OP-ED

John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Continue reading “A Time For Revolutionary Thinking”

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Screen Shot 2014-08-12 at 5.37.18 PMThe much awaited WHO ethics advisory group on the use of experimental drugs to combat Ebola has issued its statement.  While a start it is no more than a baby step.

The advisory panel did decide that they found the case for using experimental drugs in African populations ethical.  While they did not say much about why they reached this conclusion it seems valid in that when facing a deadly plague the overwhelming majority of people infected would want a drug, even one that has barely been tested, to try to save themselves or a family member.  In reaching this conclusion the committee puts to rest the argument that experimental drugs could not go to Africans at all or ought to go to Americans or Europeans first in order to avoid the charge of exploitation.  In a plague that kills 90% of its African victims complaints about unwarranted exploitative research seem a bit ridiculous even against a long history of misuse and abuse of poor desperate persons in poor African nations.

The committee did not say a good deal more other than that informed consent and choice ought to be respected.  This is far less helpful.

Continue reading “Why the WHO ethics advisory group is a start but hardly sufficient”

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Screen Shot 2014-08-01 at 9.42.53 PMMany doctors are frustrated by pressures to practice a faster and more impersonal brand of medicine, but some are actually doing something about it.  I recently spoke with one such doctor, Tom O’Connor, MD, who practices general internal medicine in central Connecticut.  He and his partner, Paul Guardino, MD, believe they were the first US physicians to begin building a fully concierge medical practice the day they completed training.  In the concierge model, their practice collects an annual fee of several thousand dollars from each patient, enabling better access, more personalized care, and even house calls.

But the real story about physicians such as O’Connor is not that they are opting for a different model of financing their practices.  Instead it is the unmistakable sense of excitement with which they talk about the way they care for patients – an attitude that has become noticeably rarer in recent years.  Says O’Connor, “I have been practicing medicine for nearly ten years this way, and I am happier than ever.”  His enthusiasm stems largely from the fact that, unlike most physicians, he is not employed by a hospital or a large practice group.  Instead, he works for himself.  He is his own boss.

Of course, the idea of doctors running their own practice is not a new one.  For much of the 20th century, most physicians were self-employed, and many operated in solo practice.  Today’s trend away from physician self-employment is driven by a number of factors, including increasingly complex and costly regulation of medical practice by government and insurance companies, the failure of medical schools and residencies to prepare physicians to manage their practices, and big financial incentives for hospitals and health systems to buy medical practices in order to capture patient referrals.

Enter a new breed of physician that includes O’Connor.  He did not want someone else telling him who he could care for, what tests and medications he could order, or how long he could spend with each patient.  In his practice, he and his partner – the doctors who actually see the patients every day – make such decisions themselves.  He sees all his own patients, whether in the office, the nursing home, the hospital, or at home – wherever care needs to be provided.  They do not go to walk-in clinics and they are not cared for by teams of hospitalists.  O’Connor is their doctor in every context.

Continue reading “Doctors Who Take Medicine Into Their Own Hands”

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Screen Shot 2014-07-31 at 8.57.28 AMPresident Obama has spent a lot of time defending his health law, but he appears to us to be quite ill-equipped to actually talk about health. In fact, it’s the just about the only thing he doesn’t talk about. He’s talked insurance, web sites, and funneling even more money to medical care providers. He’s talked about deadlines. He’s talked about glitches. The shocking lack of official communication about  what should be the central message of any drive to make Americans healthier should tell us something.

In point of fact, no American leader since John F. Kennedy has had the courage to implore us to work for our own better health. He wrote in 1961 in Sports Illustrated:

“Thus, in a very real and immediate sense, our growing softness, our increasing lack of physical fitness, is a menace to our security…if our bodies grow soft and inactive, if we fail to encourage physical development and prowess, we will undermine our capacity for thought, for work and for the use of those skills vital to an expanding and complex America. Thus, the physical fitness of our citizens is a vital prerequisite to America‘s realization of its full potential as a nation, and to the opportunity of each individual citizen to make full and fruitful use of his capacities.”

By JFK’s clear, powerful, and time-tested standard, we are a disaster. We have no leader on health. Nobody.

If the Forest Service has Smokey Bear and local law enforcement agencies have McGruff the Crime Dog, where is our fearless leader who makes doing healthy things cool, interesting, and desirable?

