Above the Fold
Commentology: Healthcare in the UK
Rod Unger writes:
I am, if you like, Joe the Plumber living here in the UK just to the North of London. I have no particular political mandate in terms of the NHS (more of this later). I don’t work for the NHS or have any other such vested interest. Nor do I have any knowledge or contact etc with any of the Pharmaceutical companies. Hence I am Joe the plumber. I am just an ordinary man in the street. Before going any further there is one other thing I would like to state as a prequalification. You have to understand the British mentality (as a generalisation). Many, many years ago we thought it proper and decent to be modest. This then slightly altered to us becoming a nation of moaners and pessimists! Unlike Americans who have (as a generalisation) a wonderful “can do” mentality and optimism.
The NHS is one of the most wonderful things about an excellent lifestyle we have here in the UK. Our weather is better than often reported. (Check out the stats if you don’t believe me) We are full of invention, fun and excel at many world wide industries and sports. But the NHS is one of the best things about the U.K. It is not run by the Pharmaceutical companies who only want to maximise profits. It is not run by lobbyists for their own benefit. It is run for the nation. It is not perfect and you will here the moaners going on about the small percentage of problems (big in number small in percentage). No government ever since the NHS as introduced has ever even considered doing away with the NHS. This is not a political issue in the UK. The NHS is supported by all parties and by everyone. Quite a few people do have private insurance as they can afford to pay for non essential matters or to jump queues. But even they in an emergency will be taken straight to an NHS hospital and receive an excellent service. There will be no queues and no questions asked!
I personally know many people who live in Spain, Portugal etc etc and they all come back to the UK for the NHS. Indeed my own parents lived in Portugal for 12 years when the retired and moved back to the UK at the age of 76!! just for the NHS. Since being back they have used the NHS on a regular basis (they are now 88) and we all have nothing but praise for all parts of this massive organisation. All their care, medications etc etc is free.
About 4 years ago my son was diagnosed with a serious ling term mental disorder. We use the NHS every day. He takes medication every day and will have to for the rest of his life. All this is free and the staff are fantastic
We do live in different societies. It is not for us to advise you as to what is best for your country but do not denigrate or criticise the NHS it is fabulous on a world wide scale. Yes there are problems not least of all trying to move this huge organisation in to the modern technological age plus coping with a huge influx of people from foreign countries many of whom cannot speak English. This has put a massive strain on the resources available, but still the staff provide a fabulous service.
Don’t believe the propaganda from those wishing to feather their own nests. It is too important
Best Wishes
Rod Unger
Data drives decisions? Crowd-sourcing as the future of research
So, I get back from lounging on the beach in Hawaii to find that two strands of the THCB and Health 2,0 worlds have connected! At the Health 2.0 Conference we’re going to be hearing from 23andme, PatientsLikeMe, Pfizer, MedHelp, Within3 and more about the role that crowd-sourced data has on the future of decisions and discovery.
And then in the NY Times today there’s an excellent article all about this called Research Trove – Patients Online Data. And the author is THCB alumna Sarah Arnquist, who is now in Africa studying health care in Uganda.
Death Panels, Palliative Care, and the Dangers of Modern McCarthyism
It’s time to fight back. The “death panel” nonsense is not a harmless and amusing political canard – it is modern McCarthyism: the shameless, heinous use of lies and distortions to scare and confuse people. The tide will only turn if all of us begin speaking up for the truth.
Read NY Times piece on palliative care, and you get a sense of the power and beauty of the modern movement to provide patients and families with information and support at the end of life. The piece chronicles the decline and ultimate death of Deborah Migliore, a former topless dancer from the Bronx, from metastatic carcinoid, and the efforts of palliative care specialist Sean O’Mahony to support the patient and her husband through her painful final weeks. The article describes palliative care providers this way:
They are tour guides on the road to death, the equivalent of the ferryman in the Greek myth who accompanied people across the river Styx to the underworld. They argue that a frank acknowledgement of the inevitability of death allows patients to concentrate on improving the quality of their lives, rather than lengthening them, to put their affairs in order and to say goodbye before it is too late.
This has been precisely my experience working with our extraordinary palliative care team at UCSF. So I was pleased to see some support for palliative care embedded into the early versions of health reform legislation.
