Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll.
Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need.
What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will make it possible for more people to get medical care at a cost they can afford to pay.
This is a major step in the right direction, but there are some major missing pieces. Mr. Gingrich would like to scrap it and start over, but then he clearly hasn't read it since he thinks we now have socialized medicine. Much of what wants to be improved in medicine can't be legislated, so I would like to keep what we now have and see what else needs to be done.
Costs are still rising and this is, at least at this point, threatening to stifle economic growth at a time when our country is struggling to be competitive in a world market where medical care is not a major part of the cost of doing business. This needs to be turned around quickly.
Despite new regulations requiring insurance companies to make policies cover basic medical needs at a cost that people can tolerate, insurance products are even now getting more expensive and less generous. Our continued reliance on insurance to pay the bills not only limits any incentives for costs of medical care to go down, but makes the insurance companies powerful enough that they will certainly have a significant influence on policy which will lessen the effectiveness of the regulations.
Doctors don't understand the new laws and are fearful and suspicious. This is causing doctors who have been in practice to consider narrowing the scope of their practices so they are less vulnerable to public insurance changes, and in many cases to consider retiring. The widespread experience of being sued for malpractice already shortens the careers of many physicians, and the lack of any serious attempt of the recent bill to solve this problem has disillusioned many of us.
So what must we do?
First costs need to go down. In looking at everyday medical practice as it goes on in my community it is clear that much of the excess money spent in medical care is due to the whims of care providers, inadequately informed by science and without knowledge of the costs involved. Almost nobody knows what most of the tests or medications we prescribe cost. Merely being made aware of costs, coupled with more widespread education on appropriate use of medications and testing would make a huge and nearly instant impact on medical costs. This can happen, but could be facilitated by our national organizations. If they are unable or unwilling to mandate transparency of costs and provide leadership on appropriate care, we can do this at a local level through working with our hospitals, clinics and pharmacies to share information.
Costs could also be impacted by changing the way physicians are paid. If we were not only aware of costs but were paid to care for a group of patients rather than by the individual encounter, there would be strong incentives to keep patients as healthy as possible so that they didn't require doctor visits or hospital care. This would line our incentives up with what patients really want: for us to keep them healthy and care for them effectively when they are sick.
One way of providing health care of this type would be through community health care systems on a cooperative model. Communities of people already spend huge amounts of money on health care, and if they pooled those resources and that money did not need to move through an insurance company in order to pay for necessary care, it would buy a great deal more health care. The health care bill supports creation of structures like this, but does not in itself make them happen. That is up to us, in our communities.
I'm not sure it is possible to reassure doctors that all will be well as health care reform goes into action, but if our own national organizations, such as the American College of Physicians and the AMA, show leadership in making our own positive changes we will all feel more in control of the process.
Suing for malpractice continues to be the dysfunctional approach often taken when a patient has a bad medical outcome or a mistake is made, especially if care was very expensive. We can, even now, tackle this in our communities by making ourselves aware of bad outcomes and medical mistakes and offering compensation as well as honestly evaluating what went wrong. This process can be done by hospitals and clinics, and has been shown to reduce costs overall. Suing for malpractice destroys lives of both injured patients and physicians, as they spend years in rancorous argument, and the medical community then loses the opportunity to learn from mistakes. Any federal law reforming medical malpractice is certainly years away, since the tort system has traditionally been a way to protect those who are vulnerable, and it is hard to make the case that medical injury should be handled differently from other sorts of injury.
I'm thinking that perhaps there is still quite a bit of work for all of us Champions of Medicine to do. I think I'll save my 5 grand and travel expenses and hotel fees and just hang out here at home and work on this stuff.
Tuesday, October 12, 2010
Monday, October 4, 2010
Newt Gingrich invited me to a party!
Today I received an invitation to an election day party from Newt Gingrich himself! Apparently I have “made the cut” as one of the 2010 Champions of Medicine and will receive a handsome certificate at an election day party at the historic Ronald Reagan Building in Washington D.C. Newt has confided to me that he has worked tirelessly of the course of his career for health care reform. He understands that I have faced challenges during the Obama administration's first two years and that this year has been especially difficult for me with the “Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine.”
Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.”
Wow.
