Healthcare Failings Due to Not Doing the Basics

For anyone interested in understanding what drives a lot of the costs in the healthcare system, the New York Times health series about the six killers in America, heart disease, cancer, stroke, chronic obstructive pulmonary disease (emphysema), diabetes, and Alzheimer's is an excellent place to start.

Some themes begin to emerge. For heart disease, the way to prevent future heart attacks is to ensure that patients understand how to take their medications and that it is often for life. For successful cancer treatment, the goal is early detection and undergoing the simple, but for some, unpleasant tests to screen for breast, colon, and prostate cancer. For stroke, it is to ensure that missed opportunities aren't missed.

Ulimately, much of the differences between a fair outcome and great outcome is focusing on the little things - taking medications regularly and as directed, getting the preventive screening tests done, and making sure that the little things are always taken care of.

Much like any coach knows before a team can be successful, each of the players must know the fundamentals. In hockey that would be skating, stickhandling, passing, and checking. It doesn't matter how expensive your skates are or what high tech materials your stick is made out of. Unless you and your team know the basics, you will fail. Unfortuantely, the healthcare system as a whole hasn't yet mastered the fundamentals.

Lessons of Heart Disease, Learned and Ignored

A fascinating piece about heart disease not because the information is cutting edge, but rather because the failures in preventing future heart attacks are due to the inability for doctors to communicate to their patients about continuing their treatments consistently, regularly, and in most cases indefinitely. The article Lessons of Heart Disease, Learned and Ignored looks at an individual who proudly stopped taking his prescription medications after losing weight and exercising. He had his first heart attack nine years earlier and reasoned, incorrectly, that by changing his lifestyle that he could avoid taking medications altogether. Had he consulted his doctor before stopping his medications, he most likely would have avoided his second heart attack.

This is a common occurance in my experience as well. Many patients don't want to take medications that are potentially life saving because they aren't natural, yet when challenged to make significant lifestyle changes to lose unnaturally heavy weight and unhealthy habits they don't want to. Any patient should always consult with his doctor before stopping any prescription medications. If you are concerned that your doctor is simply writing medications and not working with you to keep you healthy, consider switching doctors. Realize, however, that there are situations that medications must be taken to keep you well. That perhaps is the most difficult idea for many patients to swallow.

Healthcare Reform - Dutch or Swiss?

The New York Times reported that Health and Human Services Secretary Leavitt was going to Switzerland and the Netherlands to see how these countries provide healthcare. In those countries there is an individual mandate, i.e. everyone has to buy health insurnace. Employers are not required to provide health insurance.

Unlike Canada and Great Britian, it appears these countries don't use the government set up the system. Will elements of the Swiss and Dutch healthcare systems work here? It probably will depend on who sits in the White House and who controls Congress.

Adult Vaccination Update

As it does regularly, the CDC revised its recommendations for adult vaccinations. Now adults who are worried about shingles or zoster, which is a very painful skin eruption that typically occurs in older adults, can get vaccinated at 60 years of age. Also new is the recommendation that all adults without proof of immunity to the chicken pox (varicella) virus should get vaccinated.

Not sure what immunizations you need? Print out the adult vaccination schedule and have your doctor explain. It's the easiest way to make sense of the alphabet soup of immunizations. In the 21st century as an increasingly number of bacteria are more resistant to antibiotics and viruses exist that can cause debilitating illnesses, vaccinations continue to have a role in keeping people healthy. Most of us immunize our children. Adults deserve the same level of care. Talk with your doctor the next time you see her.

Too Many Drugs?

The New York Times article titled "The Poisonous Cocktail of Multiple Drugs" illustrates a fairly common occurance for many patients, taking multiple prescription medications. Known as polypharmacy, patients have many different medications prescribed by multiple doctors who don't know what the other one wrote. As a result, these patients, unfortunately, are at higher risk for having medication side effects or interactions.

As people live longer with more chronic illnesses, their care becomes more complex. This is why patients may find it valuable to have one primary care doctor coordinate care and ensure that the treatments rendered by various specialists are compatible with each other. The other is having technology like the free web-based eRx Now system to help busy doctors check different medications for drug interactions and track a person's treatment.

