Saturday, December 20, 2008
"People can choose from 240 models and makes of cars pretty intelligently," she says. "Why do we assume they can't do the same when it comes to their health?"
Huh, here is why.
There are some markets where the consumer isn't necessarily the best at making informed and intelligent decisions. One is in healthcare. There other is in financial services. As employers stepped away from pension plans and workers were given defined contribution plans- 401(k)s, workers ended up working longer and had less savings set aside for retirement, even though planning for their future was in their best interest and despite an entirely new industry - mutual fund companies and financial advisors.
Unlike retiring, one can't choose or delay when to have a serious medical problem. How do consumers know what is good in healthcare when they can't figure out something as simple as saving money?
The other is consistently survey after survey consumers routinely indicate that they don't want the responsibility.
I certainly hope her perspective is not the dominant plan that the new Obama administration hopes to use to fix the healthcare system. Seriously.
Thursday, December 18, 2008
Shocking? Hardly. These are the kinds of disparities that arise in our healthcare system everyday. Often the treatments aren't driven by science but by reimbursement.
When you get any treatment, ask your doctor, where's the proof that the treatment you offer is better than others? As the article implies, you may get a newer procedure not because it is necessarily better than others, but because someone, like Medicare will pay for it.
Wednesday, December 17, 2008
Fascinating. An admitted "rebel", his perspective that healthcare is a major contributor to the gross domestic product and that expansion is a good thing is not commonly accepted.
At yet, he might be right.
He's not the only one. A recent piece in Businessweek called "Want Real Stimulus? Try Universal Healthcare" has the same perspective.
Sunday, December 14, 2008
What Dr. Chen fails to address and which often is the reason that the primary care crisis hasn’t been addressed is the current fee for service payment structure. It favors procedures and doing more rather than prevention and coordination of medical care. It isn’t just the paperwork and administrative hassles, the healthcare system as a whole doesn’t favor paying these critical frontline doctors in preventing complications and promoting wellness.
Current graduates aren’t dumb or greedy, they favor work life balance and are flocking toward radiology, ophthalmology, anesthesiology, and dermatology because they offer a more predictable lifestyle with relatively good compensation.
As a practicing primary care doctor, I understand the challenges and feel quite blessed and privileged to be in a practice that values my profession. However, I realize that I am in the minority to feel that way. For primary care to attract more medical students, it will need to transform the delivery of care to improve the doctor-patient relationship, as well as professional satisfaction in addition to significant payment reform.
Unless President Elect Obama and Secretary of Health and Human Services nominee Daschle reform the payment structure to favor prevention and coordination of care will the numbers of primary care doctors increase. But the real question is do they have the leadership needed to make the changes? To do so, that means someone else will lose, specifically specialists, like Dr. Chen. Will they be willing to give up some of their financial livelihood for the good of the healthcare system? What do you think?
I’m thankful that I’m primary care doctor because as an insider I know how to navigate the healthcare system. Without primary care doctors, who is going to help you?
Thursday, December 11, 2008
When it comes to healthcare, I personally believe that the public doesn't want to do all the research in uncovering the best doctors, hospitals, or health insurance plans anymore than they want to research the most financially solvent bank or safest restaurant to eat in. Nevertheless I wrote my book Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System precisely because that is how the healthcare industry and employers, who purchase the insurance, feel that the system as a whole will improve. At least if that is the expectation, provide the public the skills and knowledge to make the right decision.
My comments to the President Elect highlight a very different system of reform, which already exists and is a uniquely American solution to the healthcare crisis.
To President Elect Obama:
Healthcare is currently provided by hospitals and doctors each working separately in little fiefdoms which worked well two centuries ago when patients died of acute illnesses and infections. Today patients are busier than ever, caring for aging parents, and dealing with chronic illnesses, that were never faced by generations ago. The public already gets a variety of choices in financial services, consumer electronics, air transportation, and dining, which are often provided by well-run, highly regarded, focused organizations. Why not healthcare? Americans don’t want the level of responsibility of researching doctors, hospitals, or health plans anymore than they wish to review the safety records of airlines, DUI reports of pilots, or the maintenance records or airworthiness of the aircraft they are about to get on. Similarly with healthcare what they expect and want is a patient friendly healthcare system to care for them when they get ill.
The good news is that a uniquely American solution already exists and can deliver on this promise. Research has shown that the vertically integrated healthcare organization Kaiser Permanente consistently outperformed university and community hospitals in decreasing risk of heart disease by 30 percent. Other studies have shown that the VA healthcare system with its salaried doctors provided better care to its diabetics than doctors in the fee for service community. Other organized healthcare organizations like Geisinger Health Plan and Harvard Pilgrim Health have also shown superior outcomes than the fragmented uncoordinated doctors and hospitals around them.
Healthcare will never be cheap, but we can get more for our dollars. The Dartmouth Atlas of Care found that even though there was not a large difference in health outcomes, the cost of caring for Medicare recipients in the last two years of life varied widely from $93,000 per patient at UCLA, $85,000 at John Hopkins, and $78,000 at Massachusetts General, to the lowest at $53,000 at Mayo Clinic. The "savings" from the most expensive programs could be moved to provide better access or quality care to those who need it, but it won't change the total medical cost expenditures.
Our healthcare crisis will only be solved if the entire industry reorganizes into systems which are aligned to focus on the end product, great healthcare delivery, rather than the piecemeal mom and pop cottage industry which currently exist. This is far harder than it sounds and will require leadership from within healthcare to get it done as well as federal leadership on changing the payment structure to encourage quality rather than volume.
If as a country we fail to solve this crisis, our economy will simply worsen as the workforce will become increasingly unhealthy as more people find healthcare unaffordable and consequently will be unable to work or be competitive in a global marketplace. This is a competition we cannot afford to lose.
Thursday, December 4, 2008
My experience is that although our bodies may feel like their physical age, the vast majority of patients don't feel or think any older. No wonder the phrase "young at heart" is often repeated particularly at birthday parties.
Be sure on your birthday to remind yourself to get all of the preventive screening tests you deserve and that you are doing all the right things, exercise, don't smoke, lose weight, so that you will more likely be around for the following year.
Thursday, November 27, 2008
Dr. Edward Jardini, a family physician focuses on one aspect of healthcare costs, specifically prescription drugs. His 20 cost-saving methods break down into the following groups.
(1) eliminate nonessential prescriptions – stop medications no longer needed because the problem resolved, medications no longer worked, medications never worked, medications were never needed.
(2) think beyond the prescription bottle – treat whatever ails you with lifestyle changes (lose weight, exercise, eat healthier, quit smoking), nondrug treatments, prevent disease naturally.
(3) avoid overpriced me-too drugs – don’t asked for advertised drugs, don’t take free drug samples (it’s how drug companies get you hooked on their most expensive drugs), insist on generic drugs, insist on cheaper drugs in the same medication class, for a particular medical problem (i.e. allergies), get the medication class that is cheapest (antihistamines like benadryl are cheaper than nasal prescription steroids).
