Fixing Health Care

The Engaged Public

Over half of the US popluation has a computer in their home (55%).  Of those people, according to Pew, 78% of broadband users and 70% of dial-up users use their computers to access medical information.

Resident Education: Top Gun or busboy

Medical residents still make the same amount of errors despite a restriction of work hours to 80 hours per week. (see the recent New York Times article here.)  Just as bad, residents had just as many accidental needle-sticks and car wrecks as they did before the workweek changes.  This is not a surprising finding.   

Consider the following:

1.  80 hours is still unreasonable. Do the math and see:
80 hours per week divided over six days (residents have a mandatory 24 hours off per week) = 13 hour days. 
And if you consider that some of those days get sucked into at least one thirty-hour call shift, the week may look like this:
Sunday off, Monday-Tuesday 30 hour overnight call shift (7am Monday to 1 pm Tuesday),  Wednesday-Saturday 12.5 hour days

AND…

2.  The dysfunctional incentives that created an abusive system also created a substandard environment for training.   That means that the long work hours are a symptom, not a cause.  The “solution” therefore missed the mark.

If what we are trying to do is train the workforce to care for our ailing bodies as we age, why have we allowed such a system to continue?   We should would want my surgeon trained like a fighter pilot at Top Gun, not like a cafeteria busboy hustling to turn over tables at a busy restaurant.  That means that from day one, their entire schedule should be optimized around becoming great doctors. 

This does not mean picking up the slack at academic centers by filling out forms which otherwise would be relegated to office staff.  This also does not involve sleep deprivation, nutritional compromise, and isolation from social support mechanisms.

In general, resident education is left to whatever studying they can accomplish in their “free time” in combination with chance.  By chance I mean that the resident hopes that they will manage a broad range of diseases. 

When I am old and in need of frequent care, I want the fighter pilot, not the busboy, to give it to me.

CMS Should Not Expand their Never-Event List

The CMS should not continue to expand their never-pay list lest they be accused of practicing Medicine.
It makes sense to say that if somebody has the wrong leg amputated, they should not get paid.  That is a big “oops” that every member of the healthcare team should prevent.   But once the CMS crosses over to problems that are questionably preventable, they risk causing more harm than good.

For example: a patient developing a blood clot after surgery.  The cause of this is complex and not fully understood.  In fact, the entire conceptual framework behind how blood clots form in the human body is currently undergoing a massive shift.   Science may just show that the combination of a big surgery plus somebody’s genetic predisposition may reliably lead to the formation of blood clots. 

Why does this matter?  Blood clots are still bad.  The answer is that this type of incentive creates a terrible moral hazard.

If you are not going to get paid for something you have no control over, are you going to admit it is even there?

Here is what CMS announced on July 31st:

In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments.  In this year’s proposed rule, CMS identified nine potential categories of conditions, but based on public comments, is finalizing three of these.  The new additional conditions in this year’s final rule include:

·         Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity

·         Certain manifestations of poor control of blood sugar levels

·         Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Good job, CMS, on putting your foot down on the craziness of wrong-site surgeries or giving the wrong blood to a patient. 

But do not make the mistake of thinking you save the world through such mechanisms.   In fact, the worse thing that can happen is that we don’t diagnose blood clots, infections, or abnormal glucose levels.  Ignoring these conditions has definitely been shown to lead to bad outcomes.

Health as a Metric. The Prerequisite for Reform

All of the debates on whether real health care reform can be achieved have me puzzled.  I come back to a simple question.  What do we mean?

Are we talking quality, affordability, or access to care?  I guess that is why the reform movement (if there is one single movement) seems disorganized.  While one reformer may optimize around one of these issues (universal coverage), others may focus on other issues (affordability).

If you were to ask a child why health care is important, and I have, the answer would be simple—to make us better.  If making us better is the goal, then we should have a metric for this.  But we don’t.  It is easy to measure coverage and cost, but “health” is an elusive concept when it comes to measurement.  For example, if a person presents to a hospital with a heart attack, even if they survive and eventually go home, we would be hard pressed to define their optimal level of “health.”  Perhaps in this person’s case, some would argue that it would be prevention of a second heart attack.

Let us go back to the child and ask her how do we know we are healthy.  This child would answer, “Because we feel good.”  Again, clarity and brilliance.  Translate this to the absence of disability or pain and the presence of fitness. 

