What does a know-nothing Republican who doesn’t believe in science and is front-runner for his party’s nomination for President say about health care? Pretty much the same that the rest of them now do–unlike McCain, Huckabee et al in 2008. What’s the new Republican ideology? Apparently. there’s not much wrong with health care and what there is wrong, caps on malpractice payouts will fix. Perry cites the increase in the number of doctors in Texas since tort reform caps were put in as proof that it works. Wendell Potter at PR Watch shows that, when corrected with facts, everything Perry says is rubbish. But then again, were you surprised?
Above the Fold
If You Get What You Pay For, How Much Should You Spend?
I have been thinking lately about the state of the field of health services research. Having plied this trade for nearly 30 years, it struck me that many of the unanswered questions that I encountered as a doctoral student remain unanswered. I plan to post occasional blogs in which I pose these questions, discuss the state of the research, and explain why it is critical that we come up with better answers. The first question is really the big kahuna: If you get what you pay for, how much should you spend?
Everyone seems to agree that the U.S. spends too much money on healthcare. This has led many to embrace machete policies: Slash payments to doctors. Slash payments to hospitals. Slash payments to drug companies. Slash the number of specialists. Slash, slash, slash.
There is abundant research that past machete policies directed towards healthcare providers have adversely affect healthcare quality and access. There is also abundant evidence supporting the view that machete policies would curtail medical innovation. Medical providers and drug companies cite this evidence whenever they are threatened with payment cuts, proclaiming that any reductions from current levels would be disastrous for the American public.
The Need for a Level Playing Field for Physician Pay
Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much. It’s part of the same ethic that teaches us not to criticize another doctor’s care.
But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest. If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrativeCPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?
History shows that physician pay rarely follows value, but rather aligns with power. When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own. Power and wealth followed.
About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT and MRI scans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.
The Wonks Are Wrong
I’ve heard critics express the idea a thousand times in a thousand ways.
The idea goes like this:
The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.
The Shadow
The problem is between the idea and reality falls a shadow. Patients aren’t listening.
They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem. Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care
Health 2.0: TweetChat and SF Agenda!
The agenda for the Fall Health 2.0 Conference is up–and it is mega, as in by far the biggest thing we’ve ever done. Just getting the agenda right online took three of us all day!
Four Pre-Conferences. An overnight Code-a-thon and Health 2.0 101, educational session for developers and people new to health care. Two full days of main stage programming including more CEOs and tech whizes than you can imagine. Over 140 live product demos. More than 25 parallel sessions or Deep Dives. Live CEO interviews. And some “Unmentionable” topics never discussed at a health care tech conference before. Not to mention at least 20 brand new product introductions.
The conference is Sept 25-7 in San Francisco. The Exhibit Hall is sold out, the room block is going fast, registration is running well ahead of last year’s record crowd of 1,000, and ticket prices go up on Wednesday. Buy yours now, while they’re still available. Deals will be done, imaginations will be blown, history will be made. You won’t regret coming!
And just in case you need a little taster. From 9.30 PST/12.30 EST I’ll be running a 30 minute tweetchat tweeting from @boltyboy and @health2con. Just follow the #health2con hashtag —this Tweetchat link is a painless way to do that— and have fun with my questions and answers! See you there!
The ‘CSI Effect’ Hits Medicine
I’m in Israel, home to some of the most innovative care in the world. Doctors here wanted to know if the high-tech tests that are an increasing part of their work help. A couple of weeks ago, they published their results.
It turns out that in about 90% of cases, it didn’t matter.
A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis. As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”
The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued. But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S. American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.
Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study. According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.
There is something more fundamental happening – and it’s happening around the world.
To understand it, look to something that is happening in courtrooms across the U.S. Some call it the “CSI Effect,” after the TV show, CSI. In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty. Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.
Something like this is happening in medicine.
Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis. They’re often surprised to see how it really works. Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis. Doctors often order high-tech tests because patients expect it.Continue reading…
Steve Jobs: Healthcare Revolutionary?
He killed the audio CD but resurrected the music industry.
Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.
Turned your hand-held into a portal to the world wide web.
Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.
Really? The practice of medicine?Continue reading…
Finding A Quality Doctor
The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.
Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”
She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”
From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –
I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.
As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.Continue reading…
Lessons Learned from Steve Jobs
I recently spoke with several reporters about Steve Jobs’ impact on healthcare, thanking him for the past 15 years of innovation. In preparing for those interviews, I reviewed Steve’s career milestones,
In 1997, Apple Computer was in trouble. Its sales had declined from 11 billion in 1995 to 7 billion in 1997. Its energies were focused on battling Microsoft. It had lost its way.
Steve Jobs made these remarks at MacWorld 1997, a few months before becoming Apple’s CEO. He outlined a simple go forward plan:
1. Board of Directors
2. Focus on Relevance
3. Invest in Core Assets
4. Meaningful Partnerships
5. New Product Paradigm
How can we apply these 5 ideas to the work we’re doing in HIT?
It’s clear that Health Information Exchanges across the country are in trouble – CareSpark closed its doors, the CEO of Cal eConnectresigned, and Minnesota Health Information Exchange ceased operations.
Aiming developers at the insurance market?
It’s hard to think of a more opaque market than that for individual health insurance. But perhaps there’s enough data that can be reworked so that ordinary people can get a better understanding of it. Todd Park, HHS’ CTO, for sure thinks so, and just last week arranged (as in he said in this blog post) to allow developers to download files with data from all the markets in all 50 states & DC. My hope is that this will inspire people like eHealthInsurance.com to put the most important part of any plan comparison (out of pocket maximums) front and center on their plan comparison tools. Otherwise, I may just have to build my own….
