NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.

In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.

 

Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”

 

I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)

 

The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 

Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.

I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 

What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
 
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

Rock Health, Enterpreneurs, Doctors and Witchcraft?

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker,

“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.

Khosla believed that patients would be better off getting diagnosed by a machine than by doctors. Creating such a system was a simple problem to solve. Google’s development of a driverless smart car was “two orders of magnitude more complex” than providing the right diagnosis. A good machine learning system not only would be cheaper, more accurate and objective, but also effectively replace 80 percent of doctors simply by being better than the average doctor. To do so, the level of machine expertise would need to be in the 80th percentile of doctors' expertise.

Is it possible technology entrepreneurs can disrupt health care? He challenged any doctor in the room to counter his points.

Silence.

Was it because everyone agreed? Were the doctors in the room simply stunned? Was there a doctor in the house? And where did he get that 80 percent statistic?

Was Kholsa serious that technology could make health care better by utilizing large data sets and computational power to clinch better and more precise diagnoses?  Was he simply being provocative to hear other points of view to learn even more? Like many others in the conference, he believes that giving consumers more opportunities, access, and choice to information about themselves and their bodies would empower them to do the right thing. He held up an EKG attachment to the iPhone which was just one of many consumer directed products in the pipeline his company has invested in.

Kholsa is a very smart and successful entrepreneur. Does innovation mean the two guys in a garage who come up with a radical idea or is it possible that innovation is having people with different experiences and point of view looking at the same problem as best selling author Malcolm Gladwell noted in his New Yorker piece Creation Myth -  Xerox PARC, Apple, and the Truth About Innovation? Surely to make health care better, technology entrepreneurs must engage with doctors. All the speakers before and after Kholsa spoke about the incredible value and insight different stakeholders to bring to the table.  The most vocal? The doctor entrepreneurs and those who worked with doctors to bring their ideas to market.

Kholsa's criticism of the health care system is completely valid. Can we do better in being more reliable, consistent, and creating a system process and design that is comparable to highly reliable organizations and industries? Of course. Can we be more systematic and doing the right things every patient every time on areas where the science is known to level of the molecule? Yes. Care must be incredibly simple to access, extremely convenient and intensely personal.

It isn't that we don't have smart people. Compared to a century ago more illness are understood, specific medications and treatment protocols can be designed. But we haven't solved it all. When we thought we knew it all, we were shown how little we truly knew. Thirty years ago, doctors predicted the demise of infectious diseases as a specialty, another footnote in medical texts as more powerful antibiotics and vaccines were available. Enter AIDS, the swine flu, and many super-bugs which have humbled our profession. Ask accomplished physician and writer Dr. Abraham Verghese about his experiences.  Dr. Verghese is rightly worried, as many others are, that even doctors are being too focused on the iPatient and not on the real patient as he writes in his New York Times op-ed Treat the Patient, Not the CT Scan. Is this what we want our health care system to look like?

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort. As conference speaker Dr. Aenor Sawyer, an orthopedic surgeon from UCSF noted, we need to figure out how to have our different cultures of doctors, gamers, designers, and technologists interact. Fixing health care is more than simply "we know the problem and we know the solution". She reflected that the level of dedication, perseverance, and a willingness to make impact among the different groups demonstrates more similarities than differences.

I know health care can't simply be solved by smart people in Silicon Valley alone.  To solve health care we need everyone to collaborate. As Harvard Business School professor Amy Edmondson noted in her book Teaming - 

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."

Perhaps Kholsa's call to action was simply an entrepreneurial mindset, but simply ignoring those who have chosen a field to improve and safe lives and who meet humanity everyday on the front-lines is problematic and dangerous. There are some things that may never be codified or driven into algorthims. Call it a doctor's experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Are Patients Becoming Day Traders?

Let me say first that I am a practicing primary care doctor who is very much focused on patient centered care.  Though I cannot go back to being a patient who is unaware about what a doctor does, the terminology she uses, or what the importance of certain test results are, I can empathize with the overwhelming amounts of information, challenges, and stressors patients and families can have in navigating the healthcare system to get the right care.  This is the reason I wrote my book.

However, over the past few months I've noticed a particularly disturbing trend.  Patients are not consulting doctors for advice, but rather demanding testing for diagnoses which are not even remote possibilities.  A little knowledge can be dangerous particularly in the context of little to no clinical experience.  Where many patients are today are where medical students are at the end of their second year - lots of book knowledge but little to no real world experience.

More patients are becoming the day traders of the dot.com boom.  Everyone has a hot stock tip, only now it is "be sure to ask your doctor for this test" or "ask for this medication because it is the only one that works".  Everyone is an expert with his own suggestion on what should be done.  If a medical expert, like a doctor, weighs in and does not agree, then there is a set of patients and doctors who begin to argue that these doctors are out of touch or arrogant.

Hardly.

I certainly agree that many doctors frown upon their patients doing research online.  I disagree with my colleagues.  I'm all for patients being partners in their health as long as when they research they also go to reputable websites, like the Mayo Clinic or Kaiser Permanente, and also give equal weight to my medical advice.  Ultimately, patients should be more knowledgeable about their health and engage not only with doctors, but with family and friends as health does not begin with doctors, but in households and communities.  However, today's world is increasingly polarized due to the ability to gather information and find opinions of like minded people quickly and easily.  A patient researching information can unwittingly blind themselves into believing that a medication, a treatment, a test, or a diagnosis is the only one that explains their symptoms. 