Doing healthy things is not cool, and until it becomes cooler than doing unhealthy things, we are delivering to ourselves and our kids a future of misery and entrapment in a medical care system that regards us and them as widgets in its revenue cycle.

Ask any kid on any playground who’s their role model for living a healthy life, who’s teaching them the value of eating smartly, exercising, and managing their stressors, and you’ll get a blank stare For example, standard medical advice is that electronic gaming is bad and is a major contributor to inactivity and declining health in our children. But, gaming is here to stay, and we don’t see how professional finger-wagging gets kids to make better choices. Who’s their enlightened leader to tell them that getting up and getting fit will make them even better gamers? Nobody. Leaders meet their followers where their “heads” are and craft messages that connect and inspire action.

Continue reading “Ask Not What Your Government Can Do For You: JFK Speaks to Us About Health”

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It was 1970. I was in my laboratory at the NIH sequencing a murine myeloma protein in order to define the structure of its antibody combining region. Studies of protein conformation were at the cutting edge of science then; enthusiasm abounded. But it was clear to me that this work, in all its scientific elegance, had little to do with treating myeloma or anything else in mice or man. The reason for all the painstaking effort was the joy of pushing back the frontier of ignorance, even if only a bit. No one could foresee clinical utility then, nor would any become apparent for decades. Today such monoclonal antibodies are widely used to treat many diseases, sometimes with efficacy that justifies the costliness.

Genomics is in a bigger hurry.

Thanks to 40 years of breakthroughs, many earning Nobel Prizes, the chromosome carrying the defective gene underlying a genetic disease, Huntington’s disease, was identified in 1983 and the gene sequenced a decade later. In short order, defective genes underlying a number of single-gene diseases were defined: cystic fibrosis, hemophilia, and others. We all wait with baited breath for these elegant insights to transform into primary treatments for single allele genetic diseases. Attempts to transfect patients with normal genes are encouraging but barely so; it has proved difficult to get the right gene to stay in the right cells. Likewise, directly modifying the abnormal genetic apparatus is still largely just promising. The fallback remains working downstream from the genetic apparatus, replacing or modifying the defective products of many of these pathogenetic genes.  Nonetheless, optimism regarding modifying the genetic apparatus itself is rational as is ever more boldness on the part of molecular biologists.

Continue reading “Hyping Cancer Genotyping”

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Screen Shot 2014-07-26 at 12.19.57 PMThere’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.

Here’s why.

The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.

But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.

So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.

More about the drugs

Wood Stay

Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.

In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.

Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all.  The next thing they know, surgery is over and they’re waking up.

Continue reading “No Mystery: Arizona Execution Lengthy Due to Drug Choice”

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Optimized-Ornstein

This story was co-published with NPR’s “Shots” blog.

In the name of patient privacy, a security guard at a hospital in Springfield, Missouri, threatened a mother with jail for trying to take a photograph of her own son. In the name of patient privacy , a Daytona Beach, Florida, nursing home said it couldn’t cooperate with police investigating allegations of a possible rape against one of its residents.

In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients’ medical information from being shared without their consent and other important privacy assurances.But as the litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation – and sometimes provides cover for health institutions that are protecting their own interests, not patients’.

“Sometimes it’s really hard to tell whether people are just genuinely confused or misinformed, or whether they’re intentionally obfuscating,” said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law’s signature guarantees.”Often they’re told [by hospitals that] HIPAA doesn’t allow you to have your records, when the exact opposite is true,” McGraw said.

I’ve seen firsthand how HIPAA can be incorrectly invoked.

In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, California, by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn’t want to ask patients for permission.

Continue reading “Are Patient Privacy Laws Being Abused to Protect Medical Centers?”

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flying cadeucii

Today’s 2-1 decision by the DC Court of Appeals striking down federal premium subsidies, in at least the 27 states that opted for the feds to run their Obamacare insurance exchanges, has the potential to strike a devastating blow to the new health law.The law says that individuals can get subsidies to buy health insurance in the states that set up insurance exchanges. That appears to exclude the states that do not set up exchanges––at least the 27 states that completely opted out of Obamacare. Another nine states set up partnership exchanges with the feds and the impact on those states is not clear.The response by supporters of the law, and the IRS regulation that has enabled subsidies to be paid in the states not setting up exchanges, hinges on the argument that the language is at worst ambiguous and the Congress never intended to withhold the subsidies in the federal exchange states.

