Friday, April 6, 2007

Ten Wild and Crazy Health Care Innovations, cont.

Part 2 – 5 -10, conceptual and perceptual

This continues yesterday's blog.

5. Government, not the private sector, distorts cost-saving incentives, and leads to higher health care costs. So contends John Goodman, PhD. He founded the National Center for Policy Analysis, in Dallas, and has talked about medical savings accounts and a consumer-driven revolutions since the early 1990s. In a recent Journal of Legal Medicine issue, Goodman argued government policies do more harm than good. He lists five "Distortions" with solutions,

Distortion Number 1: Our system of government funded (and mandated) free care encourages people to forego insurance and rely on charity of others.
Solution: Let government offer just as much financial incentive for people to privately insure as the expected free-carespending under the current system, making private insurance just as financially attractive as reliance on charity care.

Distortion Number 2: The existence of government funded insurance Medicaid and SCHIP) encourages people to drop their private coverage and become insured at taxpayer expense.
Solution: Let people apply their Medicaid subsidy to private insurance, making the two types of insurance equally attractive from a financial point of view.

Distortion Number 3: While the current system provides lavish tax subsidies for employer-specific insurance, it provides very little tax relief for people who purchase individually owned, personal and portable insurance.
Solution: Create a level playing field for all forms of insurance under tax law.

Distortion Number 4: Although there is in principle no limit to the amount of tax subsidy available for spending on third-party insurance, the tax relief for self-insurance (though a savings account) is very limited and tightly constrained.
Solution: Put third-party insurance and individual self-insurance on a level playing field under the tax law.

Distortion Number 5: Largely in response to the problems created by all of the above, government has essentially outlawed a real market for risk - encouraging individuals to be uninsured while healthy, secure in the knowledge that insurance will be available at premiums totally unrelated to the expected cost of their care if they get sick.
Solution: Like the market for life insurance, allow the market to price and manage risk.

Goodman's thinking offends universal coverage advocates, who argue nations with single payer systems often spend half of what we do in the United States. Critics may fail to mention these features of most single payer systems: waiting lines, rationing, and suboptimal technologies.

6. Informed patients, properly informed, are perfectly capable and willing to make rational health care decisions. Regina Herzlinger, professor of business administration at Harvard Business School, has long championed the idea informed consumers are capable of making complicated and reasonable decisions about their own health care. In an interview I conducted with Dr. Herzlinger for, we had these exchanges.

Reece: Do you think consumers are smart enough to make reasonable choices?

Herzlinger: I do. Consumers want choice, control, convenience, and good value for their money, and their insistence of obtaining these things is a big factor driving specialized facilities and bringing down integrated health systems. Consumers are very bright people, especially when they are spending their own money, and they recognize value when they see it.

Reece: Every seven seconds, another baby-boomer is turning 60, and there are 78 million more of them out there. You have written baby boomers are the most manipulative, self-seeking, and effective generation ever. Then, you added, "I ought to know, I am one of them."
Herzlinger: Yes, baby boomers will be a driving force changing the system. You don't have to look any further than the recently passed Medicare bill to recognize that. AARP's decision to support the bill is evidence of that. AARP was responding to its fastest growing constituency –baby boomers. The Medicare bill was a consumer-driven bill if I have ever seen one.
Reece: Critics also say that sick consumers aren't smart enough or intelligent enough to make the right decisions. That's a somewhat paternalistic attitude, isn't it?
Herzlinger: Yes. Consumers are very smart, and they will make better decisions than those would act for them. Many of the "top-down" technocrats who run HMOs or government programs don't believe consumers are smart enough and only they, the technocrats, have the wisdom and compassion to run the health system. On the contrary, I would say nobody at the top is smart enough to know everything that goes on at the market level. Nobody's that brilliant.

3. Doctor's failures to inform patients in a timely fashion in clear language with instructive illustrations, contributes to " health illiteracy."

In the U.S. today , a brisk movement is growing to overcome hazards of health illiteracy. The traditional reasons given for this illiteracy are: a poor public health system producing graduates that can barely read at the sixth grade level, growing numbers of non-English speaking immigrants, and lack of clear communication by doctors and nurses.