Without either of these interventions, the case of the 78 year old lady who passed out from a stomach ulcer due to the combination of aspirin, ibuprofen, and Celebrex, will undoubtedly continue.

Finding the Right Doctor

A recent article in the Atlanta Journal Constitution titled "Rx for a doctor: Here are some tips for finding the right physician" had comments from yours truly.

Overall, it provides an excellent starting point on how to find a primary care doctor.

Better Screening Test for Cervical Cancer - Are Pap Smears Obsolete?

Very exciting news about the war against cancer. A published article in the New England Journal of Medicine found that screening for the human papilloma virus (HPV) was far more accurate in detecting cervical cancer than the current PAP smear.

Highlights from the article.

The HPV test, which looks for the virus that causes cervical cancer, correctly spotted 95 percent of the cancers. The Pap test, which checks for abnormal cells under a microscope, only found 55 percent, according to researchers at McGill University in Montreal.

The Canadian study, which was government-funded, included 10,154 women ages 30 to 69 in Montreal and St. John's, Newfoundland. The women got both tests. Still to be determined is the best way to start using the HPV test by itself and what follow-up action to take after positive results, the researchers said.

Dr. Carolyn D. Runowicz, who wrote a journal editorial, noted that the two studies used a different kind of Pap test, not the liquid-based technology used in the U.S, which may be more sensitive The results of a British study that used liquid Pap are due to be presented in November.

"We're not ready for prime time. We're moving in that direction. But we're not there yet," said Runowicz, a former president of the American Cancer Society.

Troubling Trend of Avoiding Vaccinations in Children

A recent article noted how more parents, skeptical about the value of vaccinations and worried about the linkage of immunizations with other problems like autism, are using religious grounds to be exempted from mandatory childhood vaccinations.

This troubling trend is fortunately relatively small. Highlights from the article.

• The number of exemptions is extremely small in percentage terms and represents just a few thousand of the 3.7 million children entering kindergarten in 2005, the most recent figure available.
• In 1991, a religious group in Philadelphia that chose not to immunize its children touched off an outbreak of measles that claimed at least eight lives and sickened more than 700 people, mostly children.
• And in 2005, an Indiana girl who had not been immunized picked up the measles virus at an orphanage in Romania and unknowingly brought it back to a church group. Within a month, the number of people infected had grown to 31 in what health officials said was the nation's worst outbreak of the disease in a decade.

I understand the parents' concerns. I also am more concerned that people have forgotten how many of these illnesses, like polio, measles, mumps, were debilitating and devastating in the past and that generations of adults, through the use of vaccines years ago, have avoided those complications or premature and preventable deaths.

This past winter, I saw first hand how powerful and effective vaccinations are. When I examined one patient, in his late 30s who was vaccinated against influenza, he felt well in a day or two despite having the flu. This was in stark contrast to other patients in their early 20s, who weren't vaccinated, felt miserable, stayed in bed for days, and wanting to die (they didn't of course). If you've had the flu, you know what they mean, fever often up to 103 to 104 F and every muscle, joint, and bone aching relentlessly. On follow-up months later, the latter group all without hesitation planned on getting the flu shot this fall, even though they are not required to based on current vaccination guidelines.

With recent reports about the rise of bacteria that are resistant to all antibiotics resulting in 19,000 deaths and the findings that cervical cancer is caused by the human papilloma virus (HPV), individuals skipping vaccinations maybe missing opportunities to stay healthy.

Those who cannot remember the past are condemned to repeat it.
* George Santayana (1905) Life of Reason vol. I, ch. XII Charles Scribner's Sons

Insurance Type and Appendicitis

An interesting article in the New York Times titled "Likelihood of Burst Appendix Tied to Insurance".

From the report, "But the kind of insurance — or lack of it — had a significant effect. Compared with patients who had private insurance coverage, those on Medicare were 14 percent more likely to have a burst appendix, people on Medicaid were 22 percent more likely, and those with no insurance at all were 18 percent more likely to have a rupture. The differences persisted even after controlling for age, sex, socioeconomic status, type of hospital and other factors."

The authors admit that this is a retrospective study and it is unclear the reasons why the difference was seen.

