I have to complement our Congressional leadership for its political fortitude and wisdom in preparing 2010 health reform legislation which is well suited to the 1970s and 80s. The late Richard Nixon, who brought us HMOs in a serious effort at health care reform (which became fouly mutated under the counter-evolutionary pressures of insurers, hospitals and other providers) would have been proud to see the 2010 reform just before "le affaire Watergate"cut his presidential career and his interest in American health care short.
What is being trumpeted as health reform is more of the old health system, redressed and reworked, with the old guard in control. The program has been shaped by pharmaceutical companies, insurers, chambers of commerce, hospital associations, device manufacturers, health care unions, high-roller physicians and other providers, through their lobbyist minions to be certain that their controlling interests and their profit centers are not perturbed, their stock prices ever climbing, their executive salaries not diminished, and the care, which Americans will receive, not improved.
[Remember: a pharmaceutical (and other company which makes its money in health care) profits by selling drugs over a long time for a chronic disease, not by efficiently curing a disease early in its course. An insurer makes money by keeping your doctor on the phone for 45 minutes, hoping that she will hang-up the phone, rather than promptly authorizing the care you need.]
How are we going to staff the clinics and hospitals to provide the facilities and office visits that adding more than 30 million Americans to the insured list will demand ("the doctor is completely booked for the next ten weeks, but we have one appointment 71 days out with our new physician's assistant")? Will the legislation's effect on doctors' offices cause them to look like overcrowded hospital emergency rooms where only visibly dying patients get immediate attention?
Under the 2010 health reform proposal, where are the skills neeeded to diagnose and treat cancers, degenerative diseases, trauma and neurologic disorders in our aging population to be gained?
Where are the financial incentives which will drive our younger generation to acquire an interest, skill and understanding of chemistry, math, physics, biology and the other sciences which will provide the springboard to careers in the healing professions? Is our "health reform" simply training generalist doctors to take care of sore throats, blood pressure elevations and type 2 diabetes using duplicative drugs purveyed by pharmaceutical companies? Will the recruitment and education of coming generations prepare them to understand complex scientific concepts of statistics, DNA, genetics, epigenetics and their interrelationship with disease and health or is there concern among political and industrial leadership that a bright, well-trained and informed health care leadership will be too hard to control?
In a country which prides itself on its capitalist tradition, the proposed 2010 health reform incorporates few capitalist incentives to recruit the people and brains who we will need to make the system work and few capitalist incentives to improve the quality of care available to Americans. It rewards the same individuals, interests, companies, systems and institutions which have traditionally lined up at the trough for slop.
It's perverse. The Republicans are less capitalist than the Democrats, the the conservative Democrats are less capitalist than the Republicans. Go figure!
Tuesday, December 29, 2009
Thursday, December 24, 2009
Coal In The Stocking
In Dickensian fashion, there will be coal in the stockings of many Americans following the Christmas holiday, but for others there will be a big, freshly roasted, fat goose provided by Senators Liberman, Nelson and others who have been agents, not of reform, but of the special interests including the insurance, pharmaceutical and financial industries, as well as parochial supporters.
We have learned that money talks, that Congressional votes flow in the direction dictated by lobbyists who direct political campaign funds, and that health reform is a fiction which was used by both major parties to atttract attention, political support and financing without any real intention of implementing serious health care reform that Americans expect and deserve.
For most Americans this is the season of opportunities lost, deeds not done, and needs not met. For others, the fat goose Congress has set at their tables, will provide bountiful feasts.
Shame.
We have learned that money talks, that Congressional votes flow in the direction dictated by lobbyists who direct political campaign funds, and that health reform is a fiction which was used by both major parties to atttract attention, political support and financing without any real intention of implementing serious health care reform that Americans expect and deserve.
For most Americans this is the season of opportunities lost, deeds not done, and needs not met. For others, the fat goose Congress has set at their tables, will provide bountiful feasts.
Shame.
Monday, December 21, 2009
Stem Cells and Biologicals
A reader asks: "My question was, with the advent of cures for chronic diseases and other maladies, brought about by advances in stem cell based treatment, will the cost of the U.S. health care system decrease in the foreseeable future?"