(4) be smart – split tablets, be prescribed the right dosage or amount (some medications cost the same for the 20 mg and 40 mg so if you take two 20 mg pills per day, it would be cheaper to tae a 40 mg pill), ask to see if another dosage exists, don’t treat one medication’s side effects with another, shop around, get it for free (take free samples that you absolutely need and enough for the short period of time you need it or if you’ll get insurance to cover the cost), and finally,
(5) use pill programs – programs from drug companies that give discounts (PPA Rx 1-888-4PPA-NOW or www.pparx.org), through the federal government like the VA, TRICARE, or state through Medicaid / Medi-Cal, and possibly Medicare Part D).
Overall the advice is good and we should always ask the doctor for generic medications that are effective for the problem at hand and not get fooled by slick advertising. An excellent free website listing drugs that are the best value for the conditions they treat is by Consumer Reports and found at www.crbestbuydrugs.org. I was surprised he didn’t include this important unbiased source. He also didn’t talk about how Wal-mart and other retailers offer $4 prescription medication and for 90 days, it would cost $10. Another cost saver.
At times, the advice given was misleading or overly optimistic. On page 3, he notes that the generic cholesterol medication lovastatin 10 mg tablet is 58% cheaper than the brand name Lipitor 10 mg pill which is true. What he failed to mention is that the generic drug is only ¼ as potent which means you’d need four times as many pills to get the same cholesterol lowering effect! For the area on think beyond the prescription bottle, yes lifestyle changes would be great, but for the vast majority of people they’ve tried dieting, exercising, and they ultimately need medications to address their medical condition. Telling us what we should do but despite our best intentions are unable to do so really isn’t a cost-saving method per se. Dr. Jardini focuses on one aspect of healthcare costs, specifically prescription drugs. His 20 cost-saving methods break down into the following groups.
(1) eliminate nonessential prescriptions - stop medications no longer needed because the problem resolved, medications no longer worked, medications never worked, medications were never needed.
(2) think beyond the prescription bottle - treat whatever ails you with lifestyle changes (lose weight, exercise, eat healthier, quit smoking), nondrug treatments, prevent disease naturally.
(3) avoid overpriced me-too drugs - don't asked for advertised drugs, don't take free drug samples (it's how drug companies get you hooked on their most expensive drugs), insist on generic drugs, insist on cheaper drugs in the same medication class, for a particular medical problem (i.e. allergies) get the medication class that is cheapest (antihistamines like benadryl are cheaper than nasal prescription steroids).
(4) be smart - split tablets, be prescribed the right dosage or amount (some medications cost the same for the 20 mg and 40 mg so if you take two 20 mg pills per day, it would be cheaper to take a 40 mg pill), ask to see if another dosage exists, don't treat one medication's side effects with another, shop around, get it for free (take free samples that you absolutely need and enough for the short period of time you need it or if you'll get insurance to cover the cost), and finally,
(5) use pill programs - programs from drug companies that give discounts (PPA Rx 1-888-4PPA-NOW or www.pparx.org), through the federal government like the VA, TRICARE, or state through Medicaid / Medi-Cal, and possibly Medicare Part D.
Overall the advice is good and we should always ask the doctor for generic medications that are effective for the problem at hand and not get fooled by slick advertising. An excellent free website listing drugs that are the best value for the conditions they treat is by Consumer Reports and found at www.crbestbuydrugs.org. I was surprised he didn't include this important unbiased source. He also didn't talk about how Wal-mart and other retailers offer $4 prescription medication and for 90 days, it would cost $10. Another cost saver.
At times, the advice given was misleading or overly optimistic. On page 3, he notes that the generic cholesterol medication lovastatin 10 mg tablet is 58% cheaper than the brand name Lipitor 10 mg pill which is true. What he failed to mention is that the generic drug is only ¼ as potent which means you'd need four times as many pills to get the same cholesterol lowering effect! For the area on think beyond the prescription bottle, yes lifestyle changes would be great, but for the vast majority of people they've tried dieting, exercising, and they ultimately need medications to address their medical condition. Telling us what we should do but despite our best intentions are unable to do so really isn't a cost-saving method per se. Also asking doctors about whether the evidence from various research studies on heart disease or osteoporosis means that medications can be stopped may be out of the reach of most patients. Often seeing a doctor is intimidating. Asking a doctor about not only the latest research but also then asking to stop the medication because of it may seem too high of a hurdle for some to do.
Nevertheless, he advocates that readers communicate with their doctors about prescription drugs and not to stop without checking in with their doctor. An excellent companion book which covers how to talk to doctors, offers the truth about herbals, dietary supplements, body scans, and also has a section on prescription drugs that would complement this book well is Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.
Tuesday, November 25, 2008
It seems that everyone is pushing hard for healthcare reform. If it can occur for about $125 billion, relatively cheap compared to the $700 to $800 billion desired by the Treasury department, then it might occur sooner than I expected. A look over the past week revealed the following.
An excellent op-ed piece by Shannon Brownlee (author of the book “Overtreated“) and Ezekiel Emanuel (an oncologist, NIH bioethicist) dispell various myths of our dysfunctional healthcare system. In the same Washington Post, columnist David Broder feels that there is a rising hope for fixing healthcare.
Uwe E. Reinhardt is an economist at Princeton has written in the Economix section of the New York Times various articles about why the healthcare system costs so much, which also shatters widely held, but inaccurate beliefs including the issue of administrative costs.
Even NPR's Marketplace had a piece today about healthcare reform.
Of course, I neglect to mention proposals offered by Senator Kennedy or Senator Baucus. It seems like healthcare reform is THE topic to discuss, until of course Senator Clinton is formally introduced as the President Elect's Secretary of State.
I for one was certain with all of the economic uncertainty that we could have kissed healthcare reform good bye. It appears from all the news reports, op-eds, and discussions by various senior politicians that I may have underestimated their desire to see this through. Thank goodness.
I hope, however, that our leaders think carefully about how to reform our healthcare system otherwise unintended consequences will surely occur which may do far more harm than good.
Sunday, November 16, 2008
The Star Tribune reported that the nation's second largest insurer, Wellpoint, will offer Wisconsin-based Serigraph Inc. and its employees the ability to go to India for elective surgeries. Serigraph will pay all of the medical costs. There will be no out of pocket expenses. Travel is paid for as well for the patient and a companion.
"Knee replacement surgery that costs between $60,000 and $70,000 in the United States can be done in India for $8,000 to $10,000, said Jill Becher, a Wellpoint spokeswoman."
The NY Times reported how South Korea has added its medical facilities and staff to be available to Americans. Shockingly a report by the consulting group Deloitte found that "750,000 Americans sought cheaper treatment abroad, a figure projected to reach 6 million by 2010".
The Wall Street Journal earlier this year cited a report by the consulting group McKinsey which suggested that overseas medical travel was posed for future growth.
