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Rethinking Medical Education

Nov 11, 2011• 25

By Victor R. Fuchs

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care. His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.” He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist. Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care. Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes.

I expressed similar concerns in 1974 in my book Who Shall Live?, but at that time I rejected the claim that the problems of medical care had reached crisis proportion. In 2011, however, I agree with those who say the need for comprehensive reform must be marked URGENT. The high and rapidly rising cost of health care threaten the financial credibility of the federal and state governments. The former finances much of its share of health care by borrowing from abroad; the states fund health care by cutting support of education, maintenance of infrastructure, and other essential functions. These are stop-gap measures; neither borrowing from abroad nor cutting essential functions are long-run solutions. The private sector is equally distressed. Surging health insurance premiums have captured most of the productivity gains of the past thirty years, leaving most workers with stagnant wages. Not only is there a pressing need for changes in organization and delivery, but Ezekiel Emanuel and I, in our proposal for universal vouchers funded by a dedicated value-added tax, argue that such changes must be accompanied by comprehensive reform of the financing of medical care (Brookings paper).

But that’s not what I want to talk to you about today. My subject is the urgent need to change the structure of medical education. It seems to me that such change is necessary, and perhaps inevitable, given the revolution in medicine over the past half century, and given the changes in organization and delivery of care that lie on the horizon.

America Needs Different Doctors. Not More Doctors.

Nov 11, 2011• 43

By Merrill Goozner

Matt Yglesias at Think Progress took a look at some OECD data comparing U.S. physicians to their international counterparts and concluded we need more doctors. The evidence? There’s only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). At the same time, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay a lot for health services including physician services (he reprints a chart showing average pay for U.S. physicians, whether highly paid orthopedic surgeons or relatively poorly paid primary care docs, that shows they are the highest paid among six well-off OECD countries). But his conclusion that America therefore needs more docs is off the mark.

This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent visit to Japan, I visited a community clinic in Kumamoto Prefecture on Kyushu that gives local citizens their annual wellness exam, which is reimbursed under their national health care system. Every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.

The Doctor Is In (And Extremely Annoyed)

Nov 9, 2011• 19

By John Maa, MD

On a Saturday around noon, an 85-year-old woman was brought by ambulance to the Emergency Department with severe abdominal pain. She was confused and unable to provide any medical information. Her X-rays showed marked accumulation of abnormal air in her abdomen, a dreaded sign of a perforation in the intestinal tract. Her blood pressure was quite low, requiring treatment with intravenous medications. As the general surgery intern on call, I was asked to see her.

A physical examination showed her abdomen was rigid and extremely tender, which confirmed this was a surgical emergency. Laboratory testing indicated a serious infection, likely the result of intestinal contents leaking into the abdomen, as well as mild kidney injury. Multiple efforts to reach either family or friends by telephone were unsuccessful, and a conservator or someone with durable power of attorney could not be identified to provide informed consent. The patient clearly needed surgical intervention, so two surgeons wrote notes documenting the need to bring her immediately to the operating room as this was a “life-threatening emergency situation.”

During a 6 hour procedure in the operating room, she underwent repair of a benign perforated ulcer in her stomach. She was brought to the recovery room with the breathing tube in place only because it was late in the evening, with the plan to remove the breathing tube promptly in the morning. I saw her during a post-operative check around 9pm, and all seemed to be improving. She was now requiring much lower doses of medications to maintain an adequate blood pressure, and her kidneys were recovering with a good urine output.

About an hour later, I was notified by the nurses that the patient’s children had arrived. They demanded immediate withdrawal of support. One produced paperwork indicating that she was her mother’s durable power of attorney. She stated that her mother would never have wanted to be “on life support, intubated, and in need of dialysis or blood pressure medications to artificially maintain her blood pressure”.

Walmart Wants To Be Nation’s Biggest Primary Care Provider

Nov 9, 2011• 45

By Julie Appleby and Sarah Varney

Walmart — the nation’s largest retailer and biggest private employer — now wants to dominate a growing part of the health care market, offering a range of medical services from basic prevention to management of chronic conditions like diabetes and heart disease, according to a confidential company document.

