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America’s New Export: Hospitals And Medical Schools
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I often cringe when I see charts displaying parallel growth lines of these two variables: the number of American fast food restaurants in a given country and local obesity rates. The bad news is that our unhealthy eating habits have been exported successfully to foreign countries. The good news is that we’re going to export hospitals and health services next.
I spoke with Emme Deland, Senior Vice President of Strategy at New York Presbyterian Hospital, about the globalization of healthcare and the exportation of American health technology and expertise. You may read my summary of our discussion, or listen to the podcast here:
[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2008/12/deland.mp3]
Dr. Val: Where does New York Presbyterian Hospital stand in terms of the global marketplace for medical tourism?
Deland: We’ve spent the last couple of years reviewing our strategy regarding medical tourism because we want to be a part of the global healthcare economy. There is a growing market for hospital development overseas, particularly in India, the Middle East, Eastern Europe, and China. The US offers the most advanced medical care in the world, and it’s only natural that other countries want to begin importing it. Whether it’s minimally invasive surgery, infertility techniques, or prenatal diagnostics and care – America is among the global leaders in health technology and services.
Dr. Val: What do these countries want to import exactly? Providers, infrastructure, physical plants, data systems, consultants who can advise on ways of doing things to reduce errors and improve quality?
Primary Care Docs Ask Permission To Be Next In Line: We Need A Bailout
By Alan Dappen, MD
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Alan Dappen, MD |
Believe it or not, this headline paraphrases the recent lead article from the American Medical News, covering a comprehensive, white paper published by the American College of Physicians (ACP). The article reviews the state of primary care physicians. The conclusion: since primary care doctors are essential to control the spiraling costs of health care, a bailout is necessary to shore up their rapidly shrinking ranks.
To understand why they argue a bailout is needed, we must look at what caused the crisis. Primary care doctors are drowning in red tape, as my partner Steve Simmons mentioned last week. Over the past 20 years have come bureaucracies and regulations with acronyms like OSHA, CLIA, HIPPA, CPT, ICD-9, P4P. Drops led to trickles: more complex certification and increasing malpractice risk. Then trickles formed streams of data that is required of practitioners: quality reporting, management reports, productivity measures, electronic medical record systems, billing reports. Finally, the flood of information needed to stay in compliance with Medicare, Medicaid and insurance regulations swamps primary care providers.
The creative and intellectual focus of primary care physicians has been diverted to understanding this new world order of business contracts, negotiated rates, billing details, payment denials, coding, and non-compensated services. This is no game. It means the difference between medical practices staying afloat or going under. There are now thousands of reasons a doctor can lose money by getting fined, sued, or refused reimbursement.
Family doctors and internists have grown weary. They feel underappreciated by their patients, undervalued by the specialists, underpaid by the insurance company, overworked to meet expenses, and overexposed to malpractice risk. U.S. medical graduates entering family medicine residencies dropped by 50% over 10 years and are now filled mostly by non-US trained physicians. American medical graduates now rush to specialties where they make better money, gain higher status and/or achieve better control of their work schedules. To keep primary care doctors in adequate supply, so the argument goes, system subsidies and readjustments are needed.
Outsiders easily “get” what went wrong the auto and financial industries. These industry execs standing in line for handouts make most of us angry. They refused to do so many things to avoid their plight: innovate, stand up to wrongs, worry about sustainability, take responsibility, invest in a new future, even ”bending the truth” and turning a blind eye was fine as long as there were profits. They say that Americans didn’t want “the truth.” They want us to believe that they are victims of circumstances beyond their control. What should we think of primary care doctors who put themselves on the same playing fields as these execs asking for a bailout?
Internists and family doctors are the backbone of a vibrant healthcare system that is cost-effective [see later blog post to learn why]. But, for far too long we in primary care have piggybacked on the insurance systems, relying on them to pay the bills, even when the costs of administering that is more expensive than the care provided in most cases. This has slowly weakened our doctor-patient relationships and our advocacy for patients, thus compromising our power and professionalism. By casting its lot with third party payers, primary care essentially has announced that it wants someone else to fix the problem of affordable care.
I feel that the solution to primary care is simple. We should not be looking for a bailout. Instead, primary care doctors must step up to initiate change. Personally, I stopped waiting for someone else to rescue me or tell me how to do my job, promising they could make me happy. The restructuring I’m suggesting to revitalize primary care is that patients retain control of the funds they (and their employers) have been giving to the insurance companies for their day-to-day care (which now account for about 30% of total costs), and directly purchase the services they need from doctors who serve them best. Doctors in Oregon (www.greenfieldhealth.com), New York City (www.hellohealth.com) and Northern Virginia (www.doctokr.com) already have set up such practices. These doctors have developed innovative business models that deliver better care to patients at much lower cost. But these will only spread on a large scale if patients understand the value of these new business models, and flock to support them.
More details about the changes needed can be found on our website or by listening to our story with “The Story” on National Public Radio, and in this blog in the coming weeks.