Many of the patients who Google their symptoms, do cursory research, and are so convinced that they have a particular problem and need a particular solution are the group I worry about the most.  They want to see a specialist for a problem adequately handled in primary care.  They want a branded medication when a generic medication works equally as well.  They want CT scans and MRIs for migraine headaches or sprained ankles when a generation ago, doctors and patients believed diagnoses based on common sense.  They decline vaccinations for preventable illnesses like pertussis, whooping cough, because they are healthy and don't want "chemicals" even though the state they live in had the worst outbreak of pertussis since 1955.

With more Americans paying for their health insurance through higher copays for doctor visits, medications, imaging, and treatment, it is understandable that they want more information and are seeking it.  What is particularly troubling, however, is much like the day traders of years ago, many are bypassing experts for some advice and consultation.  Indeed a decade ago many ridiculed financial guru Warren Buffet for failing to understanding the new world and being a dinosaur.  Principles of the past no longer applied.  (Of course, financials principles remained - you do need to make money to be an ongoing company).  As a front line doctor, I'm seeing the same phenomenon in health care.  Doctors still clinch the right diagnoses by talking to and then examining patients.  Skipping directly to lab work or imaging often gets the wrong answer.  Sometimes there is no test or imaging study that can get the diagnosis.  Yet somehow if asked, patients retort I don't have money to see you, I'd rather spend the money on the test or medication, so can you order it?

Like the day traders of a decade ago, these individuals have the illusion of control or mastery.  Only later do they discover when the results are normal and the problem remains that being an expert and having the ability to take in information, process it, and then come up with a plan is harder than it looks.  (Dr. Lisa Sanders, whose New York Times series Diagnosis was the inspiration for the television show House, M.D., has excellent patient cases which challenge the public on getting the right diagnosis).

That is not to say that there are not patients who are indeed experts.  The individuals who are leading the empowered patient movement often know a lot about their diagnoses and treatment options and have mutual respect from their doctors.  Enlightened doctors realize that they cannot know it all.  I would hope and believe that empowered patients also recognize this inherent problem in themselves as they also cannot know it all either.  It is the rich discussion and collaboration which occurs when both groups are on relatively equal footing in terms of knowledge that the answers, solutions, and treatment plans are far better than if only one side or the other led the conversation.  Those patient experts probably can and have identified their condition when they read it in Dr. Sander's column.

Who would have guessed that the day traders of the past would now appear as patients?  Funny and sad how history repeats itself.  The difference is unlike money the stakes are significantly higher when it comes to health.

Not sure what to do when you have a problem?  It's ok to research online, but then have an open mind when talking to your doctor.  If your doctor does not want to listen, then find another one.  Be sure, however, as you research and listen, that you do not become a day trader.  Indeed, if not done correctly the consumer driven health care movement has the potential to be equally as problematic as the retirement planning and investing movement a decade ago.

What Dr. Oz Learned From His Cancer Scare - Honest and Unplugged. What Doctors Can Learn.

Dr. Mehmet Oz recently had a piece in Time titled "What I Learned from My Cancer Scare" in which he became the the more humbled Mr. Mehmet Oz.  As noted previously here, Dr. Oz last summer had a colonoscopy at age 50 and much to everyone's surprise had a precancerous colon polyp.  He was advised to follow-up again for a repeat test in 3 months.

As the Time magazine piece noted, he didn't return for 9 months despite repeated reminders from his doctor.

From this experience, he essentially stumbled upon what has been challenging American medicine and primary care.  How do we enable patients to do the right thing and get the screening tests done and treatments necessary to avoid premature death and maintain a high quality of life?  As a highly trained professional, Dr. Oz knows the risks and benefits of not doing a preventive screening test.  As a doctor, he knows all of the secret protocols and codespeak we use when calling patients or asking them to see us in the office for important matters.  As a doctor, he also understood the importance of a repeat colonoscopy to ensure no more colon growths.

Yet he didn't return for 9 months.  Why?

None of us want to deal with our mortality.  Having a screening test means there is a possibility that the test may be abnormal and now we must confront it face to face. Skipping the test means to be blissfully ignorant, even if it is the wrong thing to do.

Also, as Dr. Oz noted, many individuals, particularly those who are otherwise healthy with no family history, feel that many of these tests or interventions don't apply to them.  Trust me, I know.  As a practicing primary care doctor, do you know how hard it is to convince someone to get screened for colon cancer?  Get vaccinated for pertussis, influenza, or pneumonia?

Dr. Oz, however, did discover what will compel people to do the right thing.  It isn't about statistics.  It isn't about knowledge.  (And though he never discussed it, it certainly won't be consumer driven health care where the theory is that forcing people to have more financial "skin in the game" will enable the right behavior).  It's about getting to our emotions.

Most important, my colonoscopy wasn't entirely about me. It was about my wife and our children. It's about our someday grandchildren. It's about my childhood friends whose lives remain closely intertwined with mine. It's about my colleagues and patients at the hospital who teach me as I learn from them. I need to be there for all these people I know and care about. I need to show up in my own life. And you need to show up in yours. Sometimes that requires courage — the courage to undergo a colonoscopy or Pap smear or mammogram or chest X-ray. It's not easy, but it could save your life. And if it helps even a little, remember that I will be rooting for you.

Reminding our patients that their inaction isn't just affecting their own livelihood but their network of family and friends.  It's the reason why certain topics in the media, like the concerns about vaccine safety and autism, gain far more momentum than the scientifically researched and proven life saving interventions and treatments do.

They focus on the emotional aspect of us that make us uniquely human.

Until we, as doctors, employ those same tools, too many Americans will not learn from Dr. Oz's cancer scare or those from a variety of public figures.  The same problems will simply repeat themselves, just different people become spokespersons (note Katie Couric from a decade earlier regarding colon cancer screening).