As this gets into the realm of “touchy-feely,” the participants in the health care debates steer clear of it.   But in the end, this is what patients want out of the healthcare system.   This is what I want.  Don’t you?

So why should this matter for the health care reform debate?  Because Americans have proven they want good health care at any cost.  They have demonstrated this by spending more than any other country in the world on health care.   They are ambivalent about how it is done (socialized vs. private, etc…), as long as they have access to health (note I said “health” rather than “health care.”)

We need to find a way to apply a set of metrics to health.  It needs to be relatively easy to administer, comprehensive, and consistent with people feeling as if they are in good health.  When there are metrics, we can point at legislatures, physicians, and industry and say, “we don’t care how you do it, just get this done.”   I believe they would.  And I believe that the problems we discuss today—affordability, access, cost—would be much easier to solve.   

The Distribution of Public Health Care Spending and the McCain Plan

Two interesting articles on the public financing of health care were published yesterday. One was an article in the Journal of Health Affairs, and the other was an op-ed piece in the Wall Street Journal.

What is interesting about the Health Affairs article is that the authors investigated the distribution of public health care financing within the population. Some of their findings are listed below:

Public spending on behalf of the civilian, noninstitutionalized population was a total of $752.9 billion in 2002 dollars, or 56.1 percent of total spending from all sources.

28% of this spending ($214.8 billion) took the form of tax preferences (i.e. tax subsidies to private insurance and the exemption of most medical care spending from sales taxes.)

Public dollars flowed disproportionately to seniors, whose benefits were more than five times those of children.

Public spending also disproportionately benefited people with health problems, paying nearly 80 percent of the total cost of those in poor general or mental health

Even among families with incomes greater than four times the poverty level, public spending accounted for 45.8 percent of total spending.

Public spending accounted for 45.5-55.5% (depending on the calculation) of total spending among the uninsured—nearly the same share as in the overall.

This research sheds light on some very important points. It is not surprising that seniors receive a large proportion of their healthcare financing from government sources. What is new information is that that the public sector finances nearly half of all health care spending for families with incomes over four times the poverty line. These "high-income families" received an average of $1,177 per person in tax subsidies compared to $102 per person for those below poverty. This is likely because many is this bracket receive employer-sponsored insurance, which has no cap.

Also published yesterday was an op-ed piece in the Wall Street Journal written by John Goodman, who is the president of the National Center for Policy Analysis and an unpaid adviser to the McCain campaign. He writes that McCain’s health care plan would to be the most impactful in terms of generating meaningful reform.

Under the McCain plan, employers could no longer buy insurance with pretax dollars. These payments would be taxable to the employee, just like wages. However, every individual would get a $2,500 credit (and every family would get $5,000) to be applied dollar-for-dollar against taxes owed.

Goodman argues that this would have multiple effects, some of which are listed below:

It would not result in increased taxes

Is more egalitarian as all health insurance would be sold on a “level playing field.”

Low- and moderate-income families would get just as much tax relief as the very rich when they purchase health insurance.

People who must purchase their own insurance would get just as much tax relief as those who obtain it through an employer.

In contrast to the Obama plan, it would give the most new tax relief to the middle class.

It would also encourage all Americans to control costs by providing coverage for catastrophic care and not the “bells and whistles.”

It is interesting to consider how these changes will impact the distribution of public health spending outlined in the Journal of Health Affairs. It would likely decrease the total amount of public health care dollars spent by decreasing total tax subsidies. It also would change the distribution of public health spending to middle- and lower-income families.

When the Faith is Gone

Everyone is agreement that the healthcare system is in shambles.  Interestingly, despite lack of satisfaction with the hospital and clinic visit experiences, most people in the U.S. still trust that physicians are doing what is right for them and their families.  That trust is important for many reasons.   One reason that trust is important is that it may be the only thing propping up our current system.  And if that were to go, well, the health care system would likely implode.

But it looks like that might be happening. 

Measles was declared eradicated in 2000 after what was touted as a successful vaccination program.  Vaccinations are advocated for all children, and this stance is endorsed by the Academy of Pediatrics.  However, over the last several years, there has been a rise in the incidence of autism.  Some believe that mercury in the vaccinations led to the development of autism in their children.  As a consequence, there has been reluctance by some parents to have their children vaccinated against measles. 