Until then, I remain yours in primary care,
Alan Dappen, MD
What Do Cigarettes and Phenergan Have In Common? Hint: Nothing
For some reason, people just love to misrepresent the issues underlying the Wyeth vs. Levine case. I have written extensively about this case here and here because I found it so amazing that the media has bungled the story so badly – and that no one is really calling them on it.
In case you don’t recall – Ms. Levine was the victim of medical malpractice. An anti-nausea drug (phenergan) was injected into (or very near) her artery by accident (the potential consequences of such an error are clearly indicated on the drug label). Tragically, the resulting chemical reaction with the oxygen in her artery caused such severe tissue irritation that her arm eventually had to be amputated. Ms. Levine settled out of court for $700,000 with the clinic where the injection occurred. Unfortunately the story doesn’t stop there.
Ms. Levine’s attorney counseled her to sue the drug manufacturer for inadequate label warnings (the potential hazard is in fact mentioned on the label six times – though it does not forbid IV administration of the drug, though it recommends a low dose and slow push). In a precedent-setting judgment, a jury in Vermont decided that the FDA-approved label was inadequate, and that it should have fully contraindicated administration via IV push. The jury awarded Ms. Levine $6.8 million and Wyeth contested the judgment, bringing the case to the US Supreme court in November, 2008. The case has not yet been decided, though it has been compared to deceptive labeling of “light cigarettes.”
How on earth is a drug that has been successfully administered (without harmful side effects and with good efficacy) over 200 million times in the U.S. equivalent to cigarettes (a known carcinogen with no therapeutic value)? It’s an exceedingly poor analogy.
To put it another way, if a nurse took an insulin syringe and injected it into a diabetic’s eyeball, causing blindness, should I say that the insulin manufacturer (because it did not forbid the injection into the eye) was engaging in deceptive labeling and should be at fault for the patient’s loss of vision? The PA who injected the phenergan into Ms. Levine’s artery, and our hypothetical nurse who injected insulin into an eyeball are the ones to blame.
But wait, it gets worse.
The attorney (David C. Frederick) who is arguing Ms. Levine’s case in front of the Supreme Court is being considered by our President elect for the position of Solicitor General of the United States. Yes, this very man who is engaged in a law suit that could potentially set a precedent that would allow all 50 states to set up their own mini-FDAs with the lay public (i.e. juries) deciding what drug label language should say.
The pro-Levine camp argues that a court ruling in favor of Wyeth would preempt consumers from being able to sue drug companies for damages related to incomplete disclosure of risks (such as the Vioxx case) but in reality, the Wyeth vs. Levine case has no bearing on pharmaceutical non-disclosure, since Wyeth did not hide the irritant risks of phenergan from the FDA. They have been known for decades.
So Wyeth vs. Levine is NOT about deceptive labeling or non-disclosure of risks – it’s about whether medically uneducated juries should have the power to set arbitrary drug labeling language standards in order to facilitate litigation against deep-pocketed pharmaceutical manufacturers whenever a patient is harmed in a case of medical malpractice.
I understand that many folks are frustrated with pharmaceutical wrong doing (and there are many cases of it), but this is just not one of them. In America, we are not supposed to bring pre-conceived notions to bear on law suits, but objectively review the facts in each case, separate from our general feelings about those involved. I do think that Wyeth isn’t getting a fair shake in the media because of the general mistrust/dislike of Big Pharma. But everyone has a right to a fair trial. I sure hope they get it.
Medical Tourism: Dr. Val Chastised By The American Medical Association
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Dr. Joseph Heyman |
Alright I admit it, that was a rather provocative title. The truth is that at the end of a recent interview with Dr. Joseph Heyman, the chair of the board of trustees of the AMA, I was in fact chided for having left full time clinical practice. Dr. Heyman was rather avuncular in his tone when he stated,
You are robbing patients of the opportunity to have a good clinician like you involved in their care. I guess it reflects badly on our profession that the best and brightest are making alternative career choices – practicing clinical medicine is becoming unbearable.
No amount of protest on my part (about my volunteer work at Walter Reed) would convince Dr. Heyman that I hadn’t abandoned my profession to some degree. And it touched a chord with me too – because taking care of patients is very gratifying for me in many ways. It was with a heavy heart that I chose to become a medical journalist instead.
And so back to the interview with Dr. Heyman. We had an interesting discussion about the concept of medical tourism:
You may listen to our conversation here, or read my summary below.
[Audio:http://blog.getbetterhealth.com/wp-content/uploads/2008/12/heyman.mp3]
Dr. Val: Is medical tourism about people coming to the U.S. for care, or about patients leaving the U.S. to get more affordable care elsewhere?
Dr. Heyman: Historically, medical tourism has been about patients coming to the United States to get high quality care. Nowadays, people are realizing that there are wonderful places overseas where they can seek treatment. If they don’t have a very exotic illness, or require a highly specialized procedure, they can get appropriate care overseas. Hip replacements are a good example of a standard procedure that can be performed without too much difficulty. It wouldn’t be as much of a draw for patients who need hip replacements to come to the U.S. Read more »
