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The Doctor-Patient Relationship. Is Over.

Sep 17, 2012• 28

By Rob Lamberts, MD

Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships. I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance. These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.

For some, this transition will be more hassle than anything. Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence. They will simply choose another provider in our office and continue avoidance as always. There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.

But there are many people, some of which have already expressed this, for whom my departure will be traumatic. ”Nobody else knows me or understands me like you do,” one person told me this week. ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another. I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why. It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure. Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.

Out of the Box Thinking on Avoiding Hospital Readmissions. Stop Trying

Sep 17, 2012• 16

By Dr. Wes

As a cardiac electrophysiologist, I’m pretty far removed from public policy. But I have to admit that I was interested in the latest move by CMS to cut their Medicare payment rates to hospitals by invoking pay cuts for hospital readmissions. The Chicago Tribune‘s article is enlightening and filled with some interesting anecdotes after the first round of pay cuts were implemented:

(1) The vast majority of Illinois hospitals were penalized (112 of 128)

(2) Heart failure, heart attack, and pneumonia patients were targeted first because they are viewed as “obvious.”

(3) “A lot of places have put a lot of work and not seen improvement,” said Dr. Kenneth Sands, senior vice president for quality at Beth Israel.

(4) Even the nation’s #1 Best Hospital (according to US News and World Report) lost out.

So what’s a hospital to do?

The Coming Health Care Singularity

Sep 17, 2012• 7

By Adrian Gropper, MD

According to Wikipedia, the Technological Singularity is the hypothetical future emergence of greater-than-human superintelligence through technological means. The Healthcare singularity could be the time when patients have access to better information and make better decisions than their physicians. The drive to this near future is fueled by the open and globaIized energy of patients as compared to physicians handicapped by closed and parochial health IT.

Physicians have skills. Institutions have capital. Patients have freedom, and that is what tips the information balance in their favor. When it comes to health IT, physicians and institutions are still busy installing closed, proprietary, single-vendor systems that erect strategic barriers to communications every chance they get. The protection of professional licensure and institutional consolidation gives both parties a sense of security even as the patient and policymaker barbarians are massing on the Web.

The Institute of Medicine just released Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Aside from reaffirming the $765 billion of “Excess Costs”, the study highlights the following:

The committee also believes that opportunities exist for attacking these problems— opportunities that did not exist even a decade ago.

Continue reading…

The Wrong Way to Save Money on Health Care

Sep 14, 2012• 40

By Robert Reich

Employer outlays for workers’ health insurance slowed from a 9 percent jump last year to less than half that — 4 percent — this year, according to a new survey from the Kaiser Foundation. Good news?

Our political class believes it is. The Obama administration attributes the drop to the new Affordable Care Act, which, among other things, gives states funding to review insurance rate increases.

Republicans agree it’s good news but blame Obamacare for the fact that employer health-care costs continue to rise faster than inflation. “The new mandates contained in the health care law are significantly increasing the cost of insurance” says Wyoming senator Mike Enzi, top Republican on the Senate health committee.

But both sides ignore one big reason for the drop: Employers are shifting healthcare costs to their workers. (The survey shows workers contributing an average of $4,316 toward the cost of family health plans this year, up from $4,129 last year. Many are receiving little or no employer-provided coverage at all.)

Score another win for American corporations — whose profits continue to be robust despite the anemic recovery — and another loss for American workers.

Those profits aren’t due to a surge in sales. Exports are down (Europeans, Japanese, and Chinese are all pulling in their belts) and American consumers don’t have the dough to buy more.

The Great Cheesecake Robbery

Sep 13, 2012• 47

By Rob Lamberts, MD

In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.

I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

Continue reading…

Rational Rationing vs. Irrational Rationing

Sep 13, 2012• 27

By David Katz, MD

Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

Health Care’s Man on the Moon Moment?

Sep 12, 2012• 7

By Peter Pronovost, MD

On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.

Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.

So we set out to change this. We developed a program that included a checklist of best practices, an intervention called CUSP [the Comprehensive Unit-based Safety Program] to help change culture and engage frontline clinicians, and performance measures so we could be accountable for results. It worked. We virtually eliminated these infections.

Then in 2003 through 2005, with funding from AHRQ, we partnered with the Michigan Health & Hospital Association. Within six months in over 100 ICUs, these infections were reduced by 66 percent. Over 65 percent of ICUs went one year without an infection; 25 percent went two years. The results were sustained, and the program saved lives and money, all from a $500,000 investment by AHRQ for two years.

My Open Source Cure

Sep 12, 2012

By Lia Steakley

[youtube width=”475″ height=”300″]http://www.youtube.com/watch?v=5ESWiBYdiN0[/youtube]

TED Fellow Salvatore Iaconesi released this video along with his digital medical records – everything from CT and MRI scans to lab notes. He posted the health files to invite the online world to participate in the process of treating his brain cancer. As he wrote on his website:

This is my OPEN SOURCE CURE. This is an open invitation to take part in the CURE. CURE, in different cultures, means different things. There are cures for the body, for spirit, for communication.

Grab the information about my disease, if you want, and give me a CURE: create a video, an artwork, a map, a text, a poem, a game, or try to find a solution for my health problem. Artists, designers, hackers, scientists, doctors, photographers, videomakers, musicians, writers. Anyone can give me a CURE.

Create your CURE using the content which you find in the DATI/DATA section here on this site… All CURES will be displayed here.

Continue reading…

Obama vs. Romney: A Detailed Analysis of Mitt Romney’s Health Care Reform Plan

Sep 11, 2012• 16

By Robert Laszewski

Let’s take a look at Mitt Romney’s Health Care plan using his own outline (“Mitt’s Plan”) on his website.

Romney’s approach to health care reform summarized:

“Kill Obamacare” – There seems to be no chance Romney would try to fix the Affordable Care Act––he would repeal all of it.
No new federal health insurance reform law – There is no indication from his policy outline that he would try to replace the health care reform law for those under age-65 (“Obamacare”) with a new federal law–his emphasis would be on making it easier for the states to tackle the issue as he did in Massachusetts.
Small incremental steps – His approach for health insurance reform for those under age-65 relies on relatively small incremental market ideas when compared to the Democrats big Affordable Care Act–tort reform, association purchasing pools, insurance portability, more information technology, greater tax deductibility of insurance, purchasing insurance across state lines, more HSA flexibility.
Getting the federal government out of the Medicaid program – He would fundamentally change Medicaid by putting the states entirely in control of it and capping the annual federal contribution–“block-granting.”
Big changes for Medicare – Romney offers a fundamental reform for Medicare beginning for those who retire in ten years by creating a more robust private Medicare market and giving seniors a defined contribution premium support to pay for it.

Healthcare Reform’s Missing Link — Nurse Practitioners

Sep 8, 2012• 44

By Patricia Dennehy, RN

Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.

It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.

Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.

Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.

Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.