In the same week in late October that Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Walmart spokeswoman Tara Raddohl confirmed the proposal but declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

The 14-page request asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.

Analysts said Walmart is likely positioning itself to boost store traffic – possibly by expanding the number of, and services offered by, its in-store medical clinics. The move would also capitalize on growing demand for primary care in 2014, when the federal health law fully kicks in and millions more Americans are expected to have government or private health insurance.

“We have a massive primary care problem that will be made worse by health reform,” says Ian Morrison, a Menlo Park, Calif-based health-care consultant. “Anyone who has a plausible idea on how to solve this should be allowed to play.”

The Growing Malware Problem

Nov 9, 2011

By John Halamka

On Friday I’m lecturing at Dartmouth College to the TISH workgroup (Trustworthy Information Systems for Healthcare) about the growing malware problem we’re all facing.

Have you ever seen a Zombie film? If so, you know that to stop Zombies you must shoot them in the head – the only problem is that the steady stream of Zombies never seems to end and they keep infecting others. Just when you’ve eradicated every Zombie but one, the infection gets transmitted and the problem returns. You spend your day shooting them but you never seem to make any progress.

A Zombie in computer science is a computer connected to the Internet that has been compromised by a cracker, computer virus or trojan horse and can be used to perform malicious tasks of one sort or another under remote direction.

Starting in March of 2011, the rise in malware on the internet has created millions of zombie computers. Experts estimate that 48% of all computers on the internet are infected. Malware is transmitted from infected photos (Heidi Klum is the most dangerous celebrity on the internet this year), infected PDFs, infected Java files, ActiveX controls that take advantage of Windows/Internet Explorer vulnerabilities and numerous other means.

Here’s the problem – the nature of this new malware is that it is hard to detect (often hiding on hard disk boot tracks), it’s hard to remove (often requiring complete reinstallation of the operating system), and anti-virus software no longer works against it.

A new virus is released on the internet every 30 seconds. Modern viruses contain self modifying code. The “signature” approaches used in anti-virus software to rapidly identify known viruses, does not work with this new generation of malware.

Mitt Romney Treads Carefully

Nov 8, 2011• 1

By Roger Collier

Presidential candidate Mitt Romney’s reform plan for Medicare is just as cautious―and carefully vague on some key details―as might be expected from an politician famously sensitive to the winds of public opinion.

Romney’s proposal looks a lot like those offered by last year’s Rivlin-Domenici Debt Reduction Task Force and the 1999 National Bipartisan Commission on the Future of Medicare. Like those proposals, and also the plan offered by House Budget Chair Paul Ryan, Romney’s would convert Medicare into a premium support program in which beneficiaries would receive a fixed contribution towards the cost of coverage. However, unlike Ryan’s plan―received so negatively by seniors that it cost Republicans a House seat―beneficiaries would still have traditional fee-for-service Medicare as an option.

Under the Romney proposal, commercial insurers would compete with traditional Medicare in offering a basic set of benefits. Beneficiaries would choose from a “menu” of plans, paying out-of-pocket for any difference between the premium and the federal support contribution. Lower-income individuals would receive larger premium support amounts, while beneficiaries selecting options with premiums below the support amount would keep the savings. Also, as with the other similar proposals, there would be a gradual increase in the Medicare eligibility age from today’s 65 years.

Although it was immediately attacked by various liberal commentators, the Romney proposal seems on the surface to be a reasonable approach to a program that otherwise is headed for bankruptcy. How reasonable, however, will depend on numerous details that have been carefully left vague. (Interestingly, the proposal is nowhere mentioned on candidate Romney’s campaign web site.)

Siemens Jumps into HIE Waters

Nov 8, 2011• 2

By John Moore

Acquisition fever has set in and they’re dropping like flies, independent HIE vendors that is. Earlier today, Siemens announced its intent to acquire enterprise HIE vendor MobileMD. So in little over a year we have seen IBM snag Initiate, Axolotl fall into the hands of Ingenix/United Health Group (Ingenix is now known as OptumInsight), Medicity tie the knot with Aetna, Harris pick-up Dept of Defense clinician portal darling Carefx and Wellogic, a damsel in distress, being rescued by Alere. Elsevier also announce an intent to acquire dbMotion for a whooping $310M, but nothing came of that other than a substantiation of the rumor that dbMotion was being shopped.