What does this mean? In the future, you might get the same excellent surgical care overseas for a lot less to your pocketbook, particularly as you are becoming increasingly responsible for healthcare costs. You might even get the opportunity to sightsee as well.
The other? Doctors will begin to discover that like auto workers, their jobs can indeed be outsourced. If we as a medical profession don't see this challenge, then we may very well suffer the same fate as that of the big three automakers, Ford, GM, and Chrysler, who as we speak are looking to the government for a multibillion dollar bailout. Don't think it can happen? That's what the UAW thought as well.
Tuesday, November 11, 2008
Wednesday, October 29, 2008
The good news is if you understand from an insider how to get prescription drugs cheaper (without necessarily purchasing online) or at least ensure that for the money you do spend that you are getting the best value then you should feel confident that you are spending your money and protecting your health wisely.
First tip, if you do need prescription medications, go to Walmart, Target, or other pharmacies which offer $4 for generic medications and $10 for a 90 day supply of generic medications. This is often cheaper than the copay offered by insurance companies. Insist your doctor write you a generic medication when available. Generic medications are simply branded medications that no longer have patent protection. Due to FDA regulations the generic medications are as good as their branded counterparts. Note that the best-selling drugs like Claritin for allergies, Prilosec for heartburn ("the purple pill"), Zocor for cholesterol, over the past few years have gone generic and do the job. Smart shoppers realize that generic medications are cheaper because you aren't paying for the brand name or the multimillion marketing campaign. Get the Walmart list of $4 medications here and take it to your next doctor's appointment and ask him to change what you are taking to medications on this list.
Second tip, find the best medications for their category (allergies, heartburn, blood pressure, cholesterol) via a free Consumer Reports website at Consumer Reports Best Buy Drugs. See which medications make the list on both the Walmart list and the Consumer Reports list. Then you know you've gotten the most for your money. Save money and stay healthy.
For more tips on saving on prescription drugs, check out a recent segment on the Today show.
Tuesday, October 28, 2008
Researchers admit that the behavior of doctors recommending treatments that weren't proven to be helpful (i.e. antibiotics for colds, which are caused by viruses and therefore can't be killed with antibiotics) was best captured by the world "placebo". Very misleading. The problem is that placebo "is a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity. Any therapeutic effect is thought to be based on the power of suggestion." Antibiotics do have therapeutic activity, just not against viruses, and can cause major side effects.
Doctors don't write prescriptions for antibiotics for the placebo effect. They prescribe it because patients demand it and to ensure that patients come back again, doctors feel pressured to comply. Research shows when patients demand advertised medications, more often then not they get exactly what they wanted. Unlike the conclusion of this study, many doctors felt ambivalent that they wrote the medication.
Saying that recommending over the counter analgesics is also a placebo is also a problem. These actually do have therapeutic effects like decreasing pain or fever. As the researchers found practically no one prescribed sugar pills.
Doctors are prescribing antibiotics and sedatives for conditions which they might not help, not because of the placebo effect, but because patients demand something be done and the offered therapies probably won't cause harm (and the doctors simply want to avoid a confrontation or discussion of why no therapy would work), doctors aren't practicing evidence-based medicine (the vast majority of sinus infections - sinusitis and bronchitis in healthy individuals does not require antibiotics and vitamin b12 injections don't help with general fatigue), or doctors just want to do something. In all three scenarios, potential harm can occur.
This is contradictory to the meaning of placebo and why the study's claim is so flawed and misleading. As the authors noted, "Few of the physicians we surveyed recommend inert placebo treatments. " i.e. pills that do nothing, like sugar pills. Why? Because unlike other cultures, like Israel where doctors about a third of the time do prescribe sugar pills, placebo treatment is not considered acceptable treatment.
Claiming that doctors commonly prescribe placebo treatments and are ethically fine with it is wrong. It is a shame that the media didn't have the level of sophistication necessary to dissect this out.
Monday, October 27, 2008
When I was in medical school, I was in a small group that met weekly for months on the topic of death and dying. A century ago, death and dying was common in America. It was before the discovery of antibiotics. People died more often from accidents, infectious disease, illnesses and even childbirth. Many others were debilitated from viruses like polio or scarred from smallpox before the discovery and use of vaccines. Everyone knew someone who died at a young age. Death was commonplace and everyone was aware. Doctors frankly could do little more than comfort and hold someone's hand as we had few tools to help.
Today, given all of the modern advances in medicine, we've seem to have forgotten that death still exists. As a society few of us have known someone who died in childbirth or from infection like many did years ago. Naturally, the lack of familiarity results in supreme discomfort and is the likely reason many of us, both doctors and non-doctors are uncomfortable.
This story on the humanities and its role in medical training frankly provides the connection of the past to the present. While we as individuals many not see death early on in life as generations before us, we can imagine and empathize their experiences through literature. Great idea. The next generation of doctors should not only be technically savvy but also equally as compassionate.
Now if they would only all go into primary care to address the national shortage!
Wednesday, October 15, 2008
Homeowners have burned many banks by being unable to pay their adjustable rate mortgages and walking away from homes which are now worth far less than the loan amount. Certainly many of these homeowners were fooled into thinking they could purchase more than they could afford. Despite who was responsible for the mess, the reality is no one will lend money out which drives the economy.
To foster more lending and hopefully to improve trust between lenders and borrowers, Federal Reserve chairman Ben Bernake and Treasury Secretary Henry Paulson convinced Congress to give them authority to invest $700 to $800 billion to simulate the economy. The federal budget which ended September 30th resulted in a deficit of nearly $500 billion. Next year because of the action taken by the Treasury, the deficit will be far larger. With a predicted price tag of nearly $65 billion to implement Senator Obama's healthcare reform plan (note Senator McCain has not indicated the costs of his plan), it is highly unlikely that even with a presumably Democratic Congress that elected officials will agree to spend even more money despite the healthcare crisis.
The even bigger issue beyond reforming a poor performing healthcare system is what to do about the looming crisis in Medicare . With the first of baby boomers entering Medicare, benefit programs like Social Security and Medicare will dominate the federal budget. Both are underfunded with Medicare being worse of the two. Neither political party, Democratic or Republican, has dared attempted to make the gutsy and necessary changes to make these programs solvent.
What can you expect? Higher healthcare costs, more uninsured, and a general decline in the nation's health. A couple retiring this year must have about $300,000 available for future healthcare costs. With a stock market in freefall, it is clear people have less available than before. As a result they may unfortunately skimp on necessary preventive care and treatments. While decreasing their costs in the short-term, these choices will cause more expensive complicated problems down the road. The country will pay a price for this with a less healthy workforce or populace with increasing diability. In addition, individuals will discover what many have already which is the leading cause of personal bankruptcy is due to medical costs.
What can you do? Educate yourself. Find out how what medications are worth your money, what screening tests you must have, what you must do to stay healthy and well, and when to seek care and utilize the healthcare system. Our government doesn't have the financial resources or the leadership needed to truly overhaul our convoluted, frustrating, and fragmented healthcare system. This is one situation where only the informed and educated individual can make the difference between getting so-so care, which is the current state of affairs, and getting the right care which is what everyone deserves but increasingly will be unable to get.
