as main sources of information for independent physicians.

Riding the Curve and Getting the Job Done

To make these keys work in their favor, independent physicians will have to ride the Internet Curve. We must acknowledge the world has irrevocably changed. It is moving with accelerating speed. Old business and practice models no longer work. We must move – systematically, organizationally, and purposefully – to a new world order for our own good, the good or our patients, and our survival.

The catch phrase of the Great Depression was “Brother, can you spare a dime?” In the Great Recession, still with us, the new phrase will be, “Brother, can you paradigm - online, realtime, all the time, everywhere?”

If independent physicians can conceive and believe in the new electronic order of things, we can achieve freedom in the clinical streets rather than submit to a new world order dictated by elites – if we have the will, the tools, the collaborative spirit, and the organizational heft – to do the job.

Cursing the darkness will not get the job done.

Physician Regulation - More on Checklists

Prelude: This is a follow-up on my last blog. It is from another doctor’s blog, Medical Rants, dated January 9, and is entitled “Processes of Care: Lessons from Gawande and Saban.”

"Readers know that I live in Alabama. We are all aglow after the big win Thursday night. The coach of the Crimson Tide is known as a grinder. In almost every press conference he emphasizes the importance of playing the right way. He worries more about process, and believes that with good process one achieves good results. His teams do not turn the ball over and they do not commit penalties."

"Process is important for many aspects of health care delivery. Process is not the only important issue, but for some things process makes a huge difference in health care safety."

"I am currently reading Atul Gawande's book – The Checklist Manifesto. This book extends a wonderful article from The New Yorker – "The Checklist,"

"This article starts with Peter Provonost's wonderful study showing that paying attention to details markedly decreases central line infections. He achieved success by requiring a checklist of 5 steps prior to placing the central line. His checklist keeps physicians and nurses from skipping steps. Skipping steps leads to increased infections."

"In reading the book, I am thinking as one who does not do procedures. We internists consider ourselves cognitive physicians. Now I must note that those who do procedures are also thinking. They do procedures and thinking. We internists who do not do procedures rely on our cerebrum and literature searches. So how can a checklist help us?"

"I actually use checkilsts in my teaching. In caring for diabetics I teach the FLECKS. When I teach about myocardial infarction patients, I discuss the 4-pack – anticoagulation, beta blocker, statin and ACE inhibitors. At discharge, unless contraindicated, patients should have at least one medication from each of these classes. I use checklists for diagnosing increased anion gap acidosis, hypercalcemia, hyponatremia … You get the idea."

"We should identify those situations in medicine helped by remembering and using checklists."

"If he understood medicine, Nick Saban would relate well to this rant. He always stresses dotting the i's and crossing the t's. As Gawande teaches us, we should take advantage of this simple solution to the frailties of memory."

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform (IUniverse.com) is available at www.iuniverse and other book websites .. For information on speaking fees and arrangements, call 860-395-1501.

Electronic Medical Records = Why Doctors Resist EMR Checklists: What Googlers May Not Understand

It sounds so logical. The doctor lists patient symptoms, types the symptoms into Google, and out pops an exhaustive list of diagnostic possibilities based on the medical literature. What could be simpler? What could be more ideal in sorting through medical information?

According to a journal Science blog, in a meeting of a group of Obama advisors that advises Obama on EMRs and other matters, Google’s CEO Eric Schmidt openly wondered why doctors haven’t embraced databases to help them sort through medical information. In a comment directed to Atul Gawande, MD, a surgeon and New Yorker writer, Schmidt said,

“So when you show up at the doctor with some set of symptoms, in my ideal world what would happen is that the doctor would type in the symptoms he or she also observes, and it would be matched against the data in this repository. Then this knowledge engine would use best practices, and all the knowledge in the world to give physicians some sort of standardized guidance. This is a generalized form of the checklists that you’re talking about…”

Gawande explained,

“I think part of the bafflement occurs because the folks who know how to make such systems don’t understand how the clinical encounter actually operates. A database is likely to return more information than a clinician could make sense of during a patient visit when there are '15 minutes to manage six problems.'

Still, he added, " the right kind of apps for 'for your iPhone or whatever the new Google one is' could be useful for doctors.”

Gawande might have added:

1) Doctors don’t like to type. That’s clerk work.

2) Doctors don’t like to place computers between themselves and patients. That depersonalizes the encounter.

3) Most diagnoses are self-evident. They don’t require a list to sort through.

4) Computer lists often contain more information that you want to know. Besides, not pursuing a lead might be used against you in a malpractice suit.

5) Inserting a computer into the work flow is expensive and disruptive and slows things up when you’re trying to see 30 patients that day.

6) Computers have their place, but when it comes to diagnoses in the course of a busy day, they offer few miracles, except perhaps, in a few isolated, difficult cases.

Health Savings Accounts - Can Capitalism Deliver Care Better and Cheaper than Socialism?