Though highly unlikely Dr. Oz will ever read this article, one thing he must do is to highlight the need for a robust primary care workforce and inspire a generation of doctors in training to become the front-line of prevention.  Despite his work as a public figure, the intimate and personal conversations needed about preventive tests and treatments happen one on one at a primary care doctor's office.  And we certainly need a lot more of us to get the job done.

Why Consumer-Driven Health Care Will Fail

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial respnonsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it's not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma.  It wasn't about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.   

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.

In others words a lot of people don't have enough money to retire.   The options they have are simply "postponing retirement, moving to cheaper housing, buying less-expensive food, cutting back on travel, taking bigger risks with their investments and making other sacrifices they never imagined....In general, people facing problems today got too little advice, or bad advice."

Though employers were able to manage retirement expenses, employees paid a significant price.  This wasn't intuitively obvious in the 1980's when these plans became more commonplace.  Over the past decade, the less than rational behavior by employees hasn't gone unnoticed by those who study behavioral economics or those in the government.  As a result, more organizations and companies are nudging employees into the right behaviors with auto-enrollment into 401(k) plans and auto-allocation of these funds with protection from any future liability as noted in the Pension Protection Act of 2006.

The analogies to health care and specifically consumer-driven health plans should be clear.  Workers don't save adequately for retirement even when in their best interest.  It's very likely that workers won't save money adequately to fund future health expenses.  After all, if people can't fund retirement, something we undoubtedly all look forward to, which one of us is willing to saving for chemotherapy or open heart surgery, which no one wants?  According to the annual Kaiser Family Foundation Employer Benefits Survey, the average annual deductible for single coverage and family coverage is nearly $2000 and $4000 respectively for health insurance plans that are health savings accounts (HSA) eligible.   The deductibles are slightly lower in health insurance policies that are linked to health reimbursement arrangement (HRA).  About 13 percent of employees are covered under either plan.

Unlike those in retirement planning who can work longer, even if not desirable, employees who are ill may not have an option to work to pay for their medical expenses.  There continues to be evidence that people are curbing their health care due to the ability to pay.

Though experts debate on whether this is a good thing (patients are avoiding unnecessary and expensive therapies and opting for less pricey but equally as effective options) or a bad thing (patients are avoiding the preventive screening tests or therapies that overall can decrease future costs), the opportunities to ensure patients make the right choices should be clear from workers' less than optimal experience with 401(k)s.

If employers wish to help curb medical costs, then they will need to engage workers with programs like employee wellness, assisted decision making (either as second opinions or patient-friendly informed consent), and access to medical experts, equivalent to personal financial advisors, who may be able to help workers make the right choices for their health.  Within the business community, there is some acknowledgment that access to these tools will be necessary to not only manage costs but keep employees healthy and productive.

Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies.  If implemented poorly and organizations simply shift health care costs and financial responsibilities to workers like retirement planning decades ago, the nation will need to accept more than ever that increasingly more people get the medical care based simply on their ability to pay and not on medical necessity.

As a practicing primary care doctor, I hope that day never comes.

Empowered Patient - Is This What Americans Really Want? Probably Not.

Empowered patient.  Consumer driven healthcare.  Transparency.  Access to their full medical records online.  Review the latest news and you'll discover more books and articles recommending patients be advocates for themselves.  The pitch?  The only way to get the best care is to be thorough, informed, and always asking questions. This perspective is understandable because advocates have observed a healthcare system that provides inconsistent quality, too many preventable medical errors, and overtreatment resulting in unnecessary injuries and deaths.  Even I've written a book saying the same thing and I hate to write. 

The public is urged to take charge of their health and their healthcare.  When they have a problem, ask the doctor questions.  Do research.  If they need a procedure, shop around to get the best deal.  Adopt good habits.  Eat more fruits and vegetables.  Stop smoking.  Maintain a healthy weight.  Exercise regularly.  These will improve health and be less costly in the long run.  


But is this what Americans really want?  Do they want to be empowered patients?  Can they be empowered patients? 

Frankly, no.

Americans don't want to be empowered patients anymore than they wish to be experts in retirement planning or IT gurus.  Life is already too busy.  Both parents are working, sometimes two jobs to make ends meet.  Children's schedules are packed with so many activities that simply having playtime to be a child is almost seen as being lazy (even though it might be the right thing to do).  People know they should exercise, lose weight, and eat fruits and vegetables.

But the problem is in adopting both healthy habits and having patients shift their behavior to be more engaged in healthcare is that it is more than the result of poor individual choices or lack of knowledge.  People are not particularly rational even when it is in their best interest and even when it makes economic sense.  In fact, it is incredibly hard to make those right choices unless the system is tweaked to promote the right behavior.  Shifting the system requiring patients to have more financial responsibility in medical care through higher deductibles and copays won't do it.  History has already shown how this failed in retirement planning.

In the 1970s when employers started shifting from pension plans (defined benefit) to 401(k) plans (defined contribution) for cost reasons, the theory was employees would do better in retirement planning.  No one would have more incentive than the individual employee to thoughtfully research and invest their money for retirement than the person directly benefiting from it.  Employees would deduct money from their paychecks, determine an appropriate asset allocation and rebalance their funds to maintain a risk level they were comfortable with.  It was thought to be a win-win.

Decades later, however, it became clear what people should have done and what they were actually doing was vastly different.  Observed behaviors were not consistent with academic theory.  Too many people didn't participate in their retirement plan.  Those who did often had funds in a money market plan which never kept up with inflation and cost of living increases.  Others didn't diversify at all putting their dollars at high risk for failure.  These discoveries led to the rise of behavioral economics which began asking the right question - why don't people do what is in their best interest?