Heart Disease - Thank You Framingham Heart Study

Recently saw this update about the famous Framingham Heart Study. Everything we know it medicine is a direct result of volunteers and doctors who 60 years ago embarked on understanding what the risk factors were for heart disease. Although today we take the risk factors for granted, smoking, high blood pressure, cholesterol, it wasn't entirely clear decades ago. Excerpts from the article.

"The death of President Franklin Roosevelt on April 12, 1945, was the wake-up call that eventually led to the study. On the day he died, Roosevelt's blood pressure was an unbelievable 300/190. Few doctors then even suspected there was a connection."

"The early findings were bombshells: smoking, cholesterol, high blood pressure, fat consumption and obesity. At first the nation was in denial. Who knew lifestyle and cardiovascular disease were connected? Practically everything we know now about heart health originated with the Framingham Heart Study. "

"Every advance in technology, every scientific breakthrough means that the longer the study goes on, the more valuable the data it generates - three generations of genetic gold to mine."

All of us, the public and doctors, owe a debt of gratitude to these individuals. Without their volunteerism as well as foresight, where would we be today?

Health Insurance - Odds 1 in 3 Yours Isn't Doing Everything to Keep You Well

One hundred million insured or one in three Americans have no idea if their health insurance plan is doing everything to keep them healthy. This ignorance could cost them their lives. This is the conclusion from the recently released 2007 State of Health Care Quality report by the National Committee for Quality Assurance, a non-profit organization which for over a decade has accredited health insurance plans for their performance. NCQA rates health plans on their ability to provide their enrollees with basic and proven preventive treatments, controlling high blood pressure, diabetes, cholesterol, among many others, consistently and routinely. While the industry has made significant improvements, much more needs to be done to save lives.

When NCQA started reviewing the quality of care delivered, it found that in 1996, on average only 62% of heart attack patients were getting beta blocker medications. These medications have been proven to decrease the risk of future heart attacks and prescribing them to these patients has been the standard teaching in medical schools for years. Over the past decade on average 98% of the time heart attack patients in health plans accredited by NCQA receive this treatment.

Unfortunately, health plans that didn't submit information for review did less well with 94% of patients getting the prescribed medication. Although it most situations this would be good enough, each drop in percentage translates into lives that could have been saved with a simple proven intervention.

Because this and many other effective preventive treatments weren't done to the level recommended by expert committees, 75,000 insured Americans died prematurely. Had these individuals accessed high performing health plans they would be alive today. If the entire industry performed as well as the top plans, $3.7 billion spent on hospital costs would have been avoided. Preventive care saves lives and money when done consistently and regularly. The problem is that within the healthcare system this is far from the case.

Part of the problem is that the most popular insurance plan, the PPO plan, does not have the same level of scrutiny when it comes to performance or accountability like a HMO plan. Until last year, no PPO plans provided NCQA any information on how well they did to keep you well. This year, those plans that cover one hundred million Americans still have not committed to submitting information for review. This lack of transparency has California's insurance commissioner developing a report card rating PPOs, much like the current system which lists HMOs, available to consumers by 2009. Until then, you have a one in three chance that you are in a plan that answers to no one and that the care you receive is not ideal.

Fortunately you aren't powerless. With open enrollment, now is a good time to see if your choices whether HMO or PPO include a NCQA accredited program by going to www.ncqa.org. If not, ask your human resources department to consider one for next year. Take the same amount of time and diligence you would do researching for your next car. It's your money. Don't you deserve the best care possible? With buying a car, if you purchase a lemon, you always have another chance to get another one. With your health, the stakes are higher. Choose wisely. The information is available. Act on it. Next year tens of thousands won't be around to rectify their mistake. Make sure it isn't you.

Breast Cancer and Colon Cancer Treatment and Survivorship Guides -- A Good Idea

The American Society of Clinical Oncologists (ASCO) last month announced that they would have suggested treatment plans and summaries for breast cancer and colon cancer care as well as a survivorship plan available on their website. The former is for oncologists and the latter is for their patients. The treatment plan and summary, which consists of two pages will help oncologists summarize and review important clinical information and well as pre and post chemotherapy information to make it easier to deliver care. These forms were not intended to replace the usual detailed medical documentation, history taking, physical examination, and assessments that oncologists already were accustomed to doing.