I would love to go! I would have absolutely no hesitation in asking uncomfortable questions and spreading sedition among the gathered faithful. For all the good that would do. But life is so full of really great things to do that don’t involve being in Washington DC on election day. There are long walks to be taken in the woods. There are songs to be sung with friends. There is a conference to be organized about appropriate use of technology at our hospital. There is real information about what is going on in my field to be read and digested and maybe turned into essays on why the finest healthcare system in the world fails to take care of its own at an affordable price, and how it can be tweaked to face its challenges. There are stories that need to be heard, poems that need writing, children to be raised, jokes to be laughed at.
I’m still filled with questions about this invitation, though. How stupid does he think doctors are? Are we really stupid enough to think that the reform package dismantled the finest healthcare system in the world and replaced it with socialized medicine? Why invite me? I’m not even Republican. Could he have invited many thousands of doctors, and if so mustn’t he believe that his message would sway very few of them, since he can’t feed thousands of doctors dinner at the Ronald Reagan building? And if I did go, what are the choices of entree?
Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.”
Wow.
I would love to go! I would have absolutely no hesitation in asking uncomfortable questions and spreading sedition among the gathered faithful. For all the good that would do. But life is so full of really great things to do that don’t involve being in Washington DC on election day. There are long walks to be taken in the woods. There are songs to be sung with friends. There is a conference to be organized about appropriate use of technology at our hospital. There is real information about what is going on in my field to be read and digested and maybe turned into essays on why the finest healthcare system in the world fails to take care of its own at an affordable price, and how it can be tweaked to face its challenges. There are stories that need to be heard, poems that need writing, children to be raised, jokes to be laughed at.
I’m still filled with questions about this invitation, though. How stupid does he think doctors are? Are we really stupid enough to think that the reform package dismantled the finest healthcare system in the world and replaced it with socialized medicine? Why invite me? I’m not even Republican. Could he have invited many thousands of doctors, and if so mustn’t he believe that his message would sway very few of them, since he can’t feed thousands of doctors dinner at the Ronald Reagan building? And if I did go, what are the choices of entree?
Monday, September 20, 2010
what do I mean by cost effective medicine?
It is not uncommon for comments about cost effective medicine to be met with mistrust by patients. Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion.
When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions. Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.
1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.
2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home. I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.
3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure. He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.
4. I have chest pain and tell my doctor. She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test. The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.
5. I have knee pain and am overweight. I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.
6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough. It gets worse, so I go to an emergency room. The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice. I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.
7. I am an 80 years old man and go to my doctor for a physical exam. He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.
8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy. The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar. I get an MRI of my breasts and that is equivocal. I get another biopsy which is normal. This process is repeated yearly until what is left of my breasts resembles the surface of the moon.
There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.
When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions. Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.
1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.
2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home. I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.
3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure. He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.
4. I have chest pain and tell my doctor. She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test. The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.
5. I have knee pain and am overweight. I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.
6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough. It gets worse, so I go to an emergency room. The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice. I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.
7. I am an 80 years old man and go to my doctor for a physical exam. He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.
8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy. The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar. I get an MRI of my breasts and that is equivocal. I get another biopsy which is normal. This process is repeated yearly until what is left of my breasts resembles the surface of the moon.
There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.
Saturday, September 18, 2010
JAMA commentary article suggests teaching medical students to be cost conscious
This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients. They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school.
A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.
Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary. I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:
A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.
Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary. I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:
This is all extremely heartening. I was especially pleased to find the article quoted so many places, because it is all well and good to have a great idea, it is something quite different to do something about it. When many people are excited, as they seem to be, momentum may build in the direction of change. The next step in such a thing would be to have the idea attach itself to some money--perhaps a grant to medical schools that try it. Medicare already funds a great deal of medical education and perhaps the proper direction for this to take would be for folks in the new center for Medicare innovation (part of the health care reform bill) to notice that it is a terrific idea and stipulate that medical schools receiving funding from Medicare begin to teach a comprehensive curriculum based on cost effective care."The commentary is written by Samuel Y. Sessions, MD, JD, a Los Angeles Biomedical Research Institute (LA BioMed) investigator, and Allan S. Detsky, MD, PhD, Departments of Health Policy Management and Evaluation and Medicine, University of Toronto."New physicians will be at the hub of the health care system throughout their careers as both patient advocates and allocators of resources," the authors write in the JAMA commentary. "Instead of considering economic forces to be extraneous, medical education should develop approaches to better equip physicians for this dual role through improved teaching of evidence-based medicine that reflects both economic and statistical realities. Good patient care and good public policy demand no less."The commentary notes that health care spending continues to grow, reaching 17.3% of gross domestic product in 2009. It points out that physicians "play a critical role not only in the well-being of their patients but also in the nation's economic welfare" as they make choices about how to care for their patients. As a result, the commentary calls for "incorporating information about economic realities into medical education to enable physicians to make better-informed decisions for patients and for the United States."The authors point out that physicians' diagnosis, choice of medication and course of treatment can affect spending and patient well-being for years to come. To ensure economic realities are part of the physicians' decision, the authors call for a "core, required medical school course that would consolidate and integrate elements of existing health policy, ethics, and evidence-based medicine courses and modify them to better reflect overt and covert economic influences on clinical decisions."The authors also call for revising "the remainder of medical school and residency curricula" to incorporate economic realities so that the medical students and residents would take these into consideration in their medical decision-making."The primary goal of incorporating economics more directly into medical education would be to improve physicians' critical capacity to assess all factors affecting their decisions, as well as their social and ethical implications," the authors write.
Wednesday, September 15, 2010
Treatment of Sleep Apnea--the cost of a good night sleep
Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people. It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat. When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath. This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. These are called CPAP (constant positive airway pressure) devices and are now commonly used in the treatment of OSA. People who use these devices have better oxygen levels during sleep, which benefits their hearts and brains, and usually feel more rested during the day.
This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment. This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2. The evaluation can be done with one night and that is a bit cheaper but still no great deal. At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.
There is another option, though, that appears to work for some people. A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such. These oral appliances are carefully fitted and are amazingly expensive. One of these things costs around $1200-$5000. Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small. It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.
It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive. This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels. I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.
What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die. What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them. E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online. These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations. Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.
A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each. If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.
This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment. This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2. The evaluation can be done with one night and that is a bit cheaper but still no great deal. At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.
There is another option, though, that appears to work for some people. A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such. These oral appliances are carefully fitted and are amazingly expensive. One of these things costs around $1200-$5000. Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small. It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.
It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive. This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels. I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.
What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die. What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them. E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online. These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations. Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.
A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each. If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.
Tuesday, August 24, 2010
Electronic medical records, revisited
Last night I realized that I actually do like having a computerized medical record system.
I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007. We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product. It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn't adjust and left.
Sounds bad, I guess.
But there's more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix.
Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.
There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can't be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be. Sometimes the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don't appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward. I can't look at a patient's medical record in the same window that I am using to take their history.
When I tell people this, they say, "oh, you just have a bad system." Well, yes, obviously that is true. Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.
But that was not the story that I wanted to tell.
I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient's medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.
Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn't find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.
Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties. I don't use even a fraction of what is available, but I can certainly see what powerful tools exist.
Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.
We could, of course, simply start charging for all forms of communication, and remain in the "fee for service" model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.
I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.
I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007. We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product. It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn't adjust and left.
Sounds bad, I guess.
But there's more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix.
Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.
There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can't be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be. Sometimes the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don't appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward. I can't look at a patient's medical record in the same window that I am using to take their history.
When I tell people this, they say, "oh, you just have a bad system." Well, yes, obviously that is true. Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.
But that was not the story that I wanted to tell.
I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient's medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.
Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn't find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.
Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties. I don't use even a fraction of what is available, but I can certainly see what powerful tools exist.
Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.
We could, of course, simply start charging for all forms of communication, and remain in the "fee for service" model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.
I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.
Thursday, August 12, 2010
Estrogen: the pendulum swings again
The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals. It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one.
When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil. It was a bad year for estrogen.
In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes. Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.
But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.
This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy. Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.
As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.
Here is a link to the Internal Medicine News article.
http://www.internalmedicinenews.com/article
When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil. It was a bad year for estrogen.
In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes. Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.
But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.
This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy. Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.
As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.
Here is a link to the Internal Medicine News article.
http://www.internalmedicinenews.com/article
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