Todays' New York Times describes the acquisition of stem cell (for treatment of inflammatory bowel disease) development rights from Athersys by Pfizer. New stem cell products, along with other biologicals which depend on genetic development (a number of which are already on the market for treatment of arthritis, neurologic disorders, bowel diseases and other immune-mediated disorders) have the promise of effectiveness (and some significant side-effects) at a very high price, amounting to many thousands of dollars a year for each patient treated and the likelihood that treatment will have to be continued for extended periods, guaranteeing income streams to those pharmaceutical companies.
While some of these products may "cure" the diseases which they target, many will be controllers which require prolonged continued use. It is understandable that pharmaceutical producers interested in the areas of stem cells and other biologicals for treatment of serious diseases have pressured Congress to extend patent protection to protect their investments and their streams of revenue and are setting their prices high to generate corporate profits.
While some of these products have social value, may keep people working and paying taxes, and sometimes produce more effective results than existing treatments, with relief from pain, deformity, debilitating disease and delay or prevention of imminent death, I see no reason to believe that they will lower the percentage of gross domestic product devoted to pharmaceutical costs and health care expenditures. The market will permit maximization of pharmaceutical companies' pricing and profit structure and foster pharmaceutical companies' choices, as to the stem cell and biological products they produce, to support drugs which are expensive and chronically used. The question is whether their use lowers other health care costs (i.e., physician and nursing services, hospital utilization, physical therapy, radiologic and therapeutic services) for a net reduction in health care expenditures.
If the net cost of all services is reduced because these new products promote efficiency, the nation will benefit. If stem cell and other biologic therapies simply add to an existing inefficient economic structure, the nation and you, the reader, as a health care purchaser will lose.
Todays' New York Times describes the acquisition of stem cell (for treatment of inflammatory bowel disease) development rights from Athersys by Pfizer. New stem cell products, along with other biologicals which depend on genetic development (a number of which are already on the market for treatment of arthritis, neurologic disorders, bowel diseases and other immune-mediated disorders) have the promise of effectiveness (and some significant side-effects) at a very high price, amounting to many thousands of dollars a year for each patient treated and the likelihood that treatment will have to be continued for extended periods, guaranteeing income streams to those pharmaceutical companies.
While some of these products may "cure" the diseases which they target, many will be controllers which require prolonged continued use. It is understandable that pharmaceutical producers interested in the areas of stem cells and other biologicals for treatment of serious diseases have pressured Congress to extend patent protection to protect their investments and their streams of revenue and are setting their prices high to generate corporate profits.
While some of these products have social value, may keep people working and paying taxes, and sometimes produce more effective results than existing treatments, with relief from pain, deformity, debilitating disease and delay or prevention of imminent death, I see no reason to believe that they will lower the percentage of gross domestic product devoted to pharmaceutical costs and health care expenditures. The market will permit maximization of pharmaceutical companies' pricing and profit structure and foster pharmaceutical companies' choices, as to the stem cell and biological products they produce, to support drugs which are expensive and chronically used. The question is whether their use lowers other health care costs (i.e., physician and nursing services, hospital utilization, physical therapy, radiologic and therapeutic services) for a net reduction in health care expenditures.
If the net cost of all services is reduced because these new products promote efficiency, the nation will benefit. If stem cell and other biologic therapies simply add to an existing inefficient economic structure, the nation and you, the reader, as a health care purchaser will lose.
Wednesday, December 16, 2009
A Long Day
Because I have been ill, my blogging has been curtailed. To give you a sense of what has been going on - I'll describe yesterday.
Phone rang once at 5:20 AM. No one there.
As instructed, I appeared ( accompanied by my spouse) at the University Medical Center at 7:20 AM. Confusion prevailed since the department's computer had me scheduled to show up at 9:30, though someone from the department had called the night before with instructions to show up before 8:00 AM. Sat and waited.