It's because we aren't as rational as we think we are.

As a result, over the past few years employers and the financial services companies having been changing retirement planning to nudge employees to make the right decision.  Employees are now automatically enrolled into a 401(k) plan and no longer need to sign up.  A small portion is deducted from their salaries automatically.  The dollars are invested in target date funds.  Target date funds invest money among a variety of assets to promote diversification to mitigate risk.  More importantly, the funds are shifted automatically over time to more conservative assets as the employee gets closer to retirement, the financially prudent thing to do.  The rate of return typically is higher than the money market accounts and ahead of inflation.

As a result of these changes the number of people not participating in 401(k)s fell from 25 percent down to 5 to 10 percent.  More importantly, they are invested correctly for their retirement.  It is what they would have chosen to do anyway.  If they had time or the desire to do so.

For the minority of individuals who were far more motivated, these programs did not hamper them to invest as they saw fit.

This is a true win-win.

Yet in healthcare, the same troubling trends are occurring again.  The risk of making the wrong choice is much higher as are the consequences.

Much like pension plans decades ago, healthcare costs for companies are increasingly a larger financial burden.  As a result, more insurance premiums are being shifted to employees with increasing copays and now deductibles.  The theory goes if patients have more responsibility for their care that they will make the right choices to stay healthy and well.  Because they have more financial responsibility, they will be more thoughtful when they need to see a doctor and if testing is required they will ask questions, shop around, and do research.  After all, it's their life and their money.  Who else would be most vested in making the right decision than the patient?  It would be a win-win.

Sound familiar?

Familiar and flawed.  It's about improving the system and not relying on individuals to be heroic to do the right thing.

A recent USA Today article about the decline death rate from motor vehicle accidents reminded me of how powerful improving the system is in nudging the right behavior.  It also reminded me how experts continue to wrongly attribute either success or failure to the individual.

The number of people killed from traffic accidents in 2009 was the lowest in 60 years despite the fact that
in 1950 there were about 45 million cars for 150 million people while today's numbers are 256 million cars for a population of 310 million.

NHTSA Administrator David Strickland contributes the drop in fatalities to increased seat belt usage and a strong anti-drunken driving campaign nationwide.

Both of which are individual behaviors.  Now Mr. Strickland may be talking about the year to year decrease in fatalities.  He doesn't address or acknowledge the system improvements that have allowed six times as many vehicles on the road with a population that has doubled in size.  There is no mention of better highway design and signage, rumble strips, crash zones in front of highway off-ramps, guardrails, red traffic light cameras, safer cars with airbags, anti-lock brakes, and better engineering with crumple zones and stronger passenger cages to protect occupants as reasons for a death rate that is the best in sixty years.

Perhaps understanding the importance of system to help the individual, this blurb from the article shouldn't be surprising:

More people die from car crashes in rural areas, with urban areas a distant second, according to NHTSA's data. Driving off the road is the largest type of fatal accident. That's followed by accidents at intersections.

It's not just about individuals making right choices but about the system enabling them to get there.  Rural areas probably don't have sophisticated road design or some of the above system improvements.  Driving off road causing a large number of fatalities makes sense.  In that situation, it really is simply the individual and the car against the wilderness.

So it isn't I'm against the empowered patient movement.  I wrote a book giving them the same tools many others have.

It's a fundamentally different view of the world.  Does enabling good health and providing the right care at the right time boil down to either asking the individual to make the right choices or making the system to enable her to easily get to the right choice?

The former won't work.  With my colleagues, I'm working very hard on the latter.

Americans Cut Back on Doctor Visits - Very Worrisome

The Wall Street Journal reported that overall medical use fell as patients had fewer doctor office visits, lab testing, and maintenance medications possibly due to the recession or as a result of consumer driven healthcare in the way of higher deductibles and copays.  This is very worrisome.  Certainly patients should have some financial responsibility for their care, but skimping on care will only result in Americans not becoming healthier, but sicker.  Though the article cited some examples of patients saving money by not seeing their allergist for a refill of medication and simply calling for one and getting an athletic physical at a local urgent care clinic for $40 rather than $90 at the doctor's office, these tiny behavior changes aren't going to bend the cost curve in medical care.

Sure, some patients are holding off on elective surgeries.  This might be a good thing as research has suggested that Americans get too many procedures compared to other industrialized countries.  However, this could be equally as bad as there may be an equal number of people who truly need surgery to improve their quality of life and ability to walk but can't do so because they can't afford it.

With more financial responsibility of higher deductibles and copays, patients will simply skip care, specifically, needed medical care.  As the drugstore CVS noted, there was a "drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits".  In other words, patients are not getting treated for their high cholesterol, high blood pressure, or diabetes to prevent premature heart attacks or strokes.


Paul Ginsburg, a respected health economist of the Center for Studying Health System Change noted that this patient behavior "could go beyond the recession. Being a less aggressive consumer of health care is here to stay."


I disagree with him in the sense that patients weren't necessarily aggressive before, but behaved in a rational manner when copays were low, there were no costs to medications, lab work, and office visits.  The question is with very high financial barriers to seek care will they make the right choices?  Will Americans change their behavior and become healthier?

The answer is no.

As a practicing primary care doctor I know when I must seek medical care and when I can safely skip.  If this data holds true for the next few years, America will have a very big problem.   We will have a less healthy workforce because they cut corners on their health.  A generation of Americans who will skip important preventive screening tests because they feel fine and aren't willing to pay the high copays.  Those with medical conditions like diabetes will develop avoidable complications of blindness, kidney failure, and amputations because patients don't renew their maintenance medications.

