From the WSJ Health Blog:

“Medicare should pay more for primary care and less for procedures and specialty care, a Medicare advisory board said at a meeting this week.”

Despite the light shown upon the non-profit hospital sector by The Wall Street Journal Friday, some hospitals around the country have struggled to keep their doors open.

And after this weekend’s airline fallout (of which you may very well have been affected by) where ATA, Aloha Airlines, Skybus, and Skyway all ceased operations leaving passengers stranded and left to deal with their credit card companies for refunds (yikes!), I’m beginning to see another developing metaphor between the airline industry and health care.

Rising fuel prices and a general economic slowdown are being held responsible for the shutdowns.  We can find similar issues in health care: rising costs of technology and more uninsured patients.

A few months ago, the future of Grady Memorial Hospital in Atlanta, which cares for many uninsured patients, was in doubt.  The Grady situation seems to have taken a better turn, but this editorial about the situation highlights other hospitals that have shut down, “Philadelphia General Hospital in Pennsylvania, the District of Columbia General Hospital in Washington, the Martin Luther King Hospital in Los Angeles.”  

Most recently, SSM St. Francis Hospital and Health Center in Blue Island, Ill., announced it is closing.  Unpaid patient bills seem to be the culprit.

Two of the most regulated U.S. industries have more than a few things in common.  Although the situations may be similar, the solutions are going to be different.  Some sort of insurance reform needs to happen in the near future to prevent more closures.  My fear is that the “solution” will come out of panic and necessity and not make the necessary changes to move us toward sustainable health care.

The Health Care Blog:

San Francisco surgeon Hootan Roozrokh faces one felony charge of dependent adult abuse, for which the maximum punishment is four years in prison. Roozrokh, 34, has pleaded not guilty and his attorney, M. Gerald Schwartzbach said his client looks forward to clearing his name at trial.

The Roozrokh case has attracted much national attention and raises worrisome questions about whether the transplant community is pressing too hard to increase the nation’s organ supply, thereby creating situations ripe for blurring ethical boundaries, such as this one.

Medicine is full of ethical dilemmas that providers must confront on a daily basis. This case shows what can result as ethical boundaries gradually gray.

While we debate the likelihood of health care reform and the form of which it may take, the most important conversations may take place post-reform decision. We must consider the ethical dilemmas we will be presented with as a result of any cost cutting measures, insurance coverage plans, methods of financing, etc.

Some of the most expensive care in this country occurs at the end of a person’s life. That is to be expected as providers try to save lives. This isn’t the case all the time, however. A 2006 USA Today article:

While researchers are able to show differences in costs, the real question remains how much of those additional hospitalizations, tests and doctor visits resulted in better care or better quality of life? Finding answers to that question is difficult and controversial, but health policy experts say doing so will become increasingly important as the U.S. seeks ways to slow the rapid rise in health care spending.

Any health care reform debates ought to include conversations of the ethical implications. Lowering costs may mean a reduction in actual care provided.  Is that a good thing?  A bad thing?  The warranted answer: It depends.

You’ve read my thoughts on primary care before. Dr. Kevin Pho, of Kevin, M.D. blog fame, has an intriguing opinion piece in today’s USA Today. He says:

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

He also offers a terrific starting point for health care reform in this country:

It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.

Have a read.

PSFK had this a few weeks ago and and I saw it again yesterday from Richard Florida.

19.20.21. stands for 19 cities in the world with 20 million people in the 21st century.

The project: “19.20.21 is a multi-year, multimedia initiative to collect, organize and better understand population’s effect regarding urban and business planning and its impact on consumers around the word.  This 5+ year initiative will deliver results via 5 channels: web (including mobile), television (broadcast and cable), print (magazines, books and atlases), exhibits and seminars (virtual and onsite).”

Most of the people in the world live in cities, and by the end of this century many more will.  19.20.21. will conduct case studies on 19 cities around the world with populations of 20 million+ (only two in the U.S.: New York and Los Angeles) to study the effect of this population shift.

The site says “Any company with a focus on globalization will find the patterns and explanations in 19.20.21. indispensable.”

There are many items on the site that will impact on your life.  It’s worth looking at.  I can’t help but ask the question: how is this going to change health care?

While much of health care consumed by Americans is hardly international, that trend is growing.  Some dignitaries come to the U.S. to receive care.  Both those trends will have an impact: people are leaving to receive comparable care in other countries and as health care systems develop in other nations, fewer dignitaries are receiving care here.