But in the DC Court ruling one of the majority judges said, “The fact is that the legislative record provides little indication one way or the other of the Congressional intent, but the statutory text does. Section 36B plainly makes subsidies only available only on Exchanges established by states.”

My own observation, having closely watched the original Obamacare Congressional debate, is that this issue never came up because about everybody believed about all of the states would establish their own exchange. I think it is fair to say about everyone also believed a few states would not establish their own exchanges. Smaller states, for example, might opt out because they just didn’t have the scale needed to make the program work. I don’t recall a single member of Congress, Republican or Democrat, who believed that if this happened those states would lose their subsidies.

Continue reading “Halbig Decision Puts Obamacare Back on the Front Burner and Will Give GOP a Massive Political Headache”

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flying cadeuciiThe answer to the doctor shortage isn’t more doctors

Yesterday, the New York Time’s Editorial Board published a piece on the shortage of physicians in the United States and what’s needed for healthcare workforce redesign.

It’s a good, concise piece about the common thinking around the gap between the needs of our growing patient population and the number of doctors available to deliver the care they need. As as an example, the article refers to a recent statement by the Association of American Medical Colleges whose models predict a shortage of 90,000 doctors in the U.S. by 2020. In Canada, the story is sometimes different where physician unemployment is growing due to inadequate infrastructure and poor workforce planning.

While I do agree that ensuring access to care is important, to think that the solution is simply more doctors comes from framing the question incorrectly.

The question shouldn’t be “how many doctors do we need for a growing population?”. Rather, the question should be “how do we care for a growing population in a cost-effective way?”

When you reframe the problem in this manner, it’s  easy to see that simply churning out more doctors isn’t the answer. In fact, with the direction healthcare is heading, those numbers are likely overestimates.

The major problem with workforce planning models is that they assume healthcare delivery of the future looks very much like healthcare delivery of the present. That the future will continue to be, in many ways, very doctor-centric.

It won’t.

Continue reading “The Answer To the Doctor Shortage Isn’t More Doctors”

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Nortin Hadler

European health care systems are already awash in “big data.” The United States is rushing to catch up, although clumsily thanks to the need to corral a century’s worth of heterogeneity. To avoid confounding the chaos further, the United States is postponing the adoption of the ICD-10 classification system. Hence, it will be some time before American “big data” can be put to the task of defining accuracy, costs and effectiveness of individual tests and treatments with the exquisite analytics that are already being employed in Europe. From my perspective as a clinician and clinical educator, of all the many failings of the American “health care” system, the ability to massage “big data” in this fashion is least pressing. I am no Luddite – but I am cautious if not skeptical when “big data” intrudes into the patient-doctor relationship.

The driver for all this is the notion that “health care” can be brought to heel with a “systems approach.”

This was first advocated by Lucien Leape in the context of patient safety and reiterated in “To Err is Human,” the influential document published by the National Academies Press in 2000. This is an approach that borrows heavily from the work of W. Edwards Deming and later Bill Smith. Deming (1900-1993) was an engineer who earned a PhD in physics at Yale. The aftermath of World War II found him on General Douglas MacArthur’s staff offering lessons in statistical process control to Japanese business leaders. He continued to do so as a consultant for much of his later life and is considered the genius behind the Japanese industrial resurgence. The principal underlying Deming’s approach is that focusing on quality increases productivity and thereby reduces cost; focusing on cost does the opposite. Bill Smith was also an engineer who honed this approach for Motorola Corporation with a methodology he introduced in 1987. The principal of Smith’s “six sigma” approach is that all aspects of production, even output, could be reduced to quantifiable data allowing the manufacturer to have complete control of the process. Such control allows for collective effort and teamwork to achieve the quality goals. These landmark achievements in industrial engineering have been widely adopted in industry having been championed by giants such as Jack Welch of GE. No doubt they can result in improvement in the quality and profitability of myriad products from jet engines to cell phones. Every product is the same, every product well designed and built, and every product profitable.

Continue reading “Missing the Forest For the Granularity”

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