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The Not-So-New Problem Of Drug Shortages

Crucial drugs are running in short supply and patients are dying as a result.

Much of the problem stem from manufacturing problems that interrupt production. There may be only one or two companies making a drug, and when something happens such as contamination, it creates huge gaps. As a result, there’s been 213 drug shortages so far this year, or two more than all of the previous year.

The shortages have forced hospitals to resort to gray market purchases. These involved third parties that may corner the market on some drugs, and resell them at exorbitant mark-ups. The practice then fuels further shortages.

And this “new” crisis has been occurring for a decade. ACP Internist ran an article 10 years ago that could run in its pages today. Read more »

*This blog post was originally published at ACP Internist*

Are Tele-ICUs The Solution To The Critical Care Crisis?

America’s ICUs are in crisis. Consider these staggering statistics: Today’s ICUs Serve 4 million patients annually, with roughly 20 percent mortality rates among those treated. On average, every patient admitted to the ICU suffers 1.7 potentially life threatening errors every day and estimates show that patients only receive half of the therapies that they should. And 50,000 patients annually die in the ICU from preventable deaths.

But research indicates that ICU patients have lower risks of death and shorter ICU and hospital stays when an intensivist is on duty in the ICU and oversees patient care. The mortality reduction has ranged from 15 to 60 percent lower than in ICUs where there are no intensivists. However, the Committee for Manpower for Pulmonary and Critical Care Services predicts a shortage of 10,000 ICU physicians, called intensivists, who have extra training to specialize in the care of the ICU patient. This   national shortage of intensivists makes it extremely difficult to find intensivists that can provide 24/7 care for today’s ICU patients.

The answer to solving this crisis has emerged from the world of telemedicine. Read more »

*This blog post was originally published at Medgadget*

Is This A Healthcare Crisis Or A Culture Problem?

I got an email today laying out the reality of our current health care debate.  Is it a crisis of culture or a health care crisis.  I am a firm believer in taking responsibility for one’s actions.  I believe those who chose not to practice healthy lifestyles should pay more for the consequences of their actions than those who do.  I believe the solution to our health care finance quandary lies not in controlling the  cost of treating disease, but rather in upholding the personal responsibility all Americans have to themselves and their country.

What does the distribution of health care dollars look like among the American population?  While we know that 50% of our population spends only 3% of health care dollars, we also  know that 50% of our health care dollars are spent by 5% of our population, a population of chronic disease sufferers who’s diseases  are, by and large,  a direct result of the personal decisions they chose to make on a daily basis.  For the most part, genetics alone is no longer an excuse.  We knew very well that lifestyle directly affects the expression of disease by genes. Read more »

*This blog post was originally published at The Happy Hospitalist Blog*

KevinMD Addresses Crowd At National Press Club About Primary Care Crisis

The following are my prepared remarks at Health Care Reform: Putting Patients First, held at the National Press Club in Washington, DC, on July 17th, 2009.

President Obama recently declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.” And indeed, finding a way to provide universal health coverage to every American is one of the focal points in today’s health care debate. There are a variety of ways we can achieve this, ranging from a Medicare for all, single payer system to requiring everyone to purchase health insurance. But no solution can work unless we first deal with the shortage of primary care doctors.

After all, what good is having health insurance if you can’t find a doctor to see you?

As a primary care physician in Nashua, New Hampshire, a city that borders the state of Massachusetts, I have had the luxury of closely observing that state’s health reform efforts. And to their credit, Massachusetts currently enjoys near-universal health coverage, in part because of the mandate requiring every resident to obtain health insurance. Many policy experts are predicting that a national plan will closely emulate the Massachusetts model, so it’s worth noting any potential consequences.

Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits. In fact, since the universal coverage law was passed, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that treating simple conditions in the ER can be exponentially more expensive than an office visit. It’s no wonder that the plan has placed significant fiscal strain on the state’s budget, which is struggling to contain soaring health spending.

This affects hospitals like Boston Medical Center, which primarily serves the city’s poor. The state’s mandatory health insurance law is causing the medical center, according to a front page story in last Sunday’s Boston Globe, to brace “for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families.”

Furthermore, consider the words of family physician Kate Atkinson, who practices in Amherst, Massachusetts. She had decided to temporarily accept new patients, as 18 doctors in her area had recently closed their practices or moved away.

“There were so many people waiting to get in, it was like opening the floodgates,” she says. “Most of these patients hadn’t seen the doctor in a long time so they had a lot of complicated problems. We literally have 10 calls a day from patients crying and begging.”

She closed her practice to new patients 6 weeks later.

I witness this phenomenon myself every day, with patients from Massachusetts routinely crossing the border to New Hampshire looking for a new primary care doctor.  These are people with chronic conditions like heart disease, diabetes, depression, and high blood pressure – all who need a regular physician to follow them.

And keep in mind that Massachusetts has the highest density of doctors per capita in the country. What do you think will happen to states that do not have a comparable supply of physicians?

