Saturday, December 20, 2008

If Health Care Were Run Like Retail... We'd All Be in Big Trouble

Businessweek recently ran an article discussing Harvard Business School professor Regina E. Herzlinger who believes that health care should be run like retail. Dr. Herzlinger is a strong proponent of consumer driven health care.

"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

Where's the beef? Show me the money! Where's the evidence?

An excellent series by the NY Times, which is increasingly asking the right and hard questions about healthcare and its costs is in the column, the Evidence Gap. The most recent piece discusses the reimbursement by Medicare for prostate cancer using radiation treatment known as a CyberKnife. Although there is no evidence that is it any better than current therapies, whether you as a patient have the CyberKnife treatment covered is mainly based on where you live. Medicare doesn't reimburse for the procedure in California or Texas, even though it is a national plan.

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

Healthcare as the Answer to the Financial Crisis

NPR has Princeton professor of economics and public affairs Uwe Reinhardt speak about his view that health care stimulus would actually HELP the economic crisis.

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

Universal Healthcare Doomed - No Primary Care Doctors

Dr. Pauline Chen writes another excellent NY Times article in her Doctor and Patient column called "Where Have All the Doctors Gone?" Specifically, where have all the primary care doctors gone, the backbone of the healthcare system.

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

A letter to the President Elect

The President Elect is welcoming comments from the public via his website at I'm sure he and his transitional team have had plenty of ideas, hopefully constructive and helpful, since his historical win.

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

Feeling Younger than Our Age

Recent article found that older people view themselves 13 years younger than their chronological age. Read more at the NY Times health blog.

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.


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