Americans will die sooner, have a worse quality of life, and more preventable complications as a result of consumer driven healthcare.  The doctors who are best in advising patients on the right care, the primary care doctors like internists and family doctors, are leaving their practice in droves because of issues of work-life balance and decreasing reimbursement.  Healthcare costs for the short-term may fall only to rise rapidly as patients are forced to be treated for conditions that could have been handled earlier more easily and for a lot less.

In other words, the perfect storm of a worsening healthcare system is upon us soon.

Which will leave the government no choice but to establish a single payer government run system.

What Steve Jobs and iPhone 4 Antennagate can Teach Doctors and Patients

First, I am a big admirer of Apple CEO Steve Jobs for his thoughtful 2005 Stanford commencement speech, his clarity of vision, and his superb skills as a leader. Fortune magazine named him CEO of the decade after turning around the company he founded from near bankruptcy in the late 1990s to becoming the most valued company today. Though I have great respect for him, I haven't bought an Apple product, ever, until this year.

So I watched with great interest his press conference regarding Antennagate which has consumed technology news with regards to the design of the new iPhone 4 and its new antenna design. Apparently this makes the smartphone vulnerable to dropping phone calls when held a certain way, known as the death grip. If one simply avoided holding the phone that one explicit way, the phone otherwise worked fine. As a result, 22 days after the latest iPhone was available to the public, Jobs and Apple were instead addressing an issue which dwarfed their latest product launch.

Doctors and patients can learn plenty by watching Jobs approach to the problem because the situation he and his team were tackling is similar to what a doctor addresses daily in the office.

• Perception is reality regardless of the truth.
• Hard data is important to have candid conversation. Specifically the right data.
  
• Sometimes emotions are so overwhelming that something needs to be done. This can be good or bad.
• People who advocate certain positions have inherent biases, which can make their argument far from objective, hence the need for hard data and expertise to interpret.

With all of the negative press, Jobs figured that a reasonable person might figure that about 50 percent of iPhone users would complain of dropped calls or that a significant number would return them. The hard data from Apple shows that only 0.55 percent of calls to their customer service center were in regards to phone call reception and that 1.7 percent of iPhone 4s have been turned. This return rate was far lower than the 6 percent observed last year during the iPhone 3GS launch.

Although Jobs noted that there were plenty of opinions about the possible reasons and solutions for the problem, the press conference was convened nearly three weeks after launch because Apple engineers needed time to understand the issue fully. As revolutionary as the iPhone 4 is, the very small technical issue which affected a very small number of users became a firestorm. Jobs announced free cases to all iPhone 4 users which seems to mitigate the problem even though the vast majority of users have no problems. He reiterated that new owners unhappy with the phone could return it for a full refund within 30 days. In the end, Jobs reflected that he and the people at Apple work extremely hard to keep their users happy.

Doctors address these issues daily which come up in conversations with patients. This could be in regards to the risk and benefits of immunizations, the need for antibiotics for possible Lyme disease exposure, or many other concerns where a person can psych himself. The internet can be powerful in arming patients with plenty of information, but fails to provide them experience or medical expertise or the objectivity needed to make a good thoughtful decision. (A good reason why doctors shouldn't take care of their own family members).

With the ongoing economic crisis, many patients are presenting with chest pain. Some are convinced that they have heart disease and won't accept anything less than a heart stress test or other imaging even if based on their symptoms, initial testing (basic labs, chest xray, and EKG), and risk factors (age, gender, smoking status) that the hard data clearly points a problem elsewhere.

At that moment, sometimes doctors are unable to talk a person down from their emotional ledge need to do something to address a patient's piece of mind. This could be a referral to a cardiologist or a basic treadmill test.

Hopefully that resolves the issue, but at what cost? Was it the right thing to do?

If the treadmill is a false positive, this will require a further work-up which may include an invasive cardiac catheterization. Although rare, patients can die from the procedure. Doing a test in a highly unlikely patient would be considered very questionable by many doctors. Will an individual doctor be confident enough to stop the process based mainly on emotion and perception when hard clinical data points in another direction? Is it possible that the tyranny of the short office visit and the need to do something perpetuate the problem and result in further testing?

In this case, all of this was done for stress? Was all of the additional testing and increased risk of harm needed to demonstrate a normal heart?

As Jobs and Apple know, an issue can be blown out of proportion and emotions can run high when perception distorts reality. Free cases are an easy fix.

When it comes to medical care, sometimes the easy fix may require doctors being calm, listening, and spending time to understand a person's concern. Does keeping patients happy and healthy sometimes mean saying no and providing rational thoughtful care?

For patients it means not believing everything they read or hear from friends, family, or the internet (or even other doctors and healthcare providers who only know pieces of information but not the entire story). With increasing financial responsibility through higher deductibles and copays (consumer driven healthcare), will patients listen to doctors who can help make the right decision with their clinical expertise or rely on the information gathered by the internet and demand testing believing that is the right thing to do?

Based on my experience, it doesn't look good. It's getting harder to talk some patients off their ledge.

We could certainly use Jobs and his leadership team in healthcare or least his presentation skills. When asked during Q&A, Jobs and his team pulled out their iPhone 4s - all without an external case.

And yes, my phone works perfectly fine.

Brittany Murphy's Death - Learnings About Consumer Driven Healthcare and Pneumonia

Actress Brittany Murphy, age 32, died unexpectedly in December 2009 as a result of pneumonia. An autopsy report noted elevated levels of medications, like Vicoprofen, which contains the narcotic hydrocodone and other medications, the anti-histamine chlorpheniramine and L-methamphetamine which is found in decongestants. The hydrocodone in Vicoprofen can cause sedation and was used by the actress to treat menstrual cramps. The other medications are often used for symptom relief from respiratory infections.