Called into the pre-op room, changed into hospital garb, climbed into the preop "bed," answered a lot of questions the answers to which were pretty much in the electronic medical record, though not entirely accurately in the electronic medical record. Nurse was very thorough and competent. Started on IV. Waited. Waited. A Fellow appeared and we discussed the proposed procedure, discussed my history, went through a limited physical exam, and negotiated some issues which were important to me relating to lab tests and operative procedure related events. Faculty member came and we had a sensible and appropriate (more mature) discussion of his plans and recommendations, the proposed procedure and the likelihood that my procedure would be significantly delayed because he had to treat a child and we agreed the child should come first (which was the faculty member's plan anyway). More waiting. More waiting. Reminded nurse that I needed a simple blood test done and it was done. Told that the procedure was going to start soon. It didn't, but eventually it did. Brought by a pleasantly chatty nurse to a high technology room containing 5 people and placed on a hard narrow table. IV running (fluids, pain relief and sedation). O2 running. Monitors running. Local anesthesia for a biopsy provided. Biopsy done with little pain or discomfort and lots of instruction for the Fellow who was there learning. Off the table to the wheeled transport. To another room for recovery and two hours of fitful dozing. Then to another room for final awakening and sitting up. Then to a wheelchair to my car. Then home where I arrived after an almost 11 hour day. Now the wait for pathology and lab results.
Phone rang once at 5:20 AM. No one there.
As instructed, I appeared ( accompanied by my spouse) at the University Medical Center at 7:20 AM. Confusion prevailed since the department's computer had me scheduled to show up at 9:30, though someone from the department had called the night before with instructions to show up before 8:00 AM. Sat and waited.
Called into the pre-op room, changed into hospital garb, climbed into the preop "bed," answered a lot of questions the answers to which were pretty much in the electronic medical record, though not entirely accurately in the electronic medical record. Nurse was very thorough and competent. Started on IV. Waited. Waited. A Fellow appeared and we discussed the proposed procedure, discussed my history, went through a limited physical exam, and negotiated some issues which were important to me relating to lab tests and operative procedure related events. Faculty member came and we had a sensible and appropriate (more mature) discussion of his plans and recommendations, the proposed procedure and the likelihood that my procedure would be significantly delayed because he had to treat a child and we agreed the child should come first (which was the faculty member's plan anyway). More waiting. More waiting. Reminded nurse that I needed a simple blood test done and it was done. Told that the procedure was going to start soon. It didn't, but eventually it did. Brought by a pleasantly chatty nurse to a high technology room containing 5 people and placed on a hard narrow table. IV running (fluids, pain relief and sedation). O2 running. Monitors running. Local anesthesia for a biopsy provided. Biopsy done with little pain or discomfort and lots of instruction for the Fellow who was there learning. Off the table to the wheeled transport. To another room for recovery and two hours of fitful dozing. Then to another room for final awakening and sitting up. Then to a wheelchair to my car. Then home where I arrived after an almost 11 hour day. Now the wait for pathology and lab results.
Saturday, December 5, 2009
Response To An Important Reader's Comment
An anonymous reader commented: "How does a patient determine the factors you mentioned? A modestly sophisticate patient may determine these things over time, perhaps too late. Many patients do not have sufficient sophistication to determine and evaluate these factors. In the past, not too long ago, doctors' advice was taken quite uncritically. LCB"
My response invokes recent experience. The story is real.
Like all of us, I develop health problems from time to time. In anticipation of my needing consultation from a physiatrist or subspecialty surgeon, my internist ordered an MRI and I visited a physiatrist to receive a series of treatments. These treatments failed; I needed a subspecialty surgical consultation. In discussing my expectations of the consultant with my referring internist, I said: I expected the consulting physician to: (1) be highly knowledgeable and experienced in the surgical subspecialty; (2) have "good hands" (which to other physicians, means that he or she has excellent surgical dexterity and technique); (3) have a good base of medical knowledge and (4) good judgment. My internist (who at the time was being "trailed" by a medical student from a nearby university medical center) seemed a little surprised by my statement of expectations, but gave me the name of two consultants, one within his group practice and the other outside. He asked me to see both physicians. The subspecialty surgeon within his group focused on the presenting diagnosis and told me that it was not the source of my problem but went no further, providing me with enough information to know that I was not going to receive the complex care I needed from him in that medical group. I proceeded to the university medical center (to which my internist had sent a letter of referral) where I found a subspecialty surgeon (recommended by the department chairperson) who immediately demonstrated his qualifications to meet the expectations described above and will follow through with my care.
