Over on our sister site, the Health 2.0 News Blog, you’ll find this week’s news bites – Take Care Clinics launch online scheduling, BitGym releases a new fitness app, Ford to embed wireless health devices in its vehicles of the future and a new study evaluates the impact of online diabetes tools.
Above the Fold
Should Your Doctor Be Thinking About Society’s Healthcare Costs?
You probably want your doctor to care about people, but how much do you want her to care about all of them? That’s the question I ask when I read articles – generally by bioethicists, often respectable ones – asserting that one of the moral responsibilities of physicians is to be responsible stewards of the healthcare dollar.
This rhetoric concerns me, because I worry it may ultimately degrade the already-challenged physician-patient relationship.
The cornerstone of medicine, the most fundamental principle, in my mind, is the absolute, rock-solid belief that your doctor is your unqualified advocate and will work as hard as possible to provide you with the best medical treatment possible, as if you were a member of her own family (Dr. Marty Samuels and I originally described this as “The Uncle Marvin Test”).
To be clear: this doesn’t mean the most expensive pills – by all means prescribe or substitute an equivalent generic, when available. This doesn’t mean the most expensive diagnostic studies – it’s generally in the patient’s medical interest to avoid unnecessary procedures that usually carry some intrinsic risk and also can lead to false positive results that can in turn lead to needless anxiety — and on occasion, permanent harm. This doesn’t mean extra days in the hospital – a hospital is one of the world’s most dangerous places, and it’s often in a patient’s best interest to be discharged as soon as possible (see here if you need more convincing).
The Awkward World of Private Insurance in the UK
I remember reading an article that observed that systems of universal insurance – which need to put their energy into providing a “decent minimum” for the masses – must also offer a “safety valve for the wealthy disaffected.” Canada bans private insurance for basic hospital and medical care services. So, when affluent Canadians want “the best,” some of them pop across the border to Cleveland or Ann Arbor.
But from the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works:
The insurance part isn’t too difficult to understand. People living in Britain can obtain private insurance, and about 10 percent of them do. About one-third of people with private insurance purchase it with their own money, while the rest receive it as a benefit of employment. Many of the big multinationals provide such insurance, either to all their employees or to senior executives. It’s considered a plum perk for everyone, and most expats coming to work in the UK consider it an essential benefit.
A Win-Win: Job Creation Will Grow the Economy and Improve Health
The current economic recovery effort presents an opportunity to build stronger, healthier communities. That’s a central goal for the Create Jobs for USA Fund that Opportunity Finance Network (OFN) and Starbucks launched late last year to support job creation and retention.
Economic growth and job creation provide more than income and the ability to afford health insurance and medical care. They also enable us to live in safer homes and neighborhoods, buy healthier food, have more leisure time for physical activity, and experience less health-harming stress. The research clearly shows that health starts in our homes and communities and not in the doctor’s office.
In that way, economic policy is, in fact, health policy.
Since 1985, OFN’s national network of community development financial institutions (CDFIs) has loaned more than $23 billion to benefit low-income, low-wealth, and other disadvantaged communities. The Robert Wood Johnson Foundation (RWJF), with an endowment of around $8.5 billion, is the nation’s largest philanthropy focused solely on improving health and health care for all Americans. Marrying the business acumen of CDFIs and others to health philanthropy’s ability to supply the research, analysis, and expertise to make sure community development activities improve residents’ health is a powerful union.
Why This Well-Known Biotech Firm Deploys 17,000 iPads and iPhones
There were some impressive enterprise deployments discussed at the AppNation conference in San Francisco on Thursday.
I’ll lead off with Genentech, the Bay Area biotech firm that is now a subsidiary of Roche. Their 7,000 iPad rollout was news to me, and ranks them sixth on my list of largest iPad deployments in the world.
(View the entire list of more than 530 enterprises that have publicly-confirmed iPad deployments here).
According to mobile application team manager, Paul Lanzi, Genentech has standardized on Apple for mobile, with 17,000 iOS device users worldwide (so by inference, 10,000 iPhones, though it surprises me less and less when I hear about companies deploying iPod Touches, too). All of the Apple devices are corporate-owned, as the company doesn’t do Bring Your Own Device (BYOD). Genentech does have 15,000 BlackBerry users, but they are only allowed to do e-mail, no apps. It doesn’t support Android due to the fragmentation-related hassle. “It’s a really tricky one,” Lanzi said.
While many firms talk about how their device deployments are driven by the ROI they hope to get from using apps, Genentech is actually following through. The company has deployed 60-some apps to employees. Indeed, Genentech rolled out its first mobile Web page even before the iPhone was released, said Lanzi. “We’ve already retired some apps,” he said.Continue reading…
Can You Really Fire Your Insurance, Mitt?
Romney’s remark last week about firing your insurance company apparently harmed him little in the New Hampshire primary. But as the quote has rocketed around, it might be misleading some into thinking that the Massachusetts health care reforms that Romney signed into law made it so people can willy-nilly get rid of an insurer that doesn’t pay their claims on time.
