Pascal Lardier, International Director of Health 2.0 asked me for an interview about the future of health 2.0. Here is the interview and an excerpt:
Basically, the medical acts remain the same: doctors will continue to receive their patients. But both stakeholders need to adapt and be able to deal with the rapidly growing amount of information available online. As the patient’s motivation is clearly more important (their health is at stake), they are more open to these innovations/developments while medical professionals use the internet and social media for other purposes: education, collaboration, diagnostic technologies, etc… Patients and doctors basically use the same type of technologies for different purposes. I’m sure social media, used with strategy and caution, will help fill the gap between patients and their physicians.
*This blog post was originally published at ScienceRoll*
Mark Lamers from Online Nursing Degrees.org contacted me for an interview. Mark, I’m flattered. People tell me that I give good interviews because I’m very opinionated. Mark asked some thought provoking questions and one of them really stood out. He asked me about something that I wrote on my blog a long time ago. The post read, “I was also taught that anyone willing to work long, hard hours could obtain the American Dream. I’m a nurse for life, which means I’m not going to retire. In other words, I’m going to die with my Nurse Mates on.” Mark asked, “At this point in your career, it is safe to say you’ve worked long hard hours as a compassionate caregiver. In retrospect, is that American Dream now your story? What would provide the happy ending? What were the necessary steps to get there?
I spoke with Harvard Business School professor Regina Herzlinger this week about health reform – the good, the bad and the ugly – touching on ACOs and demonstration projects under the Affordable Care Act; innovations coming down the pike in the private sector either because of the law or because of market forces; social media in health care; and two key fixes to the ACA that she believes are absolutely necessary in order to make it work, or work as best it can.
First of all, she expressed her delight at the passage of a federal law nudging us ever closer to universal coverage, combined with dismay at its failure to address rising costs (noting that we’re looking at policies yielding an accumulated Medicare deficit of $90 trillion, as compared to an annual GDP of $12-14 trillion) and at the paltry fines to be leveled at noncompliant employers that do not offer health insurance as required. As rational actors, she expects that more and more employers will simply opt out of the health care insurance market one way or another: Read more »
My Interview With President Obama On Health Care Reform
I met President Obama yesterday. I interviewed him at the White House about his proposals for health care reform. But naturally, as we greeted each other, I asked about his throwing out the first ball at the All Star Game the night before.
“Were you nervous about bouncing the ball?” I asked. He grinned. “I will say it’s actually nerve-wracking,” he said. “When they hand you the ball, there are just a lot of things that can go wrong.” I found that to be a perfect metaphor for his assuming the Presidency of the United States and attempting to overhaul the health care system.
The biggest news from yesterday’s interview: President Obama has changed his position from the campaign trail and now believes that health care insurance should be mandated for all Americans, with a hardship exemption.
Dr. LaPook: Ultimately, philosophically, do you believe that each individual American should be required to have health insurance?
President Obama: I have come to that conclusion. During the campaign, I was opposed to this idea because my general attitude was the reason people don’t have health insurance is not because they don’t want it, but because they can’t afford it. And if you make it affordable, then they will come. I’ve been persuaded that there are enough young uninsured people who are cheap to cover, but are opting out. To make sure that those folks are part of the overall pool is the best way to make sure that all of our premiums go down. I am now in favor of some sort of individual mandate as long as there’s a hardship exemption. If somebody truly just can’t afford health insurance even with the subsidies that the government is now providing, we don’t want to double penalize them. We want to phase this in, in a way that we have time to make sure that coverage is actually affordable before we’re saying to people “go out and get it.”
The interview went very smoothly and fairly predictably until we reached the following exchange:
Dr. LaPook: You’ve said that if doctors have the information, they’ll do the right thing. And generally, I like to — I’m a physician and practicing — I think that’s true. But actually, there are a lot of times when that’s not the case. For example, angioplasties — elective angioplasties, where you open up a clogged artery in the heart. It turns out that about 30 percent of them are unnecessary, that they’re done and you try to open up an artery of the heart, but really it’s no better than medication, and doctors know this, but they still order them.
President Obama: Why are they still ordering them, do you think?
I will admit that he took me by surprise by turning the question on me. Suddenly I was not in a one-way interview, I was in a conversation. Politics aside, it was clear to me that he was listening and he was curious.