Tuesday, October 7, 2008
Recently California Governor Arnold Schwarzeneggar signed into law a proposal which requires restaurants operating more than 20 sites to have calorie counts posted on the menus by 2011, becoming the first state in the union to do so.
Will calories displayed prominently help consumers make wise decisions about their eating habits and decrease the numbers of individuals who are now overweight or obese? While both the NYC and California proposals are excellent (and note that the restaurant industry is fighting the NYC plan and yet seems on board with the California one), perhaps they could take it a step further and indicate how much activity it takes to burn off calories. After all, calories are simply numbers. To make people fully appreciate their caloric intake, illustrate how much time and what type of exercise would be needed to burn off a muffin or hamburger.
Since few of us have free time, if these groups showed us that we needed to exercise for four hours to maintain our weight, I'm sure most of us would be much more careful about how much we eat. After all, who has four hours to exercise everyday?
Saturday, September 27, 2008
One of the statements by Dr. Pauline Chen in her new column Doctor and Patient in the NY Times. The inspiration for the article was from a recent piece in the Annals of Internal Medicine which found that doctors missed the chance to give an empathetic statement the vast majority of time.
What Dr. Chen illustrates with her comment is the fear that the vast majority of doctors have and that is by being compassionate and empathetic that not only will it take too much time, but frankly is too uncomfortable for doctors to dare open the door. The reality is it doesn’t take much time and in fact may take less time. As Dr. Chen notes, when patients don’t get the feeling of a connection, they unconsciously fill this void some other way and lengthen the visit.
The issue isn’t whether doctors have enough time to be empathetic, which was suggested as the reason for doctors to miss 90 percent of the opportunities to provide a empathetic comment. The issue is whether medical students are trained adequately to be compassionate and thoughtful doctors.
It’s our training that fails us. It’s not the clock. The good news is like all other skills we developed in medical school, all doctors have the potential of becoming more empathetic with some simple behavioral interventions.
Until we as a profession realize that, it is no wonder patients feel increasingly alone when they access the healthcare system.
Tuesday, September 23, 2008
For primary care to attract more medical students, it will need to transform the delivery of care to improve the doctor-patient relationship, as well as professional satisfaction. While I applaud the efforts of the solo practitioners who follow the micropractice model ["The one-person show," June 20, 2008], this evolution won't save our specialties of internal medicine or family medicine.
Current graduates are flocking toward radiology, ophthalmology, anesthesiology, and dermatology because they offer a more predictable lifestyle with relatively good compensation.
Micropractice practitioners not only take a substantial pay cut, but also are wedded to their practice by being a sole proprietor.
Despite some erroneous assumptions, many patients find their primary care doctors in large group practices particularly satisfying and personal. These innovative groups practice the medical home touted by the AAFP and the ACP as the future for primary care.
With the use of electronic medical records, same-day access for appointments, the ability to communicate via e-mail, and improved revenue generation, patients and doctors are finding this model of delivery far superior to what has been practiced in the past.
Unless medical students and current practitioners see and join practices where primary care doctors have rewarding professional lives and are compensated well, the numbers of primary care doctors will dwindle rapidly, which will result in a complete collapse of the health-care system in the near future.
Tuesday, September 16, 2008
This is a big problem. Fewer US medical students wish to do internal medicine or family medicine because of the administrative hassles, decreasing compensation, and increasingly demanding workloads. It isn't necessarily because they are lazier or more money hungry than previous generations because doctors currently in primary care are retiring, leaving medicine entirely, or doing something else like hospital medicine or urgent care. Students are opting for fields that offer work-life balance which include radiology and dermatology. And why not? The way the healthcare system is structured, the more procedures you do the more you are compensated which isn't always in your best interest. Doctors, who are paid to be more cognitive, like primary care, as a result can spend much more time with a patient and prevent complications from happening, but because the specialty isn't procedurally based, they have continued to watch their income decrease. With increasing medical student loans, it shouldn't surprise anyone that the crisis is at hand.
Why is this a problem for you? It is expected that with the baby boomers that the nation will need to increase the number of internists by 38 percent or roughly add 2000 internists per year. As a nation, we only train about 1000 internists that will go on to do primary care and that number is falling rapidly. With a shortage of primary care doctors, it means you are more likely to get worse care, pay more, and wait longer. Research consistently shows that patients with a primary care doctor do far better healthwise and financially than those that don't.
Adding more stress is the goal of the nation to address the 47 million uninsured. While Senator Obama and Senator McCain both have healthcare plans, neither actually address universal coverage, which may be years away because if everyone is covered, not everyone can access the healthcare system. We don't have enough doctors. Take the Massachusetts experience where health insurance in mandatory. Although the state has more primary care doctors per capita than any other state in the union, the newly insured now are either unable to find an accepting doctor or need to wait an average of seven weeks to see one. Though legislators want to increase the number of students trained, the fact is students won't go into the field until the issues that are causing those to leave are addressed.
The problem is that no one is willing to address the fundamental problems anytime soon. To do so, specialists would have to give up some of their income. After all, we spend a lot as a nation and it is unlikely we can increase the total amount spend to make up for the deficiency, but will need to re-distribute some of the income. This is why it won't happen.
Get ready to get more fragmented uncoordinated care, increased costs and frustration, and worsening health outcomes. If you still have a primary care doctor, then give him or her a hug because they are disappearing rapidly and frankly their skills and expertise are priceless.
Friday, September 12, 2008
Basically, is using the latest imaging technology helpful? Already, the American Cancer Society recommends that women at high risk of developing breast cancer, those with a family history or personal history of breast biopsy for example, get screening MRI in addition to mammography. Whether MRI can and should be used as a tool before breast surgery was the reason for the research. The study looked at 577 women, who were referred to the breast cancer clinic between July 2004 and December 2006. The average age of a woman in the group was 57 years old. Nearly 23% of the women had MRI. Women who received MRI were younger (52 years old) than those who did not (59 years old).
Researchers found that having a MRI appeared to delay treatment by nearly 25 days after the initial doctor evaluation. Patients who had a MRI were two times more likely to have a mastectomy rather than breast conserving therapy (BCT). Interestingly, the women who received MRI were not considered at high risk for breast cancer (family history of breast cancer or ovarian cancer) or for recurrence based on tumor size, staging, or pathology. It wasn’t clear to researchers why some women received MRI and why others didn’t.
Perhaps MRI was ordered to help surgeons prepare their plan for surgery. An ideal pre-surgical tool would help the surgeons and patients make better decisions prior any surgery so that an operation is only done one time. So, how did MRI do for breast cancer surgery? Having a MRI before breast cancer surgery made no difference in the likelihood another excision would be needed because the biopsy margins weren’t free of tumor and it didn’t decrease the chance that a lumpectomy would be needed to be converted to a mastectomy. In other words, MRI made no difference, even though intuitively you would think it would. After all, isn’t more information better?