Moving away from Massachusetts, let’s look at two other examples where universal coverage was promised before ensuring adequate primary care access. One would be our military veterans, who are guaranteed health care through the Department of Veterans Affairs, also known as the VA. Earlier this decade, the wait to see a primary care doctor in the VA routinely exceeded 50 days in various parts of the country. Although that number has improved, a recent report by the Office of the Inspector General concluded that more than a third of veterans still waited a month or more to see a doctor. And with tens of thousands returning home from Iraq and Afghanistan straining an already overburdened VA health system, it’s no wonder that my practice in Nashua, New Hampshire sees a fair amount of veterans who are unable to obtain timely care from their local VA clinic up north in Manchester, or from down in Boston.

Next, consider the care Native Americans receive via the Indian Health Service. Despite having guaranteed health care coverage, President Obama himself cites Indian reservations in South Dakota that have some of the lowest life expectancies in the Western Hemisphere. American Indians are twice as likely to die from diabetes when compared to whites, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease. Although each of these conditions can be treated or prevented with timely primary care, according to a 2005 Government Accountability Office report, patient waits within the Indian Health Service for routine women’s care and general physicals lasted anywhere between two and six months.

It is encouraging that the President and members of Congress recognize the threat that the primary care shortage poses to their health reform efforts. But some of the solutions being discussed, such as reducing medical school debt, increasing funding to the National Health Service Corps, and training more mid-level providers like nurse practitioners and physician assistants, fall woefully short. None will have any immediate impact, which will be especially critical if there’s a distinct possibility that already overwhelmed primary care doctors will be responsible for almost 50 million additional, newly insured, patients overnight.

Instead, we need to value primary care, and make it central to our health system. Rather than being encouraged to squeeze in appointments and rush through office visits, doctors need to be incentivized to practice patient-focused primary care, including, managing chronic diseases, providing preventive medicine guidance, and taking the time to counsel patients.

There’s no question that we need to find a way to provide health coverage for every American. But we must do so in a responsible manner, and that starts with ensuring that we have a strong primary care system first.

*This blog post was originally published at*

Rushing Healthcare Legislation Through Without Consensus

I belong to a terrific organization that brings together C-level executives, once a month, to discuss issues each of us face.  It’s called Vistage.  One of the subjects we talked about yesterday was health care.  It was like a focus group made up of seasoned, senior executives from many different industries.

The discussion revealed the tremendous divide between what ordinary Americans think about health care and what policy makers in Washington are doing.  It’s a combination that is almost certain to ensure that whatever reform passes may make our problems worse, rather than better.

At the meeting were about 30 executives, representing everything from financial services, commercial real estate, manufacturing, high technology, pharmaceuticals, insurance, retail, non-profits, travel and others.  Although all thought health care costs were in a state of crisis in America, I did not hear anyone say this was the case in their business.  To be sure, some complained that health costs were high, and that there were few alternatives available.  But others described changes they had made to their plan designs that had actually reduced their corporate health expenses.

We talked about the proper role of government, the comparative worth of systems in other countries, the responsibility of people to take care of their own health, end-of-life care, over-treatment, the uninsured, access to care, comparative effectiveness, and our own expectations of what the system should do for all of us.  There was no consensus among this group of 30 business leaders as to these subjects and what we should do about them, other than that they are important topics that we need to address.  I suspect this is true outside of this group, too.  Indeed, the huge collection of issues that fall under the category of health care reform is something I’ve pointed out before.

But the President and leaders in Congress want debate on health care to end.  They want a a bill to pass in the next couple of weeks.

Most of the group members were surprised to hear that Congress had already drafted legislation and was getting ready to vote on it.

It’s a remarkable thing.  We are in the midst of trying to redesign the largest health care system in the world, and we’re barely debating the merits of it.  How many members of Congress will have read the 1,1018-page bill once they vote on it?  How many Americans will understand what implications it has for their health care if it — or something like it — becomes law?

The President often says that the status quo in health care is “not an option.”  The trouble is, the status quo in health care is a rapidly changing thing.  Today, every day, employers and doctors and so many others are busy making real, meaningful changes to our health care system.  Not by waiting for committees of Congress to pass legislation, but by getting together and doing things that improve the quality and cost of care and the lives of patients.  We need to be listening to their stories, and learning from them.  Congress hasn’t done this, and can’t now.

There is an opportunity to build a real consensus around the important issues we talked about yesterday.  We can transform our health care system in ways that make all of us proud.  But it can only happen by working through these hard questions, not by hurrying to pass a bill before the August recess.  Those who say we have a once in a generation chance to reform health care today may be right, but not for the reasons they think.  By passing bills without consensus on this deeply important and emotional issue, they are ensuring that no one will really want to try to reform health care again for a very long time.

Which leaves us very much where we started.  I will continue to do my part to share the important stories of how real people are making real reform.  The political attention to reform may end sometime this year, but the reality of people trying to figure out what to do when sick will continue.

*This blog post was originally published at See First Blog*

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…

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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…

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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…

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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…

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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…

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