That does not leave many small, independent HIE vendors that have some traction left in the market. Following is our list of such vendors and what might become of them:

4medica: A relative new comer to the HIE market, 4medica will be profiled for the first time in the upcoming HIE Market Trends Report which is scheduled for release in early 2012. 4medica is quite strong on lab information exchange. Future: 4medica still remains under the radar screen as it completes its platform to truly serve all HIE needs. Once that process is complete, the company is likely to gain increasing attention and will be acquired in 18-14 months.

Care Evolution: Privately owned and self-funded, founder has every intent to stay independent. As he has told us on more than one occasion, I’ve already made plenty of money and this is not about cashing out to the highest bidder. Future: Everyone has a price but this company may be one of the last to fall into the arms of another.

Looking for Interoperability in All the Wrong Places

Nov 8, 2011• 4

By Adrian Gropper, MD

To achieve interoperability, simply reduce the cost of interfaces. The economic value will follow.

Vendors, hospitals, patients and the states are all the wrong places to look for interoperability. Vendors prefer to lock-in their customers, differentiate their product and derive revenue from interfaces. Hospitals prefer to lock in their patients, differentiate their service and derive revenue from pricing power in the marketplace that results from consolidation. Patients confused by the technical nature of interoperability are easily misled into erecting privacy barriers that obscure quality and cost transparency. Finally, the states spend federal money designed to seed interoperability following established bureaucratic and political paths dominated by unchallenged input from vendors, hospitals and misinformed patients.

The cost of interfaces is the sum of Identity, Consent, Transport, Software and Opportunity. Reducing the cost of all five to near zero is possible and relatively easy. The Web and DICOM interfaces to radiology systems demonstrate many of the details at a large scale and for over a decade.

Identity can be free and easy if it’s voluntary to the person or system being identified. On the Web, identity is an email address. Email is free and available to all, even if they have to go to the library to use it. Email IDs are voluntary, you can use one or another as you choose without prejudice or permission. For a system example, DICOM interface IDs are IP (Internet Protocol) Addresses. They too are free and voluntary. The Direct Project is healthcare’s version of a free and voluntary ID for people and for systems. For both patient and clinicians, Direct Project identity is based on email addresses. Patients can already get a free Direct email ID from Microsoft HealthVault. Doctors can get one from Surescripts/AAFP for $15/month and free options are sure to follow. Free, voluntary identity eliminates one of the major costs of health information exchange: the Master Patient Index (MPI). MPI is one of those technologies that costs more the larger it gets. It’s time we abandon MPI as a path to interoperability.

What Difference Does Health Insurance Make?

Nov 7, 2011• 61

By John Goodman

Almost everyone thinks we should insure the uninsured. I don’t recall even a single dissenter. Yet it is precisely when everyone agrees on something that thinking begins to get very sloppy. So let me be the devil’s advocate and challenge the idea.

Why do we want to insure the uninsured? Forget about the costs, for a moment. Are there any benefits? What are they? I can think of four candidates. If people are insured:

They may get more health care.
They may get better care.
They will enjoy protection from the financial effects of catastrophic illness.
They will be less likely to be free riders on the charity of others.

The first three items are “it’s for his own good” benefits and, frankly, the case for them is pretty lame — especially in the context of RomneyCare and ObamaCare. If you expand the demand for health care but do nothing to increase supply, people in the aggregate will not be able to get more care. One person’s gain in care will be offset by someone else’s loss. (At least that tends to be the case, when the principal currency patients use to pay for care is time and not money.) Since the costs of non-price rationing will rise in the process, the whole exercise must make society as a whole worse off.

The same objection applies to the idea of “better care.” Better care for one person must be obtained at someone else’s expense, if the supply of medical resources is unchanged.

[I suppose you could make an additional argument: If we insure the uninsured, they will have a better chance of getting a “fair share” of health care. In other words, care will be distributed more equally. While that argument makes sense in the abstract, it doesn’t work if you segregate the previously uninsured into plans that pay providers below-market rates — as both RomneyCare and ObamaCare do — and cause them be pushed to the rear of the waiting lines. See below.]