Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

How To Fix Healthcare

Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject.  While my post was just a gripe about the problem, the comments were mainly focused on solutions.  How do you fix the problem?  I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.

You have to realize that I’m basically chicken (as are most doctors).  I like to point the finger and avoid the fingers of others.  It’s much easier to gripe than to fix things.  It’s much easier to criticize than it is to say things that can be criticized.  But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured.  Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.

So here are my suggestions:

1.  The government has to take on tasks that are in the best interest of the public.

Preventive healthcare should be paid for.  This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.

There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears).  Simply building a relationship between people and primary care physicians also has benefits by itself.

The overall goal is to improve the overall health of the American public.  Promote behavior that deals with problems when they are still small or before they happen at all.  Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.

2.  Promote proper utilization

One of the main costs to any system, public or private, is overutilization of services.  Any solution that does not somehow look at utilization will automatically fail.  More care costs more.

Here are areas of increased utilization:

  • Emergency room visits for non-emergencies.
  • Visits to specialty physicians for primary care problems.
  • Unnecessary tests ordered – more likely in a setting where the patient is not known.
  • Patient perception that “more care is better.”
  • Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital.  This causes duplication of tests.

Solutions to these problems include:

  • Better access to primary care or other less costly care centers
  • Increase the ratio of primary care to specialists
  • Care management for high utilizing patients
  • Public education (not through the press but through better public health).
  • Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
  • Make the malpractice environment less frightening to doctors.  A large amount of questionable care is given to protect physicians from lawsuits.  (A good example is PSA Testing.  Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).

How does this help the problem of the uninsured?  It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.

3.  Fix problems with Pharma

Medication costs are a huge problem to my uninsured and insured populations.  There are many reasons for this, but some of them are simply due to a bad system.  For example:

  • Medication discount programs cannot include Medicare patients.  Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
  • High cost of generic drugs.  When a drug goes generic, there is usually only a slight drip in the price.  The system allows only limited competition for price, so the cash price remains high.  Encourage cost competition.
  • Drug Rebates.  This raises the overall cost of drugs to everyone.  Rebates are sent to insurance companies by drug companies for inclusion on the formulary.  It pretty much looks like extortion.  The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate.  These need to be eliminated.
  • Get rid of direct to consumer marketing of drugs.  This is pure capitalism that encourages over-utilization.

All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.

4.  Address Conflicts of Interest

Insurance companies are largely publicly-traded companies.  This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue.  Having them the ones managing care is like putting the kid in charge of the cookie jar.  Insurance companies should get back to the business of insuring.  Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).

Insurance companies promote themselves as healthcare companies.  They don’t provide care, and they shouldn’t.  Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.

How does this help the uninsured?  It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance.  It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place.  If insurance costs less, there are less uninsured.

5.  Focus on the “uninsurable”

5% of Americans account for over 50% of the overall cost of care (reference).  These are the uninsurable people – those who are truley expensive to treat.  There needs to be very close management of these people.  Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government.  It also leaves them unmanaged.  Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition).  These people need management, either in a “medical home” or by some sort of care management.

There you have it.  Follow these rules and everything will be fine.

Yeah, right.  Alright everyone, have at it!  Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.