This population shift will increase the specialization of American health care, especially in urban areas, as we strive for competitiveness on the global front (“we have the best health care in the world”).  It’s also going to force smaller hospitals in less densely populated areas to change their operations as well.  Maybe we’re moving to the Porter model of health care, where (real) competition reigns, care is delivered in patient-focused practice groups, and smaller hospitals deliver primary care and refer to the specialists at the large institutions.

Anyway, this is the start of the debate.  Any reform in the country needs to target the population’s needs at least 10 years from now…because it’s going to take us that long to figure out what we want; and add five years to that…to account for the “how” of implementation.

The folks of Health 2.0 (definitions) missed each other so much that they held an interim conference (excuse me, Health 2.0 “Unconference”) from March 3-5 to stoke conversations amongst participants.

Microsoft showed off HealthVault. American Well was explained. And a whole bunch of other stuff happened…

The rush through the summary of what happened is because I wanted to get to Scott Schreeve’s closing comments blog post. The point Mr. Schreeve makes is that while the companies of Health 2.0 are serving the needs of someone (hopefully a group of people, read the post for a worthy health care long tail explanation), we must also remember the raison d’etre of new technology: improve the health care delivered in this country.

I have always maintained that the enabling technologies were only part of the story - and the thing they should be enabling is the transition to next generation healthcare (which is going to involve some very painful reform - ie, “this is going to sting a little”). For this reason, I have focused on the concepts of value driven health care (outcomes/price), transparency, openness within healthcare (and open source!), and collective intelligence via networked collaboration (social or otherwise). These reform concepts are critical if we are to begin to correct the fundamental and foundational problems that plague our health care “system.”

What I liked most, however, were the seven words Mr. Schreeve used to describe the “next generation health system:”

Effective, Efficient, Equitable. Technology Enabled Reform. Thrive.

Looks like I have found my raison d’etre.

A friend (who shall remain nameless, let us just suffice it to say that he has created almost all postings up to this point) and I were discussing the viability of a truly universal health care system last night. His argument was that everyone needs to be covered (which I agree) by insurance and that serious changes need to occur in our health ’system’ in this country (duh?). A major point of contention in our discussion was how universal health care would be paid for. His belief is that everything is too expensive. insurance, medical technology, salaries for physicians, etc. My point of contention with this argument is this: People respond to two things in life: 1. Fear 2. Greed.

Now, I realize that I am going to have to play the bad guy here for a minute and risk my credibility (of which I have little) going up in smoke, but I believe that the high level of ’sick care’ that we are able to provide in this country is a direct result of health care’s partially private system that offers inventors of technology and medical devices, providers, and managers an economic incentive to provide health services that are second to none (for those that can afford it). Postulating on what might have happened if things had been different and there had been no economic incentive to provide health care is called “counter-factual history” and is highly suspect and unprovable. I am merely inserting my opinion and asking that others do the same.

No matter how you cut the cake that is health care, in the end the money used to pay for cake is coming straight from our (Americans’) pocketbooks. Whether it be in the form of lower wages from employers trying to cover the health insurance they offer their employees or the money that people have to shell out of their own pockets for private insurance, or the taxes we pay that go to cover (very necessary) programs like Medicare and Medicaid, in the end the money that pays for our ’sick care’ comes from us, and only us. I don’t know about you, but if (God forbid) I come down with a serious illness, I want the best physicians working with the best equipment used in conjunction with the most recent and advanced technology to be working to make me better. Would that be possible in a system where the prospect of economic gain is non-existent?

I put it to you to decide. For my part, this was just a rambling, jumbled, thinking-out-loud kind of post intended to raise more questions without providing any solutions or answers.

Yesterday, CMS and Health Affairs published an analysis of the growth of U.S. health care spending through 2017.  In one word: Up.

Covered here by the WSJ Health Blog, go here for the AP string.

$4.3 trillion is the expected amount that we, as a country, will spend on health care in 2017.  That’s only slightly more than double what we spent in 2006, $2.1 trillion.

The big point:

“As a percentage of gross domestic product, known as GDP, health care spending is projected to increase to 16.3 percent in 2007 from 16.0 percent in 2006.  By the end of the projection period, health care spending in the United States is expected to reach just over $4.3 trillion and comprise 19.5 percent of GDP. ”

Forgive me for addressing the elephant in the room, but where is an extra $2.2 trillion going to come from?  Listen/read/watch anything on health care  and you are sure to hear about our unsustainable spending habits.