The study concludes that, “our findings suggest that MRI should not be a routine part of patient evaluation for BCT. Greater efforts to define the limitations and appropriate use of breast MRI are needed.”
What does this mean for you? MRI for breast cancer surgery planning is not the standard of care, there is currently no evidence that it makes surgical outcomes better than without it, trying to obtain one can delay treatment by 25 days, and it can also increase your chances of having a mastectomy. Understand that the findings should be limited to those patients in their fifties and probably older. It is difficult to say whether the findings are applicable to younger women in their twenties and thirties as MRI has been found to be somewhat helpful in breast cancer screening and could possibly have a role in pre-surgical planning.
As has been demonstrated many times in medicine, don’t fall into the trap of always assuming the latest technology or test is any better than traditional therapies. As this study suggests, newer methods may actually delay care and result in more surgery (mastectomy) than initially intended. Always try to demand treatments and therapies that are evidence-based.
Read more from the abstract.
Sunday, September 7, 2008
- According to a controversial body of research, is that our passion for running is natural. A small group of biologists, doctors, and anthropologists say our bodies look and function as they do because our survival once depended on endurance running, whether for long-distance hunts like the one Liebenberg witnessed or for racing the competition across the African savanna to scavenge a kill.
- In his book Why We Run, the biologist and runner Bernd Heinrich, Ph.D., argues that something exists in all of us that still needs to be out chasing antelopes, or at least dreaming of antelopes. Without that instinct, "we become what a lapdog is to a wolf. And we are inherently more like wolves than lapdogs, because the communal chase is part of our biological makeup."
- Anyone who has put in some miles knows how good running can feel, once it stops feeling bad. But beyond the way it feels, medical evidence also suggests that humans are built for endurance exercise. In response to a good training program, for instance, the left ventricular chamber of the heart can increase as much as 20 percent in volume. The chamber walls thicken, too. So the heart fills up faster and pumps more blood to the rest of the body. The coronary arteries also change, dilating more rapidly to meet the body's demand for oxygen. Endurance exercise won't make anyone live forever. But it seems to make the cardiovascular system function the way the owner's manual intended.
- In the skeletal muscles, increased blood pressure causes new capillaries to emerge. The mitochondrial engines of the cells ramp up to consume energy more efficiently, helped along by an increase in the production of various antioxidants. These changes in the heart and extremities together typically boost the maximum amount of oxygen the body can consume each minute by 10 to 20 percent. For men who used to become short of breath slouching to the fridge for a beer, VO2 max can increase even more. Lapdogs start to function like wolves.
- More surprisingly, the brain responds as if it was built for endurance exercise, too. researchers have discovered lately that exercise affects the function of 33 different genes in the hippocampus, which plays a key role in mood, memory, and learning. By stimulating growth factors, exercise also produces new brain cells, new and enhanced connections between existing cells, new blood vessels for energy supply, and increased production of enzymes for putting glucose and other nutrients to work.
- People who exercise regularly perform better on some cognitive tests: Run more, think better, hunt smarter, eat better. Exercise also seems to buffer the brain against neurological damage, reducing the effects of stress and delaying the onset of Alzheimer's and other diseases. Most significant, exercise helps prevent and alleviate depression, which afflicts one in six Americans and costs $83 billion a year.
Not advocating everyone start running, you might need to check with your doctor first before doing any vigorous exercise, but what is clear is that people were built to move. In our American 21st century society where everything is built on convenience and relatively little work -- cars allow us to travel distances without walking / running, grocery stores and restaurants provide us food without us actually laboring in the fields to grow, harvest, and then prepare food, entertainment is becoming more sedentary with internet, video games, television, movies, instead of us actually participating in activity, and finally that for many of us work isn't as laborious as the past -- perhaps it isn't surprising as a nation we are getting fatter and less healthy than a generation before even though we understand more about health and illness.
It appears we were born to run or be active. Our society makes our bodies more like lapdogs rather than the wolves that our anecestors evolved to be to survive. The fountain of youth is very much staying active whether dancing, swimming, walking, running, biking, or whatever. It affects our bodies and our minds. Unlike any machine that exists, our body is dynamic and adapts to the challenges ahead, regardless of your age or whatever happened (or didn't happen) in the past. So even lapdogs have the potential to slowly become wolves again with increased activity. So start getting active!
Sunday, August 31, 2008
Book Review - Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life
Overall, the book was a mixed blessing. It has interesting factoids, ideas we should all take to heart, but at times is misleading. As a consumer and a patient, I thought the truths and news you can use pieces were interesting. As a primary care doctor and patient advocate, however, I felt that many parts of the book were misleading. Perhaps one of the faults is it tries to be too ambitious and attempts to cover too many topics, which often are not in depth enough to be of much value.
Dr. Snyderman points out correctly multiple times that the path to good health is through prevention by adopting healthy habits, staying physically active, and maintaining a sensible weight. The structure of the book reflects this preventive focus and chooses to debunk many myths with these clever chapter titles - Annual Checkups Are Obsolete, Vaccinations Are Just For Kids, Doctor's Don't Play Favorites, Only Old People Get Heart Disease and Stroke, We're Losing the War on Cancer, Natural Means "Safe", and You Can Just Snap Out of Mental Illness. She tackles the truth about herbal and dietary supplements, the unproven value of full body scans, as well as the importance of vaccinations and preventive screening tests for cancer, heart disease, and diabetes.
Throughout the book there are plenty of truth tidbits including, "you cannot catch sexually transmitted diseases from toilet seats; you do not need to drink eight glasses of water every day", among many others and news you can use segments that will make some readers hopefully more aware of what is myth and what is fact. These small sidebars were very interesting. I think patients and consumers will find these factoids topics of conversation.
As a practicing doctor, however, there are many areas which are misleading and others that provide information too superficial to be of value. Dr. Snyderman is correct in one of her chapters that heart disease and stroke are the leading causes of death in this country. However, she uses two individuals, a twenty-six year old former beauty pageant winner, who suffered from a stroke, and a forty year old woman, who died suddenly from swimming, as reasons why we should be concerned. The problem is that these type of occurrences are extremely unlikely and rare for these age groups and gender. The typical cause of these problems, atherosclerosis, or hardening of the arteries didn't cause these cases. The former was most likely due to a heart wall septal defect or a blood clotting disorder, known as a hypercoagulable state. The latter was probably due to sudden cardiac death from a fatal arrhythmia, like ventricular fibrillation.
In the area of stroke, she talks about atrial fibrillation, a heart arrhythmia, as the leading cause of stroke. It is a cause, but this heart condition is typically found in patients over age 60 and far more common in people over 80 years old. She doesn't say that and one would naturally and wrongly assume based on the prior patient stories that it can happen at younger ages, which again is extremely unlikely.
