There ‘s an excellent article by physician Ken Murray at Zocalo Public Square suggesting that few (or no) doctors would put themselves through routinely practiced end of life care. Let’s face it. The system is on automatic for reasons that are lost in professional medical culture and propagated by the Jerome Groopman meme that we must keep practicing new stuff to find out what works, and if lots of people suffer on the way….well that’s the cost of progress. The result is a medical system that does massively excessive care of everyone–especially the nearly dead. As the old joke goes, they really do put nails in coffins to keep the oncologists out. Yes there are cases when intensive treatment does work, but I suggest everyone looks at the engagewithgrace.org site in order to start the conversation with their own families and providers. At least take the system off automatic for you and your loved ones.
Above the Fold
Should Doctors Make House Calls?
In the olden days, doctors would travel from house to house when community members fell ill. Now, we usually expect patients to come to our office-based clinics. The modern model of care is certainly more efficient for us as physicians. But it’s also a barrier for patients to receive medicine; the highest-risk people usually make it to our clinics after being discharged from their first or second hospitalization, well after high blood pressure or diabetes has already taken its toll on their bodies. Our latest research suggests that we can statistically predict which people are most likely to end up having chronic diseases five or ten years from now. We can pinpoint these people right down to which house they live in. Such predictive models present a new opportunity to prevent disease before it becomes costly or deadly. In this week’s post, we look at a new idea for community-based disease prevention in medicine: the geographical mapping of chronic disease risks, and preemptive visits of healthcare workers to households where people are likely to become ill in the future.
The physician Jeffrey Brenner became famous for piloting a model of healthcare that would attempt to simultaneously improve services while reducing healthcare costs in his city of Camden, New Jersey. His model, recently profiled in Atul Gawande’s popular New Yorker article “The Hot Spotters”, was based on a simple observation: that sick people with poorly-treated diseases tend to be clustered in certain parts of the city.
The Last Six Months of Life
This discussion was inspired by the two women I owe my life to: my mother and my wife.
I cannot identify the citation for this factoid, but the assertion has become engrained in the lore of medical urban myth: “50% of healthcare costs are incurred in the last 6 months of life.” (or some similar figure) There are other less arresting but more concrete statistics to be found. For example, according to Health Affairs, July 2001 vol. 20 no. 4 188-195, one quarter of Medicare outlays are for the last year of life. Another more recent discussion concerned the various factors that influence that spending in the last 6 months. An article in the Annals of Internal Medicine for February 15, 2011 vol. 154 no. 4 235-242 describes determinants of healthcare spending and points out that regional variation in medical care does not account for as much variation as is sometimes pretended.
A concise summary of that article by one consulting firm states “Individual characteristics such as black or hispanic race, severe functional impairment, having Medicare Supplement coverage, suffering from certain chronic diseases or from four or more, were associated with higher spending. Others, such as having a relative live nearby or having dementia, are associated with lower spending. And some, such as having an advance directive, sex, marital status, education, net worth, or religiosity, appeared to have no relationship. Altogether, patient characteristics account for 10% of the variation in spending in the last 6 months of life.” (Quoted from Kevin Roche at vitaadvisors.com) Yet even with all this taken into account, patient and regional factors accounted for only 15% of the variation.There seems to be a major subtext to all of this discussion about the last six months of life, whether the topic is cost, ethical issues, quality of life, or whatever. The unstated message is “WE ARE WASTING MONEY ON FUTILE CARE!”. The implication seems to be, “couldn’t we devote these scarce medical resources to more beneficial use?” and “Why are we prolonging suffering and poor quality of life at such great expense to so little gain?” I ask myself these same questions whenever I walk down the corridor of the ICU to see a consult, past room after room of people on ventilators, bloated, mittened and tubed beyond our ability to recognize them as the same individuals seen in the photos I sometimes see pasted to the wall opposite the bed. “Don’t we know”, I ask, ”when to cease and decist?
2011 EHR Adoption Rates
On Wednesday the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by state, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Fig. 1] to this year’s estimated EHR adoption numbers [Fig. 2].
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EMR’s hockey stick up!
Every VC loves and hates the hockey stick–that growth curve that potters along and then suddenly shoots up. But if you check out the new numbers from CDC the use of a basic EMR is on that hockey stick curve. Adoption of a “basic system” has gone from under 17% in 2008 to 33% this year, with another 40% of doctors saying they’re going for the Meaningful Use gold–which means essentially a more than “basic” system. So maybe this is a hockey stick curve that we can all love. (Well all other than the curmudgeons over at Health Care Renewal!). On a somewhat related personal note, I too was awaiting the hockey stick of EMR adoption. I abandoned my attempt to catch the start of the hockey curve in 2000 when I quit my EMR survey job at Harris Interactive. All I had to do was hang on for another eight years and I’d have been proved right!
Do We Really Spend More and Get Less?
The conventional wisdom in health policy is that the United States spends far more than any other country and enjoys mediocre health outcomes. This judgment is repeated so often and so forcefully that you will almost never see it questioned. And yet it may not be true.