During this time, there has also been an increase in the incidence of measles. In May 2008, the CDC issued a report on Measles.  They reported that during 2000--2007, 29 to116 measles cases (mean: 62, median: 56) were reported annually. However, during January 1--April 25, 2008, a total of 64 confirmed measles cases were preliminarily reported to CDC, the most reported by this date for any year since 2001.  Sixty -three were not vaccinated.  Clearly, there is a growing concern that the medical profession is causing harm rather than good.

Public concern has continued to deepen.  Last Friday, CBC reported that the vaccine industry gives millions to the Academy of Pediatrics for conferences, grants, medical education classes and even helped build their headquarters.

I do not raise this issue to discuss the merits of the accusations made by CBC.  Instead, I bring it up as an example of failing trust in the medical profession. 

Whether or not this is true, I believe this to be symbolic and a first sign of a significant crack in the trust that has been provided to health care professionals. There are a significant number of parents who are saying that physicians are not always good and, hey, may not even be ethical.   

Many people may see this as a singular example that is not relevant.  I disagree.  Until recently, all of those interested in reforming healthcare have granted physicians a certain respect.  In fact, there are many who believe that physicians are impediments to significant healthcare change, but that they must be accommodated because they are ultimately to be trusted.  When that confidence is shaken, that latitude will likely no longer be granted. 

Regulating Our Intake

In response to the mounting evidence demonstrating the negative health effects of trans-fats, Governor Arnold Schwarzenegger signed a bill banning the use of trans-fats in California over the next few years. 

While nobody will argue that trans-fats are bad and that the elimination of them from our diets would not be missed, I do not think we should raise a toast and commend it as a worthy step towards a healthy America.  Do not get me wrong.  I agree that large amounts of trans-fats have no place as a food group in our diet.  I am not even opposed to banning them.  I am just worried that the excitement and promises of improved health detracts from the real reason why Americans are obese and unhealthy:  we eat a lot (emphasize a lot) of bad stuff and do not exercise.

The addition of trans-fats to our diets occurred in part as a response to America’s eating habits.  The AHA website has a FAQ page about trans-fats.  On that site, they state that trans-fats can be found in many foods,

...but especially in fried foods like French fries and doughnuts, and baked goods including pastries, piza dough, cookies, crackers, and stick margarines and shortenings.

What strikes me is that these “foods” are not the basis for a healthy, diverse diet.  This list is a poster child for bad foods.

America’s appetite for unhealthy foods drove the need for food industry to make those foods available and cheap.   In fact, there may be other evils lurking out there that we have not even identified.  Margarine was touted as healthier than butter for decades—trans-fats did not get attention until the 1990’s.  What else on the ingredient list of our favorite packaged snacks is the next killer? 

National Health Care Priorities and Progress

As electronic medical records receive growing amounts of attention, so do its byproducts.  On byproduct of electronic data is Bioinformatics.  Bioinformatics, or just Informatics, are evolving terms.  In general these terms refer to the leveraging of computer technologies to improve delivery and analysis of health care data.

From the provider and vendor side, one area of interest in informatics has been the development of computer-based decision support systems.  As we discuss quality and improvements in health care, exploration of new applications such as these are absolutely critical to achieving the goal of better quality health care.

However, there is a potential difficulty as we attempt to grow and improve.  That difficulty is potentially-cumbersome government regulation. 

While at the American Medical Informatics Association Summit on Translational Bioinformatics in March of this year, I listened to an interesting panel discussion.  The panel was designed to discuss regulatory issues associated with clinical support tools.  I learned that the FDA is watching the development of this area closely.  Currently, they consider computer-based decision support systems to be “medical devices” which means that computer programs such as these fall under their watch.  Therefore, before use in the clinical realm, FDA approval is required.  This means that nobody in his or her right mind who knows this will want to go through an FDA-approval process.  Therefore this area will not develop.  Luckily, not many people are aware of this regulation.

I was reminded of this fact after seeing another complication of government regulation on a post on the Commonwealth Fund website. 

Vida Foubister wrote an article summarizing the drama surrounding the initial shut-down (and later re-opening) of a Michigan quality improvement project. The Michigan project was an amazing initiative that won widespread praise in the Medical community.  With their initiative, they were able to reduce the number of life-threatening catheter-related bloodstream infections in over 100 intensive care units. Most ICUs are now trying to mimic their process to improve their outcomes.  Sounds like progress.   Until they were shut down.