*This blog post was originally published at Musings of a Distractible Mind.*

Important reminders for parents of newborns

A big part of pediatrics is what we call “anticipatory guidance” and preventive medicine.  This is where we get to impart our wisdom on parents, particularly the vulnerable, first-time ones.  For them, everything is new, exciting and, yes, anxiety provoking.  We hope that we can teach and guide them to raise medically and psychologically healthy children.  One of the first and most important things we can do is stress the importance of immunizing children on time.  I know – I have talked about this ad nauseum!!  But that is because when newborns, children and, yes, adults, are not adequately immunized, they are at risk of developing serious illnesses.  As you may recall, I blogged a couple of months ago about the haemophilus influenzae outbreak in Minnesota, where several children became ill and one died.  Well, guess what?  Now there are cases of measles in my hometown, Rockville.  It appears that an unimmunized adult contracted it and has infected several others, including an 8 month old child who is too young to have received the routine immunization.
But, believe it or not, I am not blogging about immunizations today.  It appears that this is just an example of what happens years after a successful plan has been implemented.  Because we don’t see many of these infections anymore, we aren’t routinely reminded of the importance of preventing them.   We seem to have forgotten that the reason we don’t see many of these deadly infections is precisely because children have been vaccinated.  So … the vaccination rate drops, and as the vaccine rate drops, the risk of contracting one of these illnesses rises.  I can guarantee that if we had an epidemic of measles here, with kids dying, parents would be lining up to ensure their kids were adequately immunized.
Well … it’s the same with ALWAYS putting your infant to bed on the back.  Multiple studies have demonstrated a significant increase in the risk of sudden infant death syndrome (SIDS) with placing your infant stomach-side down to sleep.  My recollection from when this recommendation first came out is that almost all parents put their infants on their backs to sleep.  Now, however, more and more parents are telling me that they are putting their infants on their stomachs to sleep because they sleep better.  Or, they are watched by a grandparent during the day, who puts them to sleep on their stomachs.  Well … it is even worse to put an infant on its stomach sometimes rather than always (not that I am EVER recommending stomach sleeping).
A study published in this month’s journal, Pediatrics, evaluated 333 infants in Germany over a 3 year period.  As noted in previous studies, those who were placed prone to sleep were at greater risk of dying from SIDS, particularly those who were not used to sleeping prone.  Other factors which increased the risk of SIDS were covers, sleeping at a friend or relative’s house, and sleeping in a living room.  The only factor which decreased the risk of SIDS was the use of a pacifier at night.   With such compelling evidence which supports many other studies on SIDS risk factors, there is no reason to place our infants on their stomachs to sleep – ever.    This includes when they are with any caretaker, including grandparents, nannies, and other relatives.
So let’s not become complacent about treatments that work.  Continue to immunize.  Continue to place infants on their backs to sleep.

Youngest Patient Fitted With Carbon Fiber Leg Prostheses

GAZ_ELLIE_1_E16_SUBMITTED_v01.jpg.display.jpgA five year old British girl who had her outer limbs amputated due to meningitis (meningococcemia with meningitis accompanied by gangrene of the extremities would be our guess) has received a new pair of legs.

The high tech carbon fiber pair is of the variety commonly seen on competitive Special Olympics athletes, some of whom run faster than old fashion legged people. Ellie’s parents say that she already walks twice as fast as her previous conventional prosthetic pair.

We believe that medical devices will greatly improve Ellie’s life in the future, and hopefully she can one day receive a proper pair of Deka arms.

More from Echo UK…

(hat tip: Gizmodo)

*This post was originally published at Medgadget.com*

House Calls Are a Necessary Component of Healthcare for Our Aged Population

By: Valerie Tinley, MSN, RNFA,  FNP-BC

House calls have long been associated with primary care providers (PCPs), the proverbial “black bag,” and days gone by. Unfortunately, house calls are often just a memory or something we watch in reruns on the television.

Those people that best remember the prevalence of house calls, the elderly, may be the same population whose needs will bring house calls back from the brink of extinction and return them to the mix of services offered by PCPs.

House calls should be a core offering of PCPs, since by nature we help patients from cradle to grave. Therefore, some of these patients may not be able to come to see us because they are too old or too sick or immobile.

Why then can’t PCPs go to these patients? We certainly can solve the majority of primary care problems where our patients want or need to be seen, including in their homes, whether these problems are run of the mill day-to-day issues; or those associated with chronic, continuous care diseases; or even many urgent care issues.

Unfortunately house calls are rarely offered because many PCPs view them as too time consuming and therefore too costly to conduct.

The need for house calls for these populations will not go away.   The populations that house calls can help include:
•    those that are bed bound, very old, who want to age at home rather than a nursing home;
•    those suffering from dementia;
•    those recently discharged from the hospital, and unable to be mobile short term or long term; and
•    those that are receiving hospice care.