Dr. LaPook: I think that because they believe — there’s this thing about — if an artery’s closed. It’s got to be better if it’s open, and it turns out that’s not true. So they have on the one side their intuition as a physician, in their bellies, and then there’s the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?
President Obama: I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices. And at the very least, you’re not taking money out of physicians’ pockets for making the better choice. So it’s a combination of better information and then, I think, a different system of reimbursement that says, “let’s look at the overall quality of the care of the patient.”
My conversation with President Obama illustrates a crucial focus of the current healthcare debate: figuring out if the American people are getting their bang for the buck when doctors order tests, perform procedures, and prescribe medications. The current buzzwords among doctors and politicians are “evidence-based medicine” (is there proof that something works?) and “comparative effectiveness” (if there’s more than one way to do something, what works best?). An Institute of Medicine workshop about evidence-based medicine began today in Washington, with the following listed as “issues prompting the discussion”:
. “Health costs in the United States this year will be about $2.5 trillion—nearly 17% of the economy.
. The United States spends far more on health care than any other nation, 50% more than the 2nd highest spender and about twice as high as the average for other developed countries.
. Overall health outcomes in the United States lag behind those achieved in other countries.
. Consistent with the per capita figures, many researchers studying the nature of U.S. health expenditures feel that 20% of our expenditures do not contribute to better health.”
Expert groups are currently trying to establish guidelines for reimbursing health expenses based on clear results from well-designed clinical studies. The problem is that for many medical issues, there is no definitive, evidence-based approach. Clinical medicine is often based on inexact, immeasurable tools such as intuition and experience. As doctors, we don’t have the luxury of waiting for the twenty-year study to be completed. We have to treat the patient now, as best we can, without perfect information.
In the absence of definitive data, we will need to account for clinical judgment in an overhauled health care system. What will happen when the doctor suggests something the insurance company says is not indicated? Opponents of a public option for insurance warn about the danger of having a bureaucrat in between the patient and the physician. But that threat already exists in the current system every time an insurance company decides whether to approve a claim. Wendell Potter, former head of Public Relations for Cigna, recently told
Bill Moyers about Cigna’s decision to deny a liver transplant to a 17-year-old girl, Nataline Sarkisyan, even though her doctors at UCLA had recommended the procedure.
A public-relations uproar forced Cigna to reverse its decision; the company subsequently explained its reversal as an exception, saying the surgery was approved “despite the lack of medical evidence regarding the effectiveness of such treatment.”
Ms. Sarkisyan died hours after Cigna’s decision, without having received the transplant.
A critical flaw in the current system – and one that must be addressed in any overhaul – is that the same people who refuse to pay for a recommended course of action are the ones who consider the appeal of that decision. And, lo and behold, they usually end up agreeing with themselves! In more than two decades of medical practice, I have spent countless hours trying to get various services covered by payors. One encounter – when I tried unsuccessfully to get a stomach-acid lowering pill approved for a patient who needed it -ended up as an example of twentieth-century frustration in
Letters of the Century.
Yes, our current health care system is not sustainable and we do need an overhaul. But there is no “exactly how” and we cannot afford to wait for one. There are so many nuances to the moving target of health care and so many unknowns that it is impossible to create a perfect solution on paper. I’ll settle for an imperfect solution that addresses the most important problems first and represents the best efforts of our most thoughtful experts. But it should not be set in stone. It must include provisions to mature gracefully into versions 2.0 and beyond.
Sam Solomon over at Canadian Medicine, did a great job of introducing our recent interview. Please check it out.
Educated in Nova Scotia before she moved to the United States to do degrees in biblical studies and medicine, Dr Val Jones is now one of the most popular physician bloggers. Her work has appeared in MedPage Today, Revolution Health, a now-defunct blog called Dr. Val and The Voice of Reason and, most recently, her own internet company Better Health.
Last year, Dr Jones was accredited as a member of the National Press Club in Washington, DC, and has focused much of her recent reporting on health policy reform efforts. She still practises medicine part-time as a rehab specialist at Walter Reed Army Medical Center. Dr Jones is also a talented cartoonist and her cartoons‘ take on medicine displays a sharp, wry sense of humour.
This week, Dr Val agreed to answer some questions for Canadian Medicine:
Canadian Medicine: Did you know as an undergrad at Dalhousie University, in Halifax, Nova Scotia, that you wanted to be a physician?
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