The impetus for government to control healthcare costs should be obvious to us all and intervention now appears unavoidable. Two issues will soon come to light: the exorbitant costs to fight disease at the end of life, often when the approach of death is barely retarded and the wide disparity in costs between different geographical regions of our country for similarly aged patients. It is estimated that 27% of Medicare’s annual $327 billion budget – one fourth of its operating budget – goes to care for patients in their final year of life while Medicare averages $20,000 more dollars for patients in Manhattan than in some rural areas of our country.
With this in mind, I share a deep concern with many of my colleagues that part of the healthcare reform debate will turn to the rationing of healthcare. This appears a logical progression from the proposed establishment of guidelines and advisory committees currently allowed for in the Health Reform bill already passed. The question as to who should receive possibly futile care is not clear, rather it is fraught with complexity, often relying as much on evidence-based research as it is on assessments made by the medical practitioner in light of the relationship the doctor has with the patient.
At the heart of the rationing issue are two, often warring, sides of medicine: art and science. Medicine began as an art thousands of years ago, and moved more towards science when, in Ancient Greece, Hippocrates taught physicians to observe the results of their treatments and make adjustments. However, art should not be removed from medicine, for this is where the doctor-patient relationship comes to play, serving as a cornerstone of effective and humane medicine. It would be impossible for physicians to uphold the noble traditions of the medical profession, adequately serve society, or preserve the dignity of human life if doctors were to become, purely, scientists. As long as we are treating people, medicine should never become solely a science.
Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession. Setting up rationing guidelines as they pertain to the end of life would circumvent patient’s trust in the doctor-patient relationship and risk the very soul of medicine by negating the importance of the doctor-patient relationship. Evidence-based recommendations can and should be set forth pertaining to protocols for offering treatments as the end of life seems near. This would likely reduce some of the high and disparate costs in caring for our elders; however, it is important to consider the input of a doctor aware of the needs and desires of his patient.
I come to this argument both as a physician and from personal experience. Several years ago, my 75 year old father was hospitalized four times over five months. His medical team, led by a kind and experienced surgeon, unburdened by guidelines or anyone else’s recommendations, gave him a chance despite long odds against his survival. Medically speaking, I am still surprised he made it out of the hospital to live a normal life again. During the subsequent five years, he has welcomed three grandchildren into our family; I would challenge anyone to assign a monetary value for that life experience. My professional and personal experience leaves me quite sure that he would have fallen a victim of any rationing guidelines that could ever exist.
In short, as the average life span increases most of us nurture the hope to live longer, cheering as science opens the door to seemingly innumerable advancements. Yet are we, as a society, equipped, whether it be emotionally or fiscally, to handle the decisions that must be made as the end of life draws near? More importantly, should government be allowed to set up strict guidelines without an active debate from physicians and patients? These guidelines could sacrifice what has long been and should still remain most important to healthcare: the doctor-patient relationship.
DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 – 1994. (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.
Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry – notably including the insurance companies, physician groups, and drug and medical device companies.
But when she finally produced her plan – a disturbingly heavy tome filled with frightening details – everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her – most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.
Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.
So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.
But they are wrong.
There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.
First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course – the only one who has been able to out-maneuver the Clintons is Mr. Obama – and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow. But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.
In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war. Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)
Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform – thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles – Mr. Obama is not. His reform plan will be bare-bones – merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.
And third, this time there is no Plan B.
In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens! We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own. But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.
“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”
And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.
To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.
And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere – one knows not where – muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.
So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.
And so, the last obstruction to healthcare reform has been removed. The path – the only path – is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.
To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth – that rationing is unavoidable – whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.
On May 9th I had the pleasure of lecturing to an audience of critical thinkers at the NYC Skeptics meeting. The topic of discussion was pseudoscience on the Internet – and I spent about 50 minutes talking about all the misleading health information and websites available to (and frequented by) patients. The common denominator for most of these well-intentioned but misguided efforts is a fundamental lack of understanding of the scientific method, and the myriad ways that humans can fool ourselves into perceiving a cause and effect relationship between unrelated phenomena.
But most importantly, we had the chance to touch upon a theme that has been troubling me greatly over the past couple of years: the rise in influence of those untrained in science on matters of medicine. I have been astonished by the ability of “thought leaders” like Jenny McCarthy to gain a broad platform of influence (i.e. Oprah Winfrey’s TV network) despite her obviously flawed beliefs about the pathophysiology of autism. Why is it so hard to find a medical voice of reason in mainstream media?