Then came Sarah Palin and the other hypocritical asses who have managed to take a serious, even profound, issue and turn it into a mockery. Read Joe Klein’s article in this week’s Time magazine to get your blood boiling. Klein begins with a poignant discussion of the end-of-life issues he’s grapping with for his elderly parents, but then – after the obligatory “there are still a few reasonable Republicans out there… somewhere” riff – gets to the point:
… But they have been overwhelmed by nihilists and hypocrites more interested in destroying the opposition and gaining power than in the public weal. The philosophically supple party that existed as recently as George H.W. Bush’s presidency has been obliterated. The party’s putative intellectuals — people like the Weekly Standard’s William Kristol — are prosaic tacticians who make precious few substantive arguments but oppose health-care reform mostly because passage would help Barack Obama’s political prospects. In 1993, when the Clintons tried health-care reform, the Republican John Chafee offered a creative (in fact, superior) alternative — which Kristol quashed with his famous “Don’t Help Clinton” fax to the troops. There is no Republican health-care alternative in 2009. The same people who rail against a government takeover of health care tried to enforce a government takeover of Terri Schiavo’s end-of-life decisions. And when Palin floated the “death panel” canard, the number of prominent Republicans who rose up to call her out could be counted on one hand.Continue reading…
Cool Technology of the Week
Before my trip to Japan, I attended the New England Healthcare Institute Medication Adherence Expert Roundtable on Thursday July 23rd, 2009. The purpose of the roundtable was to prioritize activities that would encourage patients to be more compliant with the medications, especially those with chronic diseases such as diabetes, congestive heart failure and COPD. Recommendations from the group included better patient education, enhanced use of IT such as medication reconciliation, and healthcare reform which ensures clinicians have the time and incentives to coordinate and manage all medications for their patients.
One technology that we discussed was an intelligent pill bottle for the home from rxvitality.com and it’s my cool technology of the week. Using technology similar to the Ambient Orb, the intelligent pill bottle flashes to indicate when it’s time to take the medication inside the bottle. When the bottle is opened it sends telemetry back to a portal which can be used to track patient medication adherence.
The device includes a small wireless access point for the home, making the device plug and play. No cell phone plan, configuration or special software is needed – just an internet connection.
A pill bottle that notifies the patient when medications are to be taken and informs the clinician when medications are actually taken.
That’s cool!
John D. Halamka, MD, MS, is CIO of the CareGroup Health System, CIO and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE, Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing emergency physician. He blogs regularly at Life as a Healthcare CEO, where this post first appeared.
More on THCB by this author:
Interview with Al Waxman, Psilos Group
Al Waxman is a healthcare entrepreneur who these days runs the Psilos Group, a venture firm that invests in health care services, health care IT and device and instrumentation companies. Among their better known investments are Active Health Management, Health Hero Network and Definity Health–now all acquired by publicly traded companies. This is a wide ranging conversation about Al’s investment philosophy, his desire to get VCs more involved in health care, his mistrust of politicians and where he thinks health care technology is headed. Here’s the interview.
Al will also be on a panel at Health 2.0 on October 6-7 talking about whether Health 2.0 can make health care more affordable.
Not Just Personal Responsibility
Off and on during the current health reform debate, politicians, leaders and pundits have raised the issue personal responsibility. For instance, take these comments from the John Mackey, the CEO of Whole Foods:
“…many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.”
That is a refrain many of us who think and discuss American medicine are used to hearing. In fact, I wrote an article over a year ago in Salon emphasizing the role of individuals in taking care of their own health. That being said, though, I think (especially after having read my readers’ comments about that piece) the view doesn’t take into account the socio-economic factors that pressure many Americans into chronic illness.
Let’s look at obesity as an example that illustrates this. Almost one-third of adults and children are obese, a problem that costs us $100 billion dollars a year. In California, where I live, our State Controller estimates that “the economic cost to California of adults who are obese, overweight and physically inactive is equivalent to more than a third of the state’s total budget.”
Those are the facts, and as Mackey so obviously says, a proper diet and exercise can help to prevent obesity. But for many, that’s not so easy.
To illustrate what I mean, consider the following experiment: a while ago, I decided to take a trip to the grocery store with $40. I spent half of that money on fresh, healthy foods and the other half on processed foods. I took my grocery bags home and counted up the calories per dollar that I spent on both types of foods. For the healthier choices, I got 140 Calories per dollar; for the processed foods, I got 370 Calories per dollar.
That little experiment has real-world implications when you think about middle class families, with two (or one or zero given our current unemployment numbers) working parents, trying to make ends meet. Even people living paycheck to paycheck know what food choices are good for them. But if you’re one of the millions of families just scraping by, popping a couple of DiGiorno pizzas in the over for dinner is cheap and calorie-laden enough to soothe your hunger pangs. It also leaves one less battle to fight with your kids between getting them to finish their schoolwork and getting them ready for bed.
Add the consequences of my little experiment to some other factors, like the lack of access to fresh foods in poorer communities (Mr. Mackey, do you have any stores in low-income areas?), or a lack of safe places to get out and exercise, and you can see that prevention has as much to do with class, income, and communities as it does with personal responsibility.