While it remains to be seen how doctors will feel about the treatment plan and summary forms, breast cancer as well as colon cancer patients will like the one page survivorship plan. Treatment of cancer is already a complicated and potentially confusing process with many different treatments, dates treatments are given, and when the various office visits and follow-up tests are needed. The survivorship plan provides a basic road map so that an individual patient will have a basic idea of what to expect over the next few weeks, months, and years. It was recommended that the details of the plan should be tailored to the individual's unique circumstances.

This initial effort is a step in the right direction. With doctors busier and more rushed than in the past and patients faced not only with the emotional impact of coping with cancer as well as the logistical challenges of getting treatment, these forms provide a starting point of conversation between oncologists and patients. Already ASCO is working on developing treatment summary plans and survivorship plans for other cancers.

If you or a loved one has been recently diagnosed with breast cancer or colon cancer, download the relevant survivorship plan (and even the treatment plan and summary form) and bring it to your oncologist. It can only help you navigate through what is often a trying and confusing time.

Healthcare Reform Essentials

As doctors, we don’t lose sight of the most critical elements, the ABCs, airway, breathing, and circulation, in an emergency. With healthcare reform, focusing on the essentials can clarify what would otherwise be a confusing situation. Improving our healthcare system will require the following issues be recognized and addressed.

We are not getting the most value out of our healthcare dollars. Repeatedly we spend the most per capita than any other industrialized country in the world and have the worst outcomes. A recent 2007 report by the National Committee for Quality Assurance found that 75,000 insured Americans died prematurely because they did not get level of care observed in the top performing health plans. Had they been enrolled, they would be alive today. If we continue to fund a system that rewards mediocrity we will have failed. We should reward those hospitals, doctor groups, and insurers, that already consistently deliver the right care at the right time and support others to improve quickly.

Our healthcare system’s financial incentives need to change. The number of primary care physicians is inadequate to meet future demand. Current and future retirees are living longer than a generation ago and also developing more chronic illnesses. At the same time, fewer graduates wish to pursue this specialty due to high medical school loans and lower reimbursement compared to specialists. Doctors get paid to perform procedures and not to think or provide counsel which disadvantages the primary care specialties. In 2003, of those resident physicians completing a three-year residency program only 27 percent planned to be internists, down sharply from 54 percent in 1998. Studies have shown that countries, healthcare organizations, and individuals who mainly rely on primary care physicians do better with less expense.

Everyone must be required to have healthcare insurance. The fundamental truth about insurance is that everyone needs to take on the responsibility for the minority who are at risk for an adverse outcome. If health insurance was not mandatory, individuals would simply jump in when expensive medical care was needed (i.e. pregnancy, cancer) and leave when the situation improved. Healthcare costs would increase exponentially. Preventing this adverse selection will mean everyone must pay into the system.

Healthcare isn't cheap. In fact, many Americans have discovered that health costs are the leading cause of personal bankruptcy. Yet odds are very good that you will. The American Cancer Society predicts that a man has a 1 in 2 chance and a woman a 1 in 3 chance of developing a cancer sometime during his or her lifetime. This calculation excludes patients with the more common forms of skin cancer like basal cell cancer and squamous cell cancer. Remember cancer is America’s second leading cause of death. Expect to need doctors and hospitals sometime in the future.

Finally, don’t let the government run healthcare. A single payer solution would put the healthcare delivery system at the mercy of political whims and the budget process. Would you like to be hospitalized only to discover that the federal budget and the funds used to provide your care were being debated or traded for other programs the President and Congress felt to be more important for their constituents and agenda? Instead, the government should provide incentives to those whom the market would not normally enroll, guarantee insurability, set up a large insurance pool or trust to benefit from the economies of scale, and assist those who need help and who don’t currently qualify for the Medicare and Medicaid programs.

This checklist of important issues, while far from comprehensive, distills the debate into key elements that are vital for healthcare reform. To be successful we will need those who provide care to do deliver care more consistently and regularly to that of recommended guidelines, a deliberate rebuilding of our insufficient primary care workforce, require an individual mandate for all Americans, and elect government leaders who support the insured marketplace to that provides coverage for all. We know what to do. We must act quickly. Without these important and essential interventions, we are simply allowing our critically ill healthcare system to slowly wither away on life support.