I take the contrarian position that doctors themselves, caught in the hurly-burly of overly busy, indeed swamped practices, and forced to see as many as 25 to 30 patients a day because of dropping reimbursement, are partially to blame.

Rather than curse the darkness, I keep my eye on innovations easing the problem without changing the world. The best example I have run across is the product of a Chicago company called Emmi (Expectation Medical Information Management). Emmi produces online interactive programs consisting of videos characterized by a soothing voice, given in the language of the viewer, with professionally produced medical illustrations, expressed in simple language pitched at the 6th grade reading levels telling patient exactly what to expect from a surgical procedure or a chronic disease episode. The patient's doctor can "prescribe" these videos by giving the patient an access code, and the patient can download the online program at their leisure to view themselves or to show to their family.

4. Chronically ill homebound patients, given easy-to-use communication devices, can virtually eliminate complications leading to hospital readmissions. The paradigm thinking about homebound patients used to be that these individual were helpless and unable to fend for themselves or defend against complications.

This is no longer true. Many patients with chronic disease – chronic obstructive pulmonary disease, heart failure, diabetes, asthma, severe hypertension, various neurological disorders – are clear-headed and capable of spotting adverse complications early. One company, American Telecare in Eden Prairie, Minnesota, has developed a bedside audiovisual communication device, controlled by the patient, with which the patient can initiate an audiovisual conversation with a doctor or nurse at a remote location over ordinary telephone lines.

The caregivers, in turn, can look at the patient, hear their story, listen to their heart and lungs, even weigh them, and measure their blood oxygen. It has been learned patients become readily educated about their disease and can quickly spot complication, early enough to ward off complications and prevent rehospitalizations.

5. With good technological diagnostic support systems, solo doctors can deliver comprehensive competent care. One of the myths, perpetrated mostly by large integrated groups, is that solo doctors are unable to function effectively in treating disease unless they operate in clinical teams in large groups. This is true to a large extent for solo practitioners who have no Internet access to the outside world. But is not true for Internet savvy soloists who can access diagnostic support systems, link to disease information sites, and refer patients to websites offered by WebMD, the Mayo Clinic, or Revolution Health . Solo doctors with extensively computerized offices can function just as effectively, and with a lot less overhead, than larger practices.

6. True innovation often comes from caregivers on the frontlines , not from managers or health care executives. I won't dwell on this except to point out that Gary Baldwin, Technology editor of Healthleaders, and Jim Molpus, another healthleaders editor, made this point on March 2 about the recent HIMSS' convention

Here's a Wild Idea--HIMSS Last Day

The last day of HIMSS is usually an exercise in information hangover. Many people have left by now, but there is usually a cadre of hangers-on. Speaker sessions are sparsely attended, which is misfortunate, as the quality of content has not diminished.
Thursday morning Harry Lukens, CIO of Lehigh Valley Health Network in Allentown, Pa., described how the community health system reaches out to the staff to develop new ideas. As Lukens pointed out, the session was not about technology, but rather the cultivation of ideas. For the last few years, Lukens has chaired a group called the "Wild Idea Team." It sports a rotating membership of 18-25 people, representing all areas—and levels—of the organization.
Staff members bring ideas about ways to use technology to improve operations. The only rule for the discussion, Lukens said, was "no snickering." It's a way to encourage participation. Ideas are vetted through a series of steps including informal evaluation, research, formal evaluation, and test. Most ideas do not make it to actual implementation. Nevertheless, the meetings are a way for the IS staff to stay in touch with their internal customers.
Lukens' punched up his talk by using an interactive audience response system. Using a small handheld device, we were asked to vote on various questions, with the results tabulated and presented on his PowerPoint. Most in the audience had no formal manner of deriving technology ideas from the staff. Lukens uses the same technology at senior staff meetings to solicit feedback on strategic planning proposals. Allowing people to vote anonymously on ideas encourages more honest responses, he pointed out.

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