The answer is probably related to two issues: first, good science makes bad television, and second, physicians are going about PR and communications in the wrong way. We are taught to put emotions aside as we carefully weigh evidence to get to the bottom of things. But we are not taught to reinfuse the subject with emotion once we’ve come to an impartial consensus. Instead, we tend to bicker about statistical analyses, and alienate John Q. Public with what appears to him as academic minutiae and hair-splitting.
I’m not sure what we can or should offer in place of our “business as usual” behavior – but I’ve noticed that being right isn’t the same as being influential. I wonder how we can better advance the cause of science (for the sake of public health at a minimum) to an audience drawn more to passion than to substance?
I would really enjoy your input, dear readers, because I’m at a loss as to what we should do next to reach people in our current culture, and with new communications platforms. What would you recommend?
Being a plastic surgeon, I have a great interest in the skin and no I don’t see or treat much dermatitis as the primary physician. Patients do occasionally ask me about patches/rashes they have. It’s always nice to be up on the topic and to know when it’s important to make sure they see a dermatologist.
The article listed below is a nice, simple review of conditions that fall into the eczema /dermatitis categories. The article discusses atopic dermatitis (AD), nummular (coin-shaped) eczema, contact dermatitis, and stasis dermatitis. It is not a deep article on the subject, but did include some nice reminders and tips.
Allergic dermatitis is not uncommon in patients with chronic wounds. One study documented more than 51% of leg ulcer patients acquire contact allergic dermatitis to local dressings and other topical treatment. This is important to any of us who treat wounds, acute or chronic. Sometimes the wound fails to heal due to this.
There is a nice table which lists the common allergens in patients with chronic wounds. If your chronic wound patient has a contact allergy to these products, it can certainly complicate their wound healing.
lanolin (common in moisturizing creams and ointments)
perfumes/fragrances
cetylsterol alcohol (used as an emulsifier, stabilizer, and preservative in creams, ointments, and paste bandages)
preservatives: quaternium 15, parabens, chlorocresol (all are used to prevent bacterial contamination in creams, but are not in ointments)
rosin (colophony) — a component of some adhesive tapes, bandages, or dressings
rubber / latex
The key to treatment and prevention of future exacerbations is identification of any provocative factors so that they may be avoided as there is no absolute cure for dermatitis. Here is a summary of tips the article gives:
Laundry and Clothing Suggestions
Avoid wearing wool or nylon next to their skin as they may exacerbate itch. Choose materials made of cotton or corduroy which are softer.
Rather than use fabric softeners and bleach, which may be irritating to the skin, add a white vinegar rinse in the washing machine rinse cycle cup/dispenser to remove excess alkaline detergent.
Moisturizers
Keep water exposure to a minimum.
Use humectants or lubricants regularly to replenish skin moisture. Apply these agents immediately after bathing while the skin is damp.
For severe hand eczema, cotton gloves may be worn at night to augment the moisturizing effect of humectants and other topical treatments.
Topical Steroids
Topical steroids continue to be the mainstay therapy for treating dermatitis.
Topical steroid creams can be kept in the refrigerator or combined with 0.5% to 1% of menthol (camphor and phenol are alternatives) to give a cooling effect. This often helps.
Treat the dermatitis with a topical steroid when the skin is red and inflamed. Tapering the topical steroid use by alternating with moisturizers as the dermatitis resolves.
Remember that percutaneous absorption of topical steroids is greatest on the face and in body folds. They suggest only weak or moderate preparations be used in these areas.
Moderate to potent topical steroids should be used on the trunk and the extremities.
The palms and soles are low-absorption areas, so may require very potent topical steroids
REFERENCE
The ABCs of Skin Care for Wound Care Clinicians: Dermatitis and Eczema; Advances in Skin & Wound Care: May 2009, Vol 22, Issue 5, pp 230-236; Woo, Kevin Y. RN, MSc, PhD, ACNP, GNC(C), FAPWCA; Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med, Derm), ABIM DABD, FAPWCA (doi:10.1097/01.ASW.0000350837.17691.7f)
At Health 2.0, Ted Eytan, MD, and I talked for a bit about why Kaiser Permanente’s “virtual health care system” has had such great success. According to his bio, Ted is a family doc from DC with a background in “working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.”