Readers can apply the same techniques. Tell the referring physician or other person what your expectations are. Ask for the names of several consultants and do not allow yourself to be locked into one medical group (may be difficult in an HMO setting). Check your state medical board listing of disciplined physicians to learn if the doctor to whom you are being referred has had medical disciplinary or competency problems. Google the doctor and the practice. Ask friends, colleagues and others in your business and personal circles if they have had experience with the physician(s) to whom you have been referred. Pay attention to what they say about competency, focus, judgment, practice habits, experience as patients billing fairness and outcome. Find out if the physician practices in a hospital and get an assessment of the quality of the institution (states have information about morbidity and mortality for certain procedures done at hospitals throughout the state and you can also ask to speak to the hospital's "Chief Medical Officer" for similar information). If you will require surgery, get the statistics on frequency of the proposed surgery at the hospital or facility at which the doctor practices and the institution's and doctor's complication or failure rate. Choose a physician who proposes to perform a procedure which he or she has performed many times before in an institution which has extensive experience with the proposed procedure: experience counts! And ask about the quality of the anesthesia services since anesthesia has its own serious set of risks.
These are some of the things a sophisticated, non-sophisticated person, or family member, can do. Much of the important information is internet-available.
And finally, pay attention to your instincts: if you are uncomfortable with the doctor or your perception ofthe facility, find someone else or go somewhere else.
My response invokes recent experience. The story is real.
Like all of us, I develop health problems from time to time. In anticipation of my needing consultation from a physiatrist or subspecialty surgeon, my internist ordered an MRI and I visited a physiatrist to receive a series of treatments. These treatments failed; I needed a subspecialty surgical consultation. In discussing my expectations of the consultant with my referring internist, I said: I expected the consulting physician to: (1) be highly knowledgeable and experienced in the surgical subspecialty; (2) have "good hands" (which to other physicians, means that he or she has excellent surgical dexterity and technique); (3) have a good base of medical knowledge and (4) good judgment. My internist (who at the time was being "trailed" by a medical student from a nearby university medical center) seemed a little surprised by my statement of expectations, but gave me the name of two consultants, one within his group practice and the other outside. He asked me to see both physicians. The subspecialty surgeon within his group focused on the presenting diagnosis and told me that it was not the source of my problem but went no further, providing me with enough information to know that I was not going to receive the complex care I needed from him in that medical group. I proceeded to the university medical center (to which my internist had sent a letter of referral) where I found a subspecialty surgeon (recommended by the department chairperson) who immediately demonstrated his qualifications to meet the expectations described above and will follow through with my care.
Readers can apply the same techniques. Tell the referring physician or other person what your expectations are. Ask for the names of several consultants and do not allow yourself to be locked into one medical group (may be difficult in an HMO setting). Check your state medical board listing of disciplined physicians to learn if the doctor to whom you are being referred has had medical disciplinary or competency problems. Google the doctor and the practice. Ask friends, colleagues and others in your business and personal circles if they have had experience with the physician(s) to whom you have been referred. Pay attention to what they say about competency, focus, judgment, practice habits, experience as patients billing fairness and outcome. Find out if the physician practices in a hospital and get an assessment of the quality of the institution (states have information about morbidity and mortality for certain procedures done at hospitals throughout the state and you can also ask to speak to the hospital's "Chief Medical Officer" for similar information). If you will require surgery, get the statistics on frequency of the proposed surgery at the hospital or facility at which the doctor practices and the institution's and doctor's complication or failure rate. Choose a physician who proposes to perform a procedure which he or she has performed many times before in an institution which has extensive experience with the proposed procedure: experience counts! And ask about the quality of the anesthesia services since anesthesia has its own serious set of risks.
These are some of the things a sophisticated, non-sophisticated person, or family member, can do. Much of the important information is internet-available.
And finally, pay attention to your instincts: if you are uncomfortable with the doctor or your perception ofthe facility, find someone else or go somewhere else.
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