The comment deserves a second look. Can you really fire your insurance company? The answer is that it’s darn difficult even in Massachusetts—the land of Romneycare.Continue reading…
Sizing Up the Obama Administration’s Defense of the Health Reform Law
Back in 2009, when the Affordable Care Act was being written, few doubted that Congress can constitutionally impose a tax penalty on people who refuse to carry adequate insurance. Congress’s power to regulate insurance markets under the Constitution’s commerce clause is settled law. While it seemed clear that Congress has the constitutional power to mandate coverage, some doubted the political wisdom of using that power. Simply forcing people to buy insurance seemed too much like a mean parent saying “eat-your-broccoli, or no dessert.” The mandate, it was feared, would arouse needless opposition. The opposition was needless because most people could be encouraged to buy coverage with positive incentives to enroll, such as direct subsidies, and penalties for refusal to enroll, such as extended denial of access to subsidies and exclusion from insurance market protections.
To the surprise of many, opponents of the Affordable Care Act took the broccoli analogy literally. Not buying insurance is simply inactivity, they argued. If government can prohibit this form of inactivity by forcing people to buy insurance, it can force them to buy anything, even broccoli. If Congress can prohibit such ‘inaction,’ they argued, freedom is in jeopardy. More to the point, the constitution doesn’t allow limits on ‘inactivity.’
The appeal to the broad public of the argument that not buying insurance is inactivity may not have been surprising. But the acceptance of the argument by some federal judges is downright astounding, as the distinction rests on a fundamental ignorance of how insurance markets work.
Tonsillectomy Confidential
In 2008, Rachael Hoffman-Dachelet’s eight-year-old son started having frequent sore throats. He’d run a fever, feel stiff and tired, and miss a few days of school. After six sore throats in a year, her pediatrician said This is crazy. I’m going to refer you to an ear nose and throat specialist. I think he’ll recommend a tonsillectomy (tonsil removal).
Rachael and her son saw the specialist, who did recommend a tonsillectomy. Tonsils are part of the lymphatic system, a network of tiny tubes and nodes all over the body. It is mostly a drainage system. Lymph drains into the tubes, which carry it to the heart, where it reenters the blood. En route to the heart, lymph passes through nodes. How can lymph move through the system if you remove part of it? Rachael asked the specialist. If there were any bad long-term consequences we’d know because so many tonsillectomies have been done, he said. The correct answer is that lymph does not pass through the tonsils. Rachael asked about the benefits of the surgery. Your son will miss a lot less school, he said.
Rachael teaches art at a Minnesota middle school. Her experience with doctors had made her skeptical of their predictions.
To decide for herself if a tonsillectomy was a good idea, she googled “pubmed tonsillectomy meta-analysis” and found a Cochrane Review about tonsillectomies and tonsillitis. There are thousands of Cochrane Reviews. Each tries to summarize the evidence about the effect of a treatment on a health problem (e.g., “Antibiotics for sore throats“). They are meant to be practical — to help everyone, including outsiders like Rachael, make treatment decisions (such as “should my son have a tonsillectomy?”). They are produced by the Cochrane Collaboration, a British non-profit, which says its reviews are “internationally recognised as the highest standard in evidence-based health care”.
Competition in Health Insurance: What Should Government Do?
Many Americans complain that there is too little competition between health plans. To some degree, this is true. Few of us are allowed to choose our own health insurance. Instead, we take whatever our employers offer us.
However, we must not succumb to the natural temptation to call for more government intervention to reverse this problem. On the contrary, concentration among health plans has largely occurred subsequent to government action.
Signed in March 2010, ObamaCare has certainly had the opposite effect than that promoted by its advocates. The table below shows premiums in the small-group market in 2008 and 2010, for 37 states with available data.
Two Patients Coded
My recent post on end-of-life care issues, “What if they had had to pay?,” generated a lot of comments in the blogosphere and beyond. One intensive care doctor sent me a particularly poignant note. It gives a good sense of what it is like on this person’s side of the bed. The note re-emphasizes the need for better end-of-life planning, for the sake of patients, families, and providers.
Here’s my day so far. This is my first day of a 7-day stretch in a tertiary ICU. The average census in this ICU is 10, but today we have had to surge to 15.
Let me stop right there. This is doctor (and nurse) shorthand for, “I expect to be very busy, very tired, and very stressed out. I am going to have to make some highly critical clinical judgments, sometimes with very little time to react. I don’t know anything about these patients beyond what is in the charts and what our care team sees and hears for themselves.”
Two patients today coded in our hospital. One family wants “everything” done, and seemed shocked to learn that I don’t think it is right to provide “everything.” The other family wished someone from the healthcare team had bothered to ask them what their 89 year old dad would really like to accomplish from his hospital stay before he tried to die. We decided to let him finish dying.