Her husband noted that Murphy "was on an antibiotic and was taking cough medicine." Yet it is unclear if she was actually under the care of a doctor at the time of death. Other reports noted that the "star had been feeling ill prior to her death and had scheduled a doctor’s appointment on a Wednesday or Thursday — days before her Sunday death."

Her husband had been ill a week before and recovered so it was certainly reasonable for the actress to care for herself at home.

So what can we learn from this tragic and untimely death?

First, even in the 21st century pneumonia can kill despite our advanced antibiotics and medical technology. Among adults in 2000, there were about 135,000 hospitalizations due to pneumonia, and 60,000 cases of invasive disease, which included 3,300 cases of meningitis. Of those patients with the aggressive invasive disease, 14 percent were fatal.

Bacteria is becoming more resistant to medications as antibiotics are overused in treating viral infections, like colds and sinusitis, as well overuse in food production and livestock.

Patients at risk of pneumonia, elderly, young children, those with compromised respiratory systems (emphysema, asthma) and immune systems (diabetes) should ask their doctors about the pneumonia vaccine. Prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

The type of vaccine administered varies depending on the age of the patient. For children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

It's unlikely Murphy would have needed a pneumococcal vaccine based on her medical history, which was otherwise healthy except for anemia, which is not unusual among women who are menstruating. However, according to the autopsy report the coroner noted a history of diabetes which alone would have been a reason for vaccination.

Second, it is unclear what dosages Murphy was taking of each of the listed medications. Certainly taking too much of any medication can be problematic particularly with hydrocodone and the chlorpheniramine. Both can cause sedation. The former drug can cause respiratory depression and decrease the drive the breathe, which can be fatal when taken in high doses.

Again it is unclear if she was under the care of a doctor at the time of her illness. Her husband notes that she was taking an antibiotic for a flu like illness. Yet, antibiotics are not appropriate for viral illnesses like the flu. Based on information from the coroner's report, the antibiotic clarithromycin which is used for pneumonia, was prescribed to her on November 17th, 2009, a month before the actress died. Was she ill before her December illness?

Finally, the assistant chief coroner noted that her death was "preventable".

Could Murphy have known how sick she was and how urgently she needed to seek medical care? It would been perfectly natural for her to have assumed that since her husband was recently ill and subsequently recovered that she would have done so as well. Isn't that what many of us do?

With increasing healthcare costs, many healthcare advisors are touting consumer driven healthcare as a way to slow medical expenditures. The theory goes that by having patients shoulder more financial responsibility on when to seek medical care and when they can safely skip advocates believe as a result people will make smarter choices and lower healthcare costs.

This is quite concerning.

Murphy, who arguably didn't have a financial barrier to seek care yet was quite ill, didn't get timely medical care. One wonders if individuals facing $50 to $100 office visits who might be equally as sick would simply stay home as well. At best, they might delay care and then subsequently end up in the emergency room or hospital not only requiring a lot more care but also a significant amount of out of pocket costs in the hundreds to thousands of dollars. At worst, they could die and have a death that was preventable.

Consumer driven healthcare, which is coming soon to you, requires that patients educate themselves in a way unprecedented than the past. Perhaps if Murphy had reviewed the symptom checker at the American Academy of Family Physicians she would have demanded an earlier appointment. (According to the coroner's report, Murphy was complaining of shortness of breath).

Instead of winging it, patients in these health insurance plans must educate themselves otherwise they are truly taking their lives into their own hands.

And the ignorance could be deadly.

(Sadly, her husband, Simon Monjack, age 39 was found dead today at home. Preliminary reports indicate he died of natural causes. Certainly he could have died from a broken heart).

Seventy Five Percent of Primary Care Doctors Provide Sub-Standard Colon Cancer Screening Care

A recent article found that primary care doctors the United States are providing sub-standard care when it comes to colon cancer screening. In the Journal of General Internal Medicine, researchers found that 25% of primary care doctors used in office stool testing to screen for colon cancer. Specifically, doctors do a rectal exam and then swipe the rectal contents off their gloves onto a stool testing card. A positive test result indicates the presence of blood, which can be invisible to the naked eye.

The in office stool testing has not been the standard of care for at least a decade. More importantly, it also misses 95% of advanced colon / rectal cancers. The study found that doctors most likely to do the in office stool testing were those in solo practice.

To confuse matters even further, another fifty percent of doctors did both in office stool testing as well as home testing. This means that essentially 75 percent of primary care doctors are using the wrong screening test.

If one is to screen for colon cancer correctly and wishes to use stool card testing, then it must be done by the patient at home, not in the office by the doctor.

If the stool test revealed occult blood, the recommended follow-up is a colonoscopy. A repeat stool test is not suggested. A sigmoidoscopy is also not recommended for a positive stool test result.

Disappointingly, 17.8% of doctors recommend repeating the stool test. If the second stool test was normal, 28.8% recommended no further workup. This is not only wrong, but now falsely assures the patient that everything is fine. Researchers found doctors most likely to recommend a repeat stool test were those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Though this study surveyed doctors from September 2006 to May 2007 and researchers noted that there was slight improvement in colon cancer screening from 2000, (more doctors did not choose sigmoidoscopy after a positive stool test) the results are still quite disturbing.