Many of these people cannot leave their home, or more importantly, should not leave the home, to go to the doctor’s office for an office visit.  It is important to understand how very expensive this is for the caregiver, in terms of time, lost hours on the job, effort and transportation costs, all to actually get them to the medical provider’s office, because their loved ones have problems with mobility or other hindrances.

The result? There are many in need of medical care that cannot receive it. This increases medical problems and mortality. When healthcare is ignored or foregone for the most routine of problems, more expensive and much more serious healthcare issues arise in its place.

A recent article in the New York Times reported that keeping geriatric patients out of the hospital and getting them the care the need at home can result in a cost savings of between 30% and 60%. In addition, a house call program, piloted by Duke University, has reduced the number of hospital admissions for those patients unable to get to the doctors office by 68% and the number of emergency room admissions by 41%.  These patients are thereby healthier, and even safer, working with a PCP that makes house calls.

Several organizations currently offer house calls as a core part of their services offerings, like Urban Medical in Boston, or the practice I am with, doctokr Family Medicine. Also there are beginnings of pilot programs for house calls, like the one at Duke’s Medical School which was mentioned earlier.

But these are only a few providers, and the movement needs to be widespread. Our aged population needs it and we as primary care providers should be listening to their needs and providing for these needs. Otherwise, we are falling short.

Until next week, I remain yours in primary care,

Valerie Tinley MSN, RNFA,  FNP-BC

Skin Checks Are Critical To Your Health

Several years ago, I was telling a patient about the importance of doing routine screening for skin cancer – by far the most common type of cancer in the U.S., affecting over a million people a year. She volunteered that she was covered, that she was seeing a dermatologist routinely for Botox injections. “Does he do a complete head-to-toe exam?” I asked. Her pause and sheepish expression told me all I needed to know. She wasn’t at all covered – because she was never uncovered.

Fortunately, the majority of skin cancers found each year are basal cell or squamous cell – the types that have a very high chance of being cured. The National Cancer Institute estimated that fewer than 1,000 people died from these “non-melanoma” cancers in 2008. Melanoma is another story, affecting over 62,000 Americans a year and causing over 8,400 deaths. The majority of melanomas occur in older patients but almost 1 percent are diagnosed under age 20 and almost 8 percent are found between ages 20 and 34. So you’re never too young to start thinking about ways to prevent skin cancer and ways to keep track of what’s happening with your skin.

Since I was in medical school in the mid-’70s, the number of yearly cases in the U.S. has more than doubled. Early detection is likely one reason for the increase but nobody is exactly sure what has been causing the dramatic rise. What is clear, however, is that early detection is the name of the game when it comes to curing melanoma. The earlier a lesion is found, the better the chance of cure – which brings us to the main point of this blog. Everybody should be getting routine head-to-toe skin exams. This means looking from head to toe at every millimeter of your body, including where the sun doesn’t shine. Skin cancers can occur in any location of the body, including the armpits, scalp, between the toes, in the groin or anogenital area – anywhere! Routine self-exam should be part of your screening regimen. If a partner is available who can examine hard to see areas such as the small of the back – all the better.

In addition, I feel that routine screening should include a well-trained health professional who is interested in performing a careful skin exam. This is where it can get tricky. We live in a time when sub-specialists abound – even among dermatologists. A patient may see a cosmetic dermatologist several times a year for Botox injections. The dermatologist may glance at areas of exposed skin but the patient should not feel that a full screening skin exam is being routinely performed. The patient I described at the top of this blog had magical thinking – somehow reasoning that she’d received skin cancer screening just because she’d seen a dermatologist, even though she hadn’t taken her clothes off! Trust me: no doctor is good enough to detect skin cancer without examining the skin.

When the CBS Doc Dot Com team was brainstorming for segment ideas recently, producer Jessica Goldman came up with the idea of following her through a complete evaluation with a dermatologist. That brings us to today’s episode with New York City dermatologist Dr. Francesca Fusco, who covers a wide range of skin issues, from cancer prevention to cosmetic dermatology.


Watch CBS Videos Online

*This blog post was originally published at cbsdoc.com*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles