Friday, June 27, 2008

Fed Chair Worries About Healthcare System

Improving the healthcare system will not save money. If done correctly, it in fact may cost more money. These comments by Federal Reserve Chairman Ben Bernanke should make us skeptical about presidential nominees' promises that fixing the system will make healthcare more affordable.

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

Could Tim Russert's Heart Attack Been Avoided?

Not a trivial or academic question. Time magazine identified the NBC's Meet the Press moderator and Washington bureau chief as one of the 100 most influential people in world in 2008. His loss at such a young age, 58, is tragic. His ability to make complex topics clear for the public and to ask the hard questions will be missed in this the most historic presidential races in American history.

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

Fed Chairman Says Improving Health Care System Is Critical

Fed Chairman Ben Bernanke told Congress that improving the performance of the US healthcare industry is critical for the nation. Healthcare costs are becoming larger aspects of government, employer, and household budgets. Already it is expected that one of every five dollars spent in 2016 in the US economy will be spent on healthcare. With the baby boomers now entering retirement and Medicare, we can expect healthcare costs to rise even further.

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.
Fed Chairman's speech in its entirety.

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

What is Your Waist Score?

The NY Times reports that in Japan companies and local governments will need to measure waist sizes of their population. Those considered "metabo" or overweight will be educated on how to lose weight and then measured later. If they still aren't at healthy weight, the companies and governments will be charged more for healthcare costs. (Japan has a publicly financed healthcare system).

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

Cancer Patients - Is It Okay to Be Scared?

The New York Times published an article titled "When Thumbs Up Is No Comfort" and the health blog asked a simple question - “What do you think? Is upbeat and positive the best way to cope with cancer? Or does unvarnished optimism deny us the opportunity to confront our real fears?”

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?


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