Prelude: On August 12, 2009, I wrote a blog containing excerpts from a WSJ article by John MacKey, CEO and Founder of Whole Foods, a national food chain featuring home-grown fresh foods. The article’s title was “The Whole Foods Alternative to ObamaCare,” and it suggested (Gasp!) that capitalism could deliver care better and cheaper than socialism. MacKey led off his piece with a Margaret Thatcher quote,

“"The problem with socialism is that eventually you run out of other people's money."

Liberals were outraged. Their bloggers had a heyday. They recommended shoppers boycott Whole Foods. Its owner, they asserted, had passed over to the dark side. Now, of all places,"The New Yorker, the doyen of liberal publications, has published a 9000 word profile on MacKey. It is called “The Food Fighter” in its January 4, 2010 edition.

Here are eight reforms MacKey said would greatly lower the cost of health care for everyone:

1. Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems. For example, Whole Foods Market pays 100% of the premiums for all our team members who work 30 hours or more per week (about 89% of all team members) for our high-deductible health-insurance plan. We also provide up to $1,800 per year in additional health-care dollars through deposits into employees' Personal Wellness Accounts to spend as they choose on their own health and wellness.

Money not spent in one year rolls over to the next and grows over time. Our team members therefore spend their own health-care dollars until the annual deductible is covered (about $2,500) and the insurance plan kicks in. This creates incentives to spend the first $2,500 more carefully. Our plan's costs are much lower than typical health insurance, while providing a very high degree of worker satisfaction.

2. Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits. Now employer health insurance benefits are fully tax deductible, but individual health insurance is not. This is unfair.

3. Repeal all state laws which prevent insurance companies from competing across state lines. We should all have the legal right to purchase health insurance from any insurance company in any state and we should be able use that insurance wherever we live. Health insurance should be portable.

4. Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.

5. Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.

6. Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor's visit and how that total breaks down? What other goods or services do we buy without knowing how much they will cost us?

7. Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

8. Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform (IUniverse.com) is available at www.iuniverse and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

U.s.Health Care System - Where U.S. Health Care Ranks Number One

Isn't 'responsiveness' what medicine is all about?

Prelude: Periodically I reprint excerpts of articles by physicians . This article appeared in the January 7 WSJ on the Op-Ed page, It is by Mark B. Constantian, MD, a plastic and reconstructive surgeon in New Hamsphire.

”A majority of Americans opposes Congress's health-care bills. Why?”

“The comparative ranking system that most critics cite comes from the U.N.'s World Health Organization (WHO). The ranking most often quoted is Overall Performance, where the U.S. is rated No. 37. The Overall Performance Index, however, is adjusted to reflect how well WHO officials believe that a country could have done in relation to its resources.”

“ WHO believes that we could have done better because we do not have universal coverage. WHO does rank the U.S. No. 1 of 191 countries for "responsiveness to the needs and choices of the individual patient." Isn't responsiveness what health care is all about? “

“Cardiac deaths in the U.S. have fallen by two-thirds over the past 50 years. Polio has been virtually eradicated. Childhood leukemia has a high cure rate. Eight of the top 10 medical advances in the past 20 years were developed or had roots in
the U.S. “

“The Nobel Prizes in medicine and physiology have been awarded to more Americans than to researchers in all other countries combined. Eight of the 10 top-selling drugs in the world were developed by U.S. companies. The U.S. has some of the highest breast, colon and prostate cancer survival rates in the world. And our country ranks first or second in the world in kidney transplants, liver transplants, heart transplants, total knee replacements, coronary artery bypass, and percutaneous coronary interventions.“

“We have the shortest waiting time for nonemergency surgery in the world; England has one of the longest. In Canada, a country of 35 million citizens, 1 million patients now wait for surgery and another million wait to see specialists.“

“When my friend, cardiac surgeon Peter Alivizatos, returned to Greece after 10 years heading the heart transplantation program at Baylor University in Dallas, the one-year heart transplant survival rate there was 50%—five-year survival was only 35%. He soon increased those numbers to 94% one-year and 90% five-year survival, which is what we achieve in the U.S. So the next time you hear that the U.S. is No. 37, remember that Greece is No. 14. Cuba, by the way, is No. 39.”

“The U.S. spends a higher percentage of its gross domestic product for health care than any other country.”

“So what does this money buy? Certainly some goes to inefficiencies, corporate profits, and costs that should be lowered by professional liability reform and national, free-market insurance access by allowing for competition across state lines. “

“Most goes to a long list of advantages that American citizens now expect: the easiest access, the shortest waiting times the widest choice of physicians and hospitals, and constant availability of health care to elderly Americans. What we need now is insurance and liability reform—not health-care reform.”

“Who determines how much a nation should pay for its health? Is 17% too much, or too little? What better way could there be to dedicate our national resources than toward the health and productivity of our citizens? “

“Perhaps it's not that America spends too much on health care, but that other nations don't spend enough.”