Without going into the regulatory details, the debacle centered on whether the project was a quality improvement project exempt from many federally-established regulations, or whether it was a research project that required more oversight. Vida summarized the consequence of the confusion and temporary shutdown:

While OHRP concluded in a February determination letter that the Michigan hospitals could continue implementing the checklist "without falling under regulations governing human subjects research," the implications of its initial action have been far reaching. "There's been an awful lot of quality improvement that has been stalled or put on hold, trying to understand this IRB issue," says Pronovost. "The chill sent through the quality improvement field has been very, very real."

With the national debates centering on improving electronic data and improving quality of care, why is it that our regulatory agencies are not aligned along the same goals?

Now, this is not meant to be a slam on the FDA.  I strongly believe there must be oversight of the medical field in order to protect the population. 

Instead, I believe that we need to seriously consider where we want Medicine as a field to go.  This means that we need national priorities that are not just articulated, but applied to the regulatory agencies that could potentially resist that growth.

It is easy to globally talk about “coverage for all” and “improving quality,” but without looking at some gritty details and addressing barriers to change, this will remain just talk.

Obama and McCain on Health Care: More of the same

Today Kevin Sack of the New York Times discussed Obama’s health care plan.  The Blogosphere responded with renewed disgust towards the politicians’ suggestions.  My thought about the article is this:  we still do not have politicians talking intelligently about health care.   Health care is just a box that needs to be checked on the politicians’ To-Do lists.  Where is the real dedication to solve a real problem?

My strong belief is that health care will remain a mess while we leave it to the whims of a politician’s sound bite. 

It is clear that the politicians’ focus is on votes, not on solutions.  Obama focuses on the popular sentiment of universal coverage for cheap.  McCain reassures conservatives that he will preserve the sentiment of individual responsibility.  The need for election dampens every candidate’s desire to make tough calls.  And why should they make those tough calls?  Their political competition is not challenging them to do so.  In fact, the first one to be honest will be shot on site.

I do not think America will ever have the “political will” to enact meaningful change.   Political Will means that you will make some segment of the population unhappy.  Rather than do this, politicians will get better at devising strategies to pass along the problem to the next generation while hoping someone else figures it out. 

The gauntlet has been thrown down:  Fix healthcare. Cost containment, quality, and coverage are the lynchpins.   The fix must be set in the context of a heterogeneous American culture that does not demonstrate the European sensibility of “solidarity.”

Our efforts should not be wasted only on dissecting Obama’s savings calculations.  Being able to intelligently criticize others is important but should not represent the only exercise we do.   It alone does not advance the cause.  I would love for those who think about these issues (in academia, the Blogosphere, patient advocacy groups, etc.) to propose a solution.  Put up a straw man or two and modify it.   Why not start a site where a real solution is fashioned?

What to do with those bad Health Scorecards?

As many people reading this site already know, The Commonwealth Fund has released their National Scorecard U.S. Health System Performance for 2008 . The summary of their report is:

Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks. Overall, performance did not improve from 2006 to 2008. Access to health care significantly declined, while health system efficiency remained low.

The methodology may not be perfect (see Maggie Mahar’s HealthBeat Blog), however, this report is still one of many describing the unacceptable level of quality associated with our healthcare system.

I do not quibble with the methodology of any of these studies. We are attempting to measure data that were not pre-ordained to be tracked as quality measures. However, I do (in general) advise caution when trying to suggest improvements based on results from studies such as these.

When reform is based on hitting specific metrics, the metrics then define the mission statement.

For example, the metrics for “Effective Care” in the Commonwealth Fund’s Scorecard include “Chronic Diseases under control,” which is defined as lower blood sugar levels and at least borderline normal blood pressure. These are important measures of disease control, to be sure. However, I am not convinced there is good evidence to say that patients with diabetes and hypertension live happier, healthier lives if this is the only metric that is met.

It’s not difficult to imagine that if we optimized our system around easily available (rather than thoughtful) metrics, we may find that hitting these metrics does not increase the quality of life.

Several medications for hypertension result have complications such as fatigue and impotence. Would we also track the resultant depression associated with loss of ability associated with over-medication? Tighter control of blood sugar by higher doses of diabetic medications may lead to increased hypoglycemic events. Would we track ER visits, ambulance calls, and the attendant anxiety of finding a loved one unconscious in the living room?

I believe that if we are to go forward, we need to develop thoughtful and global measures. Then we need to measure them. Then we may see the type of change we seek.

As this is an interest of mine, I will be writing more on this in future postings.