Dr. Rahul Parikh is a Pediatrician in the San Francisco Bay Area and a frequent contributor to Salon.com and THCB. Dr. Parikh practices with the Walnut Creek Medical Center and Kasier Permanente.
Commentology: Thoughts on the Death of Primary Care
Vance Harris MD writes:
We are our own worst enemies, as we have allowed insurance companies and Medicare to set the value of our services. Clearly those values they impose have nothing to do with our contribution to the health of our patients or the cost savings we bring about.
Case in point:
How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.
How many times has an anxious patient come in, almost demanding an endoscopy, who I examined, after taking a good history, and then decided to treat for 3-4 weeks before making the referral? Few of these patients are happy with me after the visit, no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before considering endoscopy. This delay in referral has lead to many a tense moment in the last 20 years. Cost savings to the system is again thousands of dollars each and every time I do this. I am willing to make the call and go with the treatment first before getting the scope. My reward is about $55 from Medicare and the Big Blues.
How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? Again a good history and a directed exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything in this setting is low. This takes a lot of time to explain as I teach them why they don’t need, and better yet, why they don’t want to get an MRI at this point. If someone else ordered the MRI guess who gets to explain the significance of bulging disks and narrowed foramen to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging that rarely helps, in the acute setting of a normal exam, saves the system thousands of dollars again. My reward is another $55 if I am lucky.
How many times does a good shoulder exam allow me not to order an MRI giving the patient time to heal and recover before imaging racks up another couple of thousand dollars followed by orthopedic referral for a shoulder that doesn’t need surgery? Another $55 will shower down on me at the end of the day when I send off the bill for that exam.
How many basal cell and squamous cell cancers have I discovered while examining some ones shoulder or abdomen or even a sore throat? How many of those was I stupid enough to remove the same day, only to find out that I would be paid for only one procedure and it would always be the least expensive of the two? How many appeals have been successful to Medicare when I performed the service and was denied payment?
How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? I have spent hundreds of hours dealing with them and their families trying to effect changes that will someday allow them to get their disease under control. I do this because the only Endocrinologist in the county will not see pediatric diabetics. I can’t say that I blame him as the time spent seems like a total waste. That is, until one day they open their eyes and want to take care of themselves. My reward for years of struggle and years of 30 minute visits trying to get them to take responsibility for their health is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.
I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else’s account drawing interest.
I have always served my fellowman out of a sense of love and compassion and for those reasons I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn’t it a shame that after all this time and with skills honed by decades of experience, I can barely afford to work as a physician? Taxes will be collected, no pass for the working physician, not like the Goldman Sacks guys and their buddies with the 9 billion in bonuses given last year after the 58 billion in funds we gave them.
My parting words next year will be good luck having PA’s provide the safety net with their 2 years of training. Good luck getting newly trained physicians to take over once they see my salary. Good luck having internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting the primary care specialists when you are short 70,000 now and 1/3 plan on retirement within 3 years.
If there is any irony in this at all, it is that I will find myself in the same boat as I struggle to find a doctor to take care of me. Now that is ironic. Anyone know who is taking new patients in California?
Vance Harris, MD
Why Standards Matter (1): The True Meaning of Interoperability
Americans are generally skeptical of words that otherwise intelligent and articulate people can’t pronounce. “Interoperability,” like nu-cu-lar, is one of these. After a while, these words can take on a mystique all their own.But interoperability is a hugely important word in the context of today’s ongoing debate about the use of EHR technology by physicians, hospitals, and patients too. The federal government is going to provide billions of dollars to encourage today’s fragmented health care providers to convert from mostly paper to mostly computerized information systems. It is critically important for these systems to talk with one another. We want health data to flow between and among these systems and to be, well, interoperable. And it isn’t now.
So how can this word be so difficult to put into action? Here’s a clue: a lot of people are confused about its meaning.Continue reading…
Can Social Media Save Healthcare Reform?
Daniel Palestrant is the Founder & CEO of Sermo, the largest online physician community, and a friend of THCB’s from the Health 2.0 world. Lately Dan has been seen on cable TV representing the 110K+ Sermo members in the health reform debate—including a very public break-up with Sermo’s former partners at the AMA, which has endorsed the House 3200 bill. I’ve been asking Dan, if his members’ don’t want the House bill, what do they want? This is the piece he sent me in reply—Matthew Holt
Speaking at Fortune’s Brainstorm Technology Conference last month, longtime healthcare reform advocate, Howard Dean pointed out that the “dirty secret” of social media is that it can put a whole lot of politicians out of business because it allows the truth to bubble up. For the sake of healthcare reform, let’s hope he is right.Continue reading…