Indeed, the reverse may be true. We may be spending less and getting more.
The case for the critics was bolstered last week by a new OECD report that concluded:
The United States spends two-and-a-half times more than the OECD average health expenditure per person … It even spends twice as much as France, for example, a country which is generally accepted as having very good health services. At 17.4% of GDP in 2009, U.S. health spending is half as much again as any other country, and nearly twice the average.
Similar claims were made recently in The New York Times by former White House health advisor, Zeke Emanuel, who added that we are not getting better health care as a result. The same charge was aired at the Health Affairs blog the other day by Obama Social Security Advisory Board appointee Henry Aaron and health economist Paul Ginsburg. It is standard fare at Ezra Klein’s blog, at The Incidental Economist and at the Commonwealth Fund. It is also unquestioned dogma for New York Times columnist, Paul Krugman.
What are all these people missing? On the spending side, they are overlooking one of the most basic concepts in all of economics.
Will Health Insurance Reform Reach Those Who Really Need It?
Issues that affect our lives don’t happen in a vacuum. Everything affects everything else, and there’s no area where that’s truer than health and access to care. So I’m going to take a slight detour from the financial and economic issues I write about most of the time to say a bit about the Affordable Care Act, which marks a historic expansion of access to health care.
Thanks to the law, an estimated 32 million previously uninsured Americans will be able to purchase health insurance in 2014. But right now there are real questions about whether this historic expansion of coverage will reach those Americans who need it most.
My colleagues on The Greenlining Institute‘s health team have been looking into this, and just published their findings in the form of a new report. They focused on the new Health Benefit Exchanges, which will allow consumers to compare the price, quality, and benefits of competing health insurance plans. Maybe most important, Americans will be able to purchase coverage through their state’s Exchange with federal subsidies that will help low and middle-income families cover the cost.
The bottom line is that getting the word out about these new options may be more complicated than it seems, and state Exchanges should get communities involved in the process sooner rather than later.
Current plans call for Web portals to serve as the main route through which consumers will access the Exchanges, but these websites won’t be able to do the job by themselves. States will need to pursue a variety of outreach and enrollment strategies, strategies that must be based on the populations they must reach.
Hey East Coast Entrepreneurs: We Fail Better.
Apparently, the secret to Silicon Valley’s success isn’t just the good weather and smart people – turns out, the secret to our region’s entrepreneurial preeminence just may be the way we embrace failure.
According to KPCB life-science (devices) partner Dana Mead – who notes he hails from the northeast — there’s a world of difference between Palo Alto and Cambridge (MA).
In Cambridge, he contends in a recent (and, as always, informative) lecture/podcast at the Stanford Technology Ventures Program, if you tell people your last three businesses failed, “they’ll look at you sideways” and shake their heads, presumably with a mixture of sadness and pity. In Palo Alto, by contrast, the reaction will be “that’s awesome! I’m sure your next company will be a world-beater.”
The Politics of Prevention
If there’s one thing everyone in Washington can agree on it’s that prevention is good. And that’s about as far as the agreement goes.
As for the rest of it – who is responsible for prevention, how to define prevention, what is the government’s role in prevention, how much to spend on prevention and when to spend it – is not so clear, and wrapped up in the bitter politics (and difficult economics) of the day.
Then, there’s the question of the Prevention and Public Health Fund created by the Affordable Care Act to enable states and communities to try to prevent illness and promote longer, healthier lives. To backers of the law, the fund is an engine for public health, community transformation, and a pivotal part of the effort to create a “health care” system instead of a “sick care” system.
To foes, it’s a “slush fund”, a $13.8 billion monument to everything they don’t like about the 2010 legislation. It’s $13.8 billion that could easily end up on one of the deficit-cutting chopping blocks.
The British Primary Care System and Its Lessons for America
I’ve heard a lot of shocking things since arriving in England five months ago on my sabbatical. But nothing has had me more gobsmacked than when, earlier this month, I was chatting with James Morrow, a Cambridge-area general practitioner. We were talking about physicians’ salaries in the UK and he casually mentioned that he was the primary breadwinner in his family.
His wife, you see, is a surgeon.
This more than any other factoid captures the Alice in Wonderland world of GPs here in England. Yes—and it’s a good thing you’re sitting down—the average GP makes about 20% more than the average subspecialist (though the specialists sometimes earn more through private practice—more on this in a later blog). This is important in and of itself, but the pay is also a metaphor for a well-considered decision by the National Health Service (NHS) nearly a decade ago to nurture a contented, surprisingly independent primary care workforce with strong incentives to improve quality.
Appreciating the enormity of this decision and its relevance to the US healthcare system requires a little historical perspective.
As I mentioned in a previous blog, the British system cleaves the world of primary care and everything else much more starkly than we do in the States. All the specialists (the “ologists,” as they like to call them) are based in hospitals, where they have their outpatient practices, perform their procedures, and staff their specialty wards. Primary care in the community is delivered by GPs, who resemble our family practitioners in training and disposition, but also differ from them in many ways.