Other areas that are covered superficially include when Dr. Snyderman discusses cancer and mental illness. She pushes for prevention as well as clarifies myths that still exist among the public. Unfortunately in the chapter on cancer, she also talks about various cancer treatments which isn't thorough enough and doesn't seem to fit in a book with this preventive theme. For the mental illness, one of the best written sections because of her personal experience, again the book is rather too ambitious and tries to cover anxiety, depression, and bipolar disorder and the various treatment options even as she admits that "it is impossible to go into as much detail as I would like to". Though she gives a website reference, perhaps it may have been better only to cover depression as she and her husband both had experienced it, and acknowledge the other conditions.
Overall, I wanted to like this book as I believe the intent of giving the public the facts about what they can do to stay healthy and well is vital. I think as a practicing doctor and insider, however, the book at times it is misleading, in some areas is too light in content and in others the information deviates from the book's intent of wellness and health promotion.
Monday, August 25, 2008
The CDC reported a large increase in the number of measles cases. An outbreak in Illinois occurred in home-schooled children and none were vaccinated. Already in 2008, 131 cases were reported, which is three times that of 2007.
- "Before the measles vaccine in this country, there were 400 deaths of U.S. children each year caused by measles," says Dr. William Schaffner, department of preventive medicine chairman at the Vanderbilt University School of Medicine. "Measles carries serious complications, including pneumonia and encephalitis, which is a life-threatening inflammation of the brain tissue that can be caused by viral infections such as measles. Measles is a serious illness. To be cavalier and not vaccinate shocks someone like me, who has seen the devastating effects of this disease."
- So far this year, 15 patients have been hospitalized as a result of measles. They suffered symptoms such as high fever, dehydration and pneumonia. Four of those who were hospitalized for measles were infants.
The other story was about raw cow milk and how 15 people became ill and one woman became partially paralyzed! This frankly is unbelievable and sad. Louis Pasteur, the famous French scientist, who figured out that organisms invisible to the naked eye caused diseases, was also the one to understand and learn how to kill them and make things like milk safer for consumption. This is where the word- pasteurized - came from.
- The raw milk came from Alexandre Family EcoDairy Farms, which supplied the product to 115 customers.
- The county's Department of Public Health suspects at least 15 people were sickened by Campylobacter, a common bacteria found in domesticated animals. The department has confirmed three cases, and are awaiting test results for the other 12.
- Alexandre EcoDairy voluntary stopped its raw milk program June 15 after learning one of its customers was hospitalized. That woman later became partially paralyzed by a rare disorder often associated with Campylobacter infection.
In a high-tech world where many of us wish for simpler times, we must not forget that these more natural methods had major problems as well. The leading cause of death about a hundred years ago was due to infectious diseases. Like the example of measles, just because we don't witness illness or problems ourselves doesn't mean that the problems still don't exist. Many of the reasons we live longer than generations ago is because of high immunization rates and more sterile and hygenic food processing techniques. Are some of the foods perhaps less natural and less safe than the past because of pesticides and hormones? Hard to say, but in that case, purchase organically grown products. Don't ignore basic common sense.
Here's the other question. If people became ill because of an accident or food poisoning, then I don't think anyone would argue we should take care of them. However, what if a person out of ignorance gets ill from a very preventable infection, should we as a society pay of their healthcare? If the woman, who is partially paralyzed doesn't regain full use of her body and requires resources from the community, is that fair for the rest of us?
Monday, August 18, 2008
What is more fascinating is the amount of calories he ingests daily to keep up with his training regimen. If anyone of us tried to eat the same amount he does, we would gain about 3 pounds per day and definitely would not have his sculpted physique!
He has 12,000 calories per day. A typical American is supposed to have 2,000 calories per day. Given the increasing numbers of obese children and adults it would be safe to assume many of us are exceeding that suggestion.
For breakfast he has:
- three fried-egg sandwiches loaded with cheese, lettuce, tomatoes, fried onions and mayonnaise.
- two cups of coffee
- a five-egg omelet
- a bowl of grits
- three slices of French toast topped with powdered sugar
- three chocolate-chip pancakes
As a quick reminder, it takes about 3500 calories to equal a pound. So for those of us who are inspired to lose weight, a brisk 30 minute walk uses about 200 calories. Therefore, if one walks this amount three times a week for a total of 600 calories, it would take six weeks to lose one pound! It's no wonder weight loss is so difficult.
Of course, you could do what Michael Phelps does and swim his intense training schedule where he burns 4,000 calories per day!
Monday, August 11, 2008
"Store brands have come a long way," said Tod Marks, a senior editor at Consumer Reports, which has tested store brands against national brands for quality and customer response. "Over the years, retailers realized that store brands were not just something to be floated out during hard times."
With consumers very price conscious these days, they should have no hesitation in asking their doctor for generic medications. These are medications that are proven but no longer have patent protection so the price is affordable. The public should not be fooled in thinking that newer is better. Most of the latest drugs are "me too" cholesterol, blood pressure, allergy, diabetes, and heartburn medications. Pharmaceutical companies spend millions of dollars equal or exceeding marketing budgets of alcoholic and soda companies to influence you to prefer their brand.
Evidently the makers of Ambien CR is acutely aware of this as in a television ad they note that Ambien CR is not available as a generic, even though there are plenty of helpful generic sleep aids that can provide sleep at a price that people can feel good about.
Monday, August 4, 2008
Although it is clear that more physical activity not only helps lose weight, but also it is important that the increased activity is sustained lifelong to maintain the weight. Calorie restriction also helps immensely as well. The trick also is that is too must be lifelong.
Find out how much activity you must do if you eat certain foods by reviewing the fun, interactive, and eye-opening experience Portion Distortion Quiz.
If we as a country are going to be healthier, then we all need to realize that the way to lose weight and keep it off is simply and as hard as eat less and move more.
Saturday, July 26, 2008
Of course in other news, more people as a result of high fuel costs are biking, taking golf carts, or scooters, as their mode of transportation. Is it possible the number of lives saved may be simply shifting to other ways of getting around? Too early to tell.
Certainly none of us expect our kitchen countertops to kill us, but an article from the NY Times found that inferior types of granite contained high levels of the radioactive substance uranium. Not only is the element radioactive, which in of itself is a concern, but it also emits the carcinogenic gas radon, which has been a risk factor for lung cancer. With homes sealed for energy efficiency, it could make levels even higher. Could this be the reason why many non-smokers are developing lung cancer?
Who would have thought it was more dangerous to be at home in the kitchen rather than on the road?
Sunday, July 20, 2008
- Increasing use of the scans, formally known as CT angiograms, is part of a much larger trend in American medicine. A faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques. Patient advocacy groups and some doctors are clamoring for such evidence. But the story of the CT angiogram is a sobering reminder of the forces that overwhelm such efforts, making it very difficult to rein in a new technology long enough to determine whether its benefits are worth its costs.
- Some medical experts say the American devotion to the newest, most expensive technology is an important reason that the United States spends much more on health care than other industrialized nations — more than $2.2 trillion in 2007, an estimated $7,500 a person, about twice the average in other countries — without providing better care.