The correct options for colon cancer screening for Americans at average risk for colon cancer beginning at age 50 include the following:

Fecal occult blood testing (FOBT) -- stool testing which is done at home, not in the office. Done annually.
or
above with flexible sigmoidoscopy every 5 years
or
colonoscopy every 10 years

The authors of the article were too kind when they subtitled their article “serious deviations from evidence based recommendations”. In 2000, when a colleague of mine and I during residency polled our twenty two other family medicine residents and interns, every one correctly knew that in office stool testing was not the standard of care.

The article concludes that “many physicians are continuing to use inappropriate implementation methods [and that] intensified efforts to inform physicians of recommended technique and promote the use of systems for tracking test completion and follow-up are needed.” In other words, if we continue educating doctors perhaps one day they will all do what the standard of care has been for the past 10 years!

Why is this study important?

The only people that can make the healthcare system better is doctors. When we fail, patients get inadequate care.

When healthcare reform proponents recommend patients be given more financial responsibility to get medical care, I wonder if they are too naive. The belief is that the public will choose more prudently when they have more monetary skin in the game. As a result, the thought is that as healthcare becomes more like other markets, consumer goods, purchasing other services, that the healthcare system will be more efficient and drive costs down further.

While I understand that patients should have some cost-sharing, this alone won’t fix the healthcare crisis. Consumer driven healthcare advocates fail to realize that the degree of information needed to make patients truly smart consumers requires a medical degree and training.

Do we expect that patients should be able to recite what are the correct screening modalities for colon cancer screening when doctors can’t do it consistently now even though guidelines have been around for years?

Will patients choose only board-certified doctors or choose quality of medical care based on bedside manner? The correct answer is they should find doctors who have both qualities. If one must choose between the two, patients should opt for board-certification over bedside manner.

This research suggest that perhaps it might be better to find a doctor not in solo practice. Is it possible that doctors are smarter and up to date on the latest research findings because of conversations that occur between patients? Are two heads better than one?

Otherwise, patients have a difficult, but not impossible responsibility to educate themselves. That is why I wrote my book so if our healthcare system truly becomes consumer driven at least there is an easy reference to get everyone up to speed.

You might need to pick up a copy for your own doctor to read.

Can Price Shopping Improve Health Care? Do Pigs Fly?

In a recent Time magazine article Could Price Shopping Could Costs and Improve Health Care, the author suggests as many others have done in the past that forcing patients to more like customers and comparison shop will drive healthcare costs down.

Nothing could be further from the truth.

The theory of consumer driven healthcare goes that if there was more information about the costs of doctors, hospitals, imaging tests, and procedures that people would hunt around to find the best deal, stimulate competition, and drive pricing downward.

Proponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure.

But that is always the only example that they give.

They fail to demonstrate how price transparency alone results in decreased costs. Look at elective plastic surgery, which like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by an machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at www.familydoctors.org).

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer driven healthcare also believe that having patients pay more of their healthcare expensive or "having more skin in the game", will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease that they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer driven healthcare.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43 percent of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer driven healthcare, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer driven healthcare is to work, it will require a few elements, which unfortunately the American healthcare system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

Guaranteed Prediction - Pay More, Get Less - Your Future Health Insurance Plan

Even with healthcare reform, Americans will increasingly be burdened with high deductibles, more financial responsibility, and less satisfaction with their health insurance for the foreseeable future. Why? Because the healthcare system is unable to transform its services in a manner that other industries have done to improve quality and service while decreasing costs. The two biggest culprits are the mentality of healthcare providers and the fee for service reimbursement system.

Doctors and patients haven't altered the way they communicate over the past hundred years. Except for the invention of the telephone, an office visit is unchanged. A doctor and patient converse as the physician scribbles notes in a paper chart. Despite the innovations of cell phones, laptop computers, and other time saving devices, patients still get care through face to face contact even though banking, travel, and business collaboration can be done via the internet, webcams, and sharing of documentation. As Dr. Pauline Chen noted in a recent article, doctors are not willing to use technology to collaborate and to deliver medical care better, more quickly and efficiently. Mostly it is due to culture resistant to change. Partly it is due to lack of reimbursement. Both are unlikely to be addressed or fixed anytime soon.

Yet, patients come to doctors for our medical expertise and insight in order to stay well or get better. They don't care if it is done via the web or in person. If doctors think their problems are safe to handle via technology then they are for it. If doctors feel a particular condition must be handled in the office, then they are willing to do it. After all, aren't we the ones who can make that assessment? They trust us to make the right determination. We must be willing to challenge tradition and training in the face of a rapidly evolving world.

If this country is going to make healthcare more affordable and more accessible, then doctors need to collaborate better. Only doctors can stop the increasing march of medical expenses.

If we as a profession are unwilling to use technology to get the information and expertise to the point of care to get people better sooner, then our country has only two options left to make healthcare affordable. The first is the government to force pricing down as it is done in other countries. Based on the agenda of Medicare, the government is already squeezing costs by dictating pricing which may not be realistic. The second is to force patients to try and figure out which tests, procedures, doctors are best to help them. Research shows they don't want that responsibility and when they do have that burden they skip care. Nevertheless, employers are increasingly moving their employees to less comprehensive consumer driven health plans (CDHP) and high deductible health plans (HDHP) to save money.

It's doctors who aren't willing to do virtual visits. The public is ready and waiting. If we as a profession won't consider using the same technology we use to communicate with family and friends as well as use these very same tools to provide "second opinions" to our loved ones who value our medical expertise to our patients, then how can we say that we are committed to making healthcare accessible and affordable to all Americans?

While there is a small group of enthusiastic entrepreneurial doctors and leading edge healthcare organizations trying to move American medicine into the 21st century, the healthcare system really needs Steve Jobs and Apple to transform healthcare. As it currently exists, the majority of doctors are either unwilling or unable to make the change.