Ted is Permanente’s Medical Director for Delivery Systems Operations Improvement. Permanente’s online system strives to bring the doctor and patient together online via the electronic health record (EHR), decision making tools and communications tools such as email. It further empowers the patient to be an active participant in the health care system by having access to the EHR and being able to book appointments online, renew prescriptions, contact health providers, and see labs and tests. Eytan has a wonderful summary of the system and the demonstration they did at Health 2.0 on his blog here.
Here are the highlights of our chat:
Dr. Gwenn: What makes Kaiser work so well compared to other areas of the country, for example Massachusetts?
Dr. Eytan: The key difference between Kaiser and here (MA) is adoption.
Dr. Gwenn: Why is that?
Dr. Eytan: The important point to teach doctors is the customer service approach. We do things because the members want it. That should be the reason for all change in health care. If places focus on quality not customer service, the system won’t work well and nothing will change.
Dr. Gwenn: What has helped Kaiser be so successful?
Dr. Eytan: Three major points that have worked well in Kaiser’s system: accountability, physician leadership and valuing members.
1. At Kaiser we have 100% accountability over everything. We own up to mistakes when they occur and help physicians learn from them.
2. Kaiser encourages physician leadership to spark reform and help IT departments facilitate change: Physicians do have value and can create the clinical vision. They work with IT to facilitate the technological changes that need to occur to make the doctor-patient encounter work better and to make the physician’s work life more manageable.
3. Kaiser listens to members… members have advisory groups, teen groups: they are involved and their voices are heard at all levels and all ages.
Dr. Gwenn: How do you oversee the online world with patients?
Dr. Eytan: The patients are the customers and the EHR must be usable to them – that is the MO of the entire system. In addition, there is an online, full time medical director responsible for the patient interface. There is no other way to have a patient-involved online system without a dedicated staff overseeing that system lead by a physician.
Dr. Gwenn: What problems do you help the clinical staff anticipate with online care?
Dr. Eytan: With virtual care, patients will see lab results and parts of the EHR they are not used to seeing and that could prompt questions or concerns. There has to be commitment from everyone to be ready to answer those questions fro the system to work well for the patient. They provide a great deal of training and support so the clinical staff will be prepared for questions from patients they may not have had when patients were not so involved in their care and seeing so much of their EHR.
Dr. Gwenn: How does virtual care help the system?
Dr. Eytan: There are a number of important ways virtual care helps the system on many levels:
1. It builds confidence in the doctor patient relationship by fostering conversation.
2. There’s a database to give patient’s article-based information (Permanente uses the “healthwise knowledge base”).
3. They use true medical terms with patients and in the EHR that patients will Google. This helps patients be more savvy in the health care system and know what terms to search for should they seek more information or have questions to ask of the clinical staff.
Dr. Gwenn: What are the benefits of virtual care for the patients and the physicians?
Dr. Eytan: There are three primary benefits:
1. Online care helps empower the patients to be part of their care and shapes use with guidance from the staff.
2. Patients become so involved they become invested in making sure the EHR is accurate and often point out mistakes they note, such as typos.
3. Doctors can be more efficient by using pre-visit emails to organize their time.
Dr. Gwenn: What’s your take on the Health 2.0 vs. Ix (Information Therapy) debate during this conference?
Dr. Eytan: Useful, accurate information is the goal. Give people what they want, when they want it. All systems need to use more health 2.0 tools member to member. Ultimately the goal is to connect to the doc.
Dr. Gwenn: How can docs be more health 2.0 savvy?
Dr. Eytan: All docs should ask patients if they use the internet. It’s the 6th vital sign.
Dr. Gwenn: Many patients don’t live in a virtual health care system like Kaiser, how can they get from their system what you offer at Kaiser?
Dr. Eytan: Ask and demand! Most electronic medical record systems have the tools in place, like email, and just have to start using them. Patients need to ask for what they want. Physicians want to do a great job and hate waste.
My final thoughts:
With such great models such as Permanente in many areas of our country, it’s frustrating we can’t get similar systems everywhere. Perhaps it is not just the patients who have to “ask and demand” for what they want in the health care system. Perhaps it’s time docs everywhere stood up and demanded a system where docs were compensated well, treated respectfully, and had a system that actually supported good care.
*This blog post was originally published at Dr. Gwenn Is In*
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