- No one knows exactly how much money is spent on unnecessary care. But a Rand Corporation study estimated that one-third or more of the care that patients in this country receive could be of little value. If that is so, hundreds of billions of dollars each year are being wasted on superfluous treatments.
What to do? Be very skeptical. Align yourself with doctors who don't tout the latest therapies, except in the case of cancer treatment where the newest can be the difference between life and death. Seek out information. Hope that reporters like Mr. Berenson and authors like Shannon Brownlee can make their voices heard loud and clear, because it is unlikely that doctors as a group can avoid the seduction of new technologies, particularly since it drives more business and revenue.
Because if the media can't get enough of us to ask these important questions, is newer better, is it proven, you and I will simply pay more thinking we are getting better care, when in fact we are simply wasting money and getting no better care.
Monday, July 14, 2008
Tim Russert's untimely death from heart disease has appeared to have many focus on decreasing their risks by quitting smoking, exercise, decreasing blood pressure and taking cholesterol lowering medications. Kudos to being unbiased in reporting that many of the fancy hi-tech scanners don't help determine whether a future heart attack is imminent. As the reporter correctly pointed out, no test is perfect.
The report also clarifies that Mr. Russert had everything humanly possible to decrease his risk from America's number one killer.
Saturday, July 12, 2008
Probably hundreds of thousands of patients, if not more, have directly benefited from his ideas which are the standard for cardiothoracic surgeons.
There is no one like him in medicine today. There will be no one like him for generations to come.
Monday, July 7, 2008
For thousands less, you can get the same care, if you have time to research what to get and when to get it. Otherwise if we don't have the time or the expertise, we outsource whether hiring a financial advisor or having an executive physical.
Friday, June 27, 2008
Mr. Bernanke spoke about the iron triangle of healthcare where only two of the three elements, access, quality, and cost, can be optimized. Like the laws of gravity, no one has found exceptions in healthcare where the iron triangle does not apply. According to a Health Affairs article earlier this year, we rank dead last among nineteen industrialized countries with the highest costs per capita, millions uninsured, and the worst quality outcomes. Despite all of our spending, we don't live the longest. When speaking to the Senate committee on healthcare reform, Mr. Bernanke noted, "that improving access and quality may increase rather than reduce total costs" and the better question may be, "whatever we spend, [are] we are getting our money's worth?" As an economist, he declined to offer solutions, but that hasn't stopped the Republicans and Democrats from offering some of their own.
The Republicans feel that consumer driven healthcare is the answer. Theoretically patients would make smarter choices if they had more financial skin in the game with higher deductibles and health savings accounts. Research by the Kaiser Family Foundation has found otherwise with patients more dissatisfied with these less comprehensive products. They are decreasing utilization by skipping tests, procedures, and medications. These short-term savings to the system may simply be overwhelmed by long-term expenditures as easily preventable problems are not addressed and treated later when complications arise. In addition, the public doesn't want this kind of fiscal responsibility. Already when tasked to fund their retirement, the vast majority don't, are inadequately prepared, and planning to work longer. This is despite that planning for their retirement is in their best interest. Unlike retirement, however, one can't plan on when to get seriously ill.
The Democrats feel that through legislation they can require insurers to expand coverage and lower costs. While a noble ambition, this ignores basic economics of the iron triangle. Although healthcare costs slowed dramatically in the 1990s due to these attempts, this trend was only temporary. Since 2000, healthcare premiums have exploded rising faster than increases in wages and inflation. This year employers expect to see a rate increase of 10 percent despite an economy in recession. It seems that healthcare has an immutable inherent cost that can't be artificially lowered.
Perhaps there is a third option. Our country has healthcare organizations that have mastered the iron triangle. Research has shown that the vertically integrated healthcare organization Kaiser Permanente consistently outperformed university and community hospitals in decreasing risk of heart disease by 30 percent. The VA healthcare system provided better care to its diabetics than doctors in the community. The Dartmouth Atlas of Care found that even though there was not a large difference in health outcomes, the cost of caring for Medicare recipients in the last two years of life varied widely from $93,000 per patient at UCLA, $85,000 at John Hopkins, and $78,000 at Massachusetts General, to the lowest at $53,000 at Mayo Clinic. The "savings" from the most expensive programs could be moved to provide better access or quality care to those who need it, but it won't change the total medical cost expenditures.
Moving the country towards streamlined information technology driven healthcare systems that deliver great care won't be easy. Healthcare is currently provided by hospitals and doctors each working separately in little fiefdoms which worked well two centuries ago when patients died of acute illnesses and infections. Today patients are busier than ever, caring for aging parents, and dealing with chronic illnesses, that were never faced by generations ago. The public already gets a variety of choices in financial services, consumer electronics, air transportation, and dining, which are often provided by well-run, highly regarded, focused organizations. Why not healthcare?
Healthcare will never be cheap, but we can get more for our dollars. With baby boomers entering retirement, the solvency of Medicare in jeopardy over the next decade, and total healthcare expenditures accounting for 20 percent of GDP by 2016, it is not surprising that Mr. Bernanke is concerned about the health of the healthcare system.
Our healthcare crisis will only be solved if the entire industry reorganizes into systems which are aligned to focus on the end product, great healthcare delivery, rather than the piecemeal mom and pop cottage industry which currently exist. This is far harder than it sounds and will require leadership from within healthcare to get it done.
If as a country we fail to solve this crisis, our economy will simply worsen as the workforce will become increasingly unhealthy as more people find healthcare unaffordable and consequently will be unable to work or be competitive in a global marketplace. This is a competition we cannot afford to lose.
Sunday, June 22, 2008
But was his sudden passing and fatal heart attack an avoidable tragedy? His internist, Dr. Michael Newman, who is affiliated with George Washington Medical Center, noted that Mr. Russert died of a sudden coronary thrombosis, which can occur without warning. Mr. Russert had been diagnosed with asymptomatic heart disease which reportedly was well-controlled with medication and exercise. He passed a cardiac stress test in late April. It seems like he got the appropriate care.
Yet, our healthcare system only provides the right preventive care 55 percent of the time. What medical students know, lowering blood pressure, controlling cholesterol, and arranging age-appropriate cancer screenings, shown to save lives, are not done routinely in this country. The ability of doctors and insurance plans to provide this
basic fundamental care varies by about 20 percent. If one compared the safety performance of the top 10 percent of airlines with the national average, the quality gap was far less at less than 1 percent.
The National Committee for Quality Assurance (NCQA) estimates that had all doctors and insurance plans performed at the level of the nation's top 10 percent that 80,000 Americans, all who had health insurance, would have avoided premature death. That is twice the number of breast cancer deaths annually. A study of 20,000 patients in 12 US major cities found that only 68 percent of those with heart disease and only 65 percent of those with high blood pressure received the recommended care developed by expert committees.