Why healthcare needs to be more like Apple and less like Windows / Intel

There is a common perception in our country that more is better, particularly when it comes with choice. More choice means more competition and the ultimate beneficiary is the consumer. Is this actually true? Can there be too much choice?

Take consumer electronics, specifically, portable music players also known as MP3 players. Various hardware companies produced them with varying options and memory capabilities. Another companies had the music content that needed to be compatible with the variety of MP3 players. In addition, the MP3 players and the content providers needed to also be compatible with the large number of computer configurations offered by even more companies.

Although the enormous choice of MP3 players, content providers, and computer configurations allowed each separate category to be priced optimally due to competition, the irony was that very few consumers took the plunge of enjoying their music libraries on portable MP3 players. Too many problems occurred. Crashing the computer was probably the most common and frustrating. Many MP3 players had plenty of options, perhaps too many while others had too few. Music content providers worked like cable companies charging monthly fees which people frankly balked at because the content wasn't broad enough. In short, too many options caused confusion, the setup caused frustration, and consequently the promise of the digital revolution was just that, a promise.

Indeed when Apple introduced its iPod music player many years ago in 2001, Apple was a late entrant in the MP3 player market.

But it didn't matter. Millions have been sold. At Apple's recent conference, they noted that iPod's marketshare is at nearly 75 percent of the MP3 market and perhaps even more fascinating is that over 50 percent of purchasers have NEVER purchased an iPod before. In other words, iPod is entering households that normally wouldn't have a need for a MP3 player, let alone an Apple product.

Apple's success speaks volumes about what people really want. It isn't about choice, choice, choice, its about asking a simple question, what do people want? For Steve Jobs and his team, the question has been that simple, yet as complex. They determined that it was to have an intuitive MP3 player and seemless integration with content providers so that people could focus on the music experience and less on the technical aspects.

In many ways, this mirrors the original thinking with Macintosh computers, where the question was what do people want from their computers? It wasn't that they wished to type commands in DOS, but use intuitive interfaces and inputs like an icon based system and interacting with it using a mouse (and now touch screen with the iPhone and iPod touch).

The introduction of the iPod was a radical departure what people had previously experienced with MP3 players and other content providers. Both the interface on the iPod and iTunes, Apple's content provider of music, audiobooks, and then later video content which includes movies and television shows, were and still are elegant and simple to use. Both iPod and iTunes continue to have further improvements. Apple recently introduced iTunes version 9 and now offers iPods in a number of configurations including iPod Touch with WiFi capability and larger screen, the new iPod Nano, a much smaller device with a smaller screen as well as a built in video camera, and the iPod classic, which has a larger memory capacity, but looks like the original iPod.

So why was Apple so successful, when other companies presumably had an advantage by being first to market? Unlike the Windows / Intel configuration where different companies produce the software and others produce the hardware, Apple is a true vertically integrated consumer electronic company. Apple designs and produces BOTH the hardware and the software. Apple products work in a closed proprietary system. Apple's original iPod came in one color, white, and one configuration. The iPod essentially works with one system, iTunes. Fortunately, iPod and iTunes works with PC computers so the rest of the world can enjoy the benefits of thoughtful Apple engineering since only 5 percent of the PC market is currently held by Apple.

Apple won in the MP3 marketplace and is making significant headway in the smartphone market with its iPhone because the company continually asks an important question - what do people want?

So, in healthcare what do people really want?

Do they want choice, choice, choice? Do they want to have every test, every medication, every imaging test, every hospital, and every doctor available to them? Do they simply want the right test, the right medication, the right imaging test, the right hospital, and the right doctor available to help them get better?

Unfortunately, Americans believe in the former. Indeed, that is what economists would argue that more choices are better for everyone. Yet in the complex world of healthcare, can consumers get the correct combination of tests, medications, imaging tests, hospitals, and doctors to get the best outcome? It makes the simple task of hooking up a MP3 player to one's personal computer seem infinitely easier, yet history shows that until the introduction of Apple's iPod that acceptance was limited to those in the know, specifically technophiles.

Apple demonstrated with its iPod and iTunes that sometimes a simple streamlined system is far better than the chaos inherent in too many choices.

In healthcare, those in the know are doctors and patients who are fully engaged in being empowered, not because they want to, but because they have to, often because of a serious illness. Otherwise for the majority of us, we don't give much thought to our health until something happens. By then it is a hard learning experience of copays, deductibles, explanation of benefits, and network and out of network discussions. The vast majority don't want this responsibilty any more than they want to be technophiles in getting a simple MP3 player hooked up to their computers. There is nothing wrong with that belief. When people get ill they should be focused on simply getting better.

If we believe that this is what people really want, then what the American healthcare system needs instead of its fragmented configurations of multiple small medical groups, multiple hospitals, multiple radiology centers, surgery centers, and duplicity of medications, many of which are not better than existing therapies, and make itself more simple and user friendly. All patients would have a primary care doctor that they could rely on should something happen. This doctor would be one working in a large multispecialty group where primary care doctors and specialists work with specific hospitals with all of the imaging and operating rooms, and robust medication formularies with just the right number of therapies needed to do one thing - get the person they are treating better.

In other words, move from the world of Windows / Intel where more groups are available but do their own thing into the world of Apple where all of the players are aligned in the same direction. In healthcare, this means do what Apple does and use integration either true vertical or virtual integration to have the desired outcome.

Would the public stand for this or complain that their choices and their freedoms are being restricted?

Steve Jobs and his team at Apple know what people want in their world of consumer electronics. With his recent liver transplant, I wonder if he ever gives much thought on how to revolutionize the healthcare system?