Add this: the report doesn’t take into consideration the possible increased role of government through health care reform, ala Barack and Hillary.  John McCain’s plan gets at reform a bit differently.  Regardless of the direction we, as a country decide to go, I’ve realized that health insurance reform addresses a piece of the puzzle, it will not be the elixir that cures all.

Further, a component of all plans is the promotion and utilization of preventive care.  While the benefits are good for public health, a report in the New England Journal of Medicine recently said, “Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.”

Quite the predicament in which we find ourselves.

Here’s an interesting post on learning from another industry.  After reading “Will Disruptive Innovations Cure Health Care?” in the Harvard Business Review (if you have access to HBR, it’s worth the read) by Christensen, Bohmer, and Kenagy, I’m beginning to think we just need to start over, completely.

Retail clinics may be a start down the right path; however, whether they will work (as in accepted) or not is still up for debate.  But the thinking is right on cue.  A bill of $4,300,000,000,000.00 leaves nothing sacred.  We can choose to change, or be forced.  The time to act is now, you can be the solution, any ideas?

It’s not a new concept. In fact, I would be willing to bet that if you ask older individuals and those living in rural areas most of them would tell you they have a family physician or primary care physician. Believe it or not, patients actually call and make appointments with one physician for every medical problem they encounter. That physician then treats or refers. Easy concept. The family physician or primary care provider serves as a gatekeeper to the rest of the system. Difficult today for a variety of reasons.

This article on the American Academy of Family Physicians website says the medical home “is both old-fashioned and thoroughly modern - a blend of the personalized, comprehensive care that family physicians have been offering for decades and coordinated care that capitalizes on new technology and helps patients make sense of the increasingly complex health care system.”

Medical homes are gaining traction in the here-and-now. And for very good reason. When you read this editorial by Dr. Benjamin Brewer at the Wall Street Journal I think you will see why.

Recently, the Illinois Medicaid program decided that nearly every recipient of public aid needed something called a “medical home.” The idea is to provide an accessible, lower-cost point of entry into the health-care system than a hospital emergency room. A practice that agrees to provide the home makes a commitment to take an active, integrated approach to coordinating a patient’s medical care.

The American Academy of Pediatrics “describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.” Their website can give you a comprehensive rundown of medical homes.

Dr. Brewer goes on:

Patients and their doctors have 24-hour access to the information or advice from us by phone or email. We provide prenatal care, delivery services, child and adult care in the office and the hospital. We measure our quality quarterly by looking at some key indicators. We don’t avoid patients of any age or gender or those with chronic, pre-existing conditions. We maintain a list of available specialists and coordinate referrals and follow-up.

All for around $2 per patient per month in addition to office visit fees for services. It seems impossible in our $2 trillion health system. But Dr. Brewer says he is doing it. The care that was once provided free is now being reimbursed.

What’s missing in the debate over our nation’s health-care crisis is that primary care is cheap. Cheaper than your cellphone bill. Cheaper than a tank of gas. Cheaper than dinner and a movie. It’s so cheap the average person doesn’t value it properly. I could have covered my salary for 2007 and the costs of all my staff and overhead for less than $20 per patient per month, including maternity and hospital care.

I’ve blogged about private industry making change in health care on this blog before and have referred to this article as well, but it is worth noting again–a group of employers is partnering with Bridges to Excellence to pay doctors for creating medical homes for patients. “The initiative is the latest and perhaps most far-reaching effort by Bridges to Excellence, a program backed by big employers and health plans and a big player in the movement to provide physicians with financial incentives for taking better care of patients.”

But considering how often we introduce new ways to deliver care and then how quickly those innovations disappear the implementation and effectiveness of the medical home is dependent upon a variety of factors.  According to the AAFP article, “Whether the concept takes root may depend on two key issues: whether payers can be convinced of the value of medical homes (and the need to pay more for them) and whether physicians can deliver what the medical home promises.”

The concept is not new. But it seems to have been forgotten. If it can help the uninsured, stymie health care costs, and make us healthier, it should be obvious that we need to explore this option further. Any thoughts?

Some more reading here that debates some pros and cons.

TransforMED is working to implement the medical home concept through its mission “The mission of TransforMED is to lead and empower medical practices in implementing the new model of patient-centered care — thereby improving health care for their patients, as well as the success of their practices.”

Cut costs, cut costs, cut costs. That’s what we have been hearing lately (30 + years?) in order to effectively reform health care.

The problem is those costs are someone’s income. In a free market economy we are able to make money as we please, and as long as someone is willing to pay, services will be provided.

When we attack costs, we attack someone else’s livelihood. I know how I’d feel if someone was trying to take away some of my income (as if I had any). How would you feel?