Unfortunately, one can't assume that the best preventive care is done at university medical centers. A study in California found that the vertically integrated healthcare organization Kaiser Permanente outperformed both university medical centers and community hospitals in decreasing their patients' heart attack risk and death by 30 percent. The integrated VA healthcare system was also found to outperform community hospitals in caring for diabetics. It consistently ensured its patients got the right medications at the right dosages better that those in the communities around them.
It seems that as a country we take for granted the failings of the healthcare system which are occurring with alarming frequency. As we mourn the unexpected passing of a great journalist, we should instead ask ourselves whether there were systematic failures in the healthcare system that Mr. Russert relied on to keep him well? The goal wouldn't be to find negligence or to identify scapegoats, as like the aviation industry, the delivery of healthcare is too complex to simply isolate one person or entity that resulted in the mishap. It is very likely that General Electric, NBC's parent company, provided him with health insurance options that were accredited by NCQA as excellent in keeping people healthy.
Is it possible, however, that the recommended care wasn't delivered? As our nation struggles with how to make the healthcare system more affordable, accessible, and with higher quality, the debate boils down to who is best in determining the right care at the right time. Is the onus on patients? Does the responsibility rest on the healthcare industry? It is an important conversation our country must have and certainly would have gone better with a skilled moderator like Mr. Russert. He will be deeply missed.
Monday, June 16, 2008
It's good that healthcare expenditures and the state of the system gets attention by the Federal Reserve Chairman. He speaks about the iron triangle of healthcare, that every medical student knows about - access, quality, and cost - and how any country or organization only optimize two of three. Unfortunately, we rank the lowest in the world among industrialized countries with higher costs per capita, poor access with 47 million uninsured, and the worst quality outcomes as we don't live the longest. The iron triangle doesn't permit universal coverage with the highest quality at the lowest price.
He correctly notes that "the solutions we choose for access and quality will interact in important ways with the third critical issue--the issue of cost. Greater access to health care will improve health outcomes, but it almost certainly will raise financial costs. Increasing the quality of health care, although highly desirable, could also result in higher total health-care spending. For example, increased patient screening may avoid more serious problems and thus be cost-saving, but it could also identify problems that might otherwise have gone untreated--a good outcome, certainly, but one that increases overall spending. These are certainly not arguments against increasing access or improving quality. My point is only that improving access and quality may increase rather than reduce total costs." Any who claims that fixing the healthcare system will make it cheaper is incorrect. Mr. Bernanke is right to ask the question "whatever we spend, is whether we are getting our money's worth"?
In a previous post, I reviewed succinctly what you must know about healthcare reform. From the article regarding the Fed Chairman:
- "Improving the performance of our health care system is without a doubt one of the most important challenges our nation faces," he said.
- On the health care front, Bernanke didn't recommend specific solutions, saying the difficult choices involved with improving access and quality and controlling costs were best left to policymakers in Congress, the White House and elsewhere.
- "Taking on these challenges will be daunting," he said. Given the complexity of health care matters, he suggested that it might be better for policymakers to consider an "eclectic approach," rather than one single set of reforms to address all concerns.
- "We may need to first address the problems that seem more easily managed rather than waiting for a solution that will address all problems at once," Bernanke offered.
Here's my take on Democratic nominee Senator Obama's and Republican nominee Senator John McCain's healthcare proposals.
I think the improvement of the healthcare system won't come from policymakers or the White House. For reform to occur it will take all participants in the system, employers, insurers, patients, doctors, hospitals, pharmaceutical companies, the government and many others to come together and work towards a solution. It will occur when patients are true consumers and shop around for the best care, not necessarily the cheapest, and patronize those services like they do other consumer products. Understandably, patients don't want this responsibility, so who else might fix the system? Employers who purchase healthcare? The providers who deliver it? Sounds like the status quo.
Unfortunately, no one is willing to step up and begin the painful and necessary process to reform the system. Costs will continue to simply spiral out of control. The public and employers will either drop health insurance benefits or purchase less comprehensive deductible products to maintain coverage.
Conclusion? Our country will end up with many more being uninsured, others not getting preventive care or delaying care due to the deductibles, and a workforce that will be increasingly unhealthy and unable to compete in a global market. As an insider, as a doctor, I know when to seek care and when to safely skip care, but what about the rest of us? Specifically, what about you? How are you feeling about your chances? Not feeling too optimistic are we?
Saturday, June 14, 2008
It will be interesting to see how this program will do. Will people be healthier because the entire nation is focused on not being “metabo”, the preferred Japanese word for overweight? Will companies and local governments, who are responsible for measuring waist lines and ultimately financial penalties if their population, help change the lifestyle in Japan to be more healthful? For example, if your company produces food for the nation, do you promote smaller serving sizes? If you are a local government, do you greenlight more parks and neighborhoods that promote physical activity? Measuring waistlines gives us a starting point and a proxy of the health of a nation.
What will be fascinating to see is what they do with that data. It will be more, however, than simply re-educating people. We all should know that being overweight or obese, which is the status of 2/3 adult Americans, is not healthy, but the challenge is how do we make our increasingly hectic 24/7 lifestyle more supportive for staying active and eating well?
Thursday, June 5, 2008
As we say in medicine, the answer is it depends. Taking a completely different example, years ago and even today, it is considered by society that a woman giving birth should be the happiest day of her life. New moms and dads should be absolutely thrilled about having a baby. It seemed that all new parents needed to smile, say how grateful they were, and repeat the mantra on how overjoyed and happy they were for the blessed event.
Certainly, having children is a precious event and most of us would never give them up. However, the societal pressure that parents should be ecstatic buried for years a more complex discussion of post-partum depression and the challenges and stressors of being parents. If one asked for help or appeared not to cope well with this monumental change then it seemed like there was something wrong with the person. Consequently they became even more alone. It hasn’t been until recently that people are more open about how difficult (and rewarding) it is to be a parent.
So for cancer, public figures, by their nature and profession need to be upbeat. For the rest of us, it is okay to be scared, frightened, and far from stoic. We all have public faces and private faces. We must reveal those private moments with our doctors, our partners, in this challenge. The right treatment for you is what you, the patient, are comfortable with. Find a doctor that listens to you and your needs and supports you and protects you from others, who cannot truly understand your experience, although they mean well.
What patients often don’t realize, but experienced and wise doctors do, is that “fighting” cancer and “not fighting” cancer provides different outcomes and one choice is not necessarily better than the other. Some patients value quality of life over weeks and months of chemotherapy and radiation and their related problems. Others prefer the latter hoping for more time later on.
As someone who had family members diagnosed with cancer, it is extremely stressful, hard, scary, and frightening for all involved. By understanding this, it has made me a far better doctor as I will routinely tell patients that it is okay to be in shock, unsure, and terrified when diagnosed with a serious illness.
What I think people fear the most is if we, doctors, family, and friends, somehow think less of them if they display these emotions. As a doctor, I reassure them that I will always be there for them on good days and bad days. In the end, isn’t that what we all want?