Great piece by a psychiatrist who used to give lunchtime talks to other docs to promote Effexor . $750 a pop for an hour’s talk. And you wonder why it’s easy for doctors to get mixed up in it all. (Answer: we’re human.)

7 Comments »

KevinMD loves loves loves to talk about how universal health care will stifle innovation , and while theoretically I see where he’s coming from, I just don’t see the overwhelming data to support the hypothesis. His most recent link is to a Happy Hospitalist post about purchasing pens and limits to innovation, but I don’t really see the connection. I’ve seen plenty of surgeons get to choose which devices they’d like to use being paid by Medicare, the VA, or private insurance.

And because timing is everything, The New Republic’s Jonathan Cohn has a really fantastic piece on innovation in universal health care: Creative Destruction: The best case against universal health care . Just like he says in the article, I’ve yet to see an innovator in the academic sector (where much of innovation begins) be driven by profit. It’s driven by wanting to alleviate suffering, to find answers to questions, to let curiosity and discovery flourish. If you didn’t know, the invention of the CT scanner is shared between the US and UK. France was the first to discover the HIV virus.

The article’s a good 5-10 minute read, but well worth it. Key bits:

But it’s one thing to say that universal coverage could lead to less innovation or reduce the availability of high-tech care. It is quite another to say that it will do those things, which is the claim that opponents frequently make. That argument requires several leaps of logic, many of them highly suspect. The forces that produce innovation in medicine turn out to be a great deal more complicated than critics of universal coverage seem to grasp. Ultimately, whether innovation would continue to thrive under universal health care depends entirely on what kind of system we create and how well we run it. In fact, it’s quite possible that universal coverage could lead to better innovation.

Of course, the idea of involving the government in these decisions is anathema to many conservatives–since, they argue, the private sector is bound to make better decisions than a bunch of bureaucrats in Washington. But, while that’s frequently true in economics, health care may be an exception. One feature of the U.S. insurance system is its relentless focus on short-term good. Private insurers have little incentive to pay for interventions that don’t yield immediate benefits, because they are gaining and losing members all the time. As a result, money invested on patient health may very well help a competitor’s bottom line. What’s more, the for-profit insurance industry–like the pharmaceutical and device industries–responds to Wall Street, which cares more about quarterly filings than long-term financial health. So there’s relatively little incentive to spend money on the kinds of innovations that yield long-term, diffuse benefits–such as the creation of a better information infrastructure that would help both doctors and consumers judge what treatments are necessary when.

The government, by contrast, has plenty of incentive to prioritize these sorts of investments. And, in more centralized systems, it can do just that. Several European countries are way ahead of us when it comes to establishing electronic medical records. When fully implemented, these systems will allow any doctor, nurse, or hospital seeing a patient for the first time to discover instantly what drugs that person has taken. It’s the single easiest way to prevent medication errors–a true innovation. Thousands of Americans die because of such errors every year, yet the private sector has neither the will nor, really, the way to fix this problem.

9 Comments »

I haven’t really seen much discussion of this really, really important 2007 Commonwealth Foundation Survey of 7 Countries (wait, don’t click!), so I thought I’d give you my take. Without all that pesky reading and analysis. We’ll just summarize the tables. (I know, I know, this is not the recommended way to read an article.)

If you want to read them yourself: Table 1 , Table 2 , Table 3 , Table 4 , Table 5 , Table 6 , Table 7 . But really, here’s the summary:

7 countries, phone interviews conducted: Australia, New Zealand, Germany, the Netherlands, the United Kingdom, and the United States. At least 1000 people surveyed in each country. A wide variety of questions asked. These ranged from questions about primary care access to prescription drug costs to medical errors to going without care because of cost to electronic medical record usage to ER visits to elective surgery wait times to chronic disease to health care quality. (Yes, of course, some of these answers depend on culture and stuff. Hear me out.)

If you do look through all that data, you’ll notice something really striking: country to country, it’s really not all that different . Sure, there’s lots of variation. Germans are the most confident they’ll receive the “best medical technology”; people in the Netherlands are the least likely to wait greater than 6 months for elective surgery; Australians are the most likely to be able to contact their doctor on the weekends; Americans were the most likely to receive reminders for preventative or follow-up care; it’s very easy for New Zealanders to contact their doctor by phone during regular hours; the Brits are the most likely to have financial incentives for quality.

If you look at the numbers, however, again: things are fairly similar. As a general trend, what separates the best from the worst is only 10 or 20 percentage points’ difference. Overall, these 7 countries are fairly similar. Sure, in some areas there are countries that seem to really be doing a better job–but it’s not consistent for every area and for every country. There’s not one health care system that’s the best, and as the authors point out, all these countries (not just ours) are struggling, trying to figure out how to provide care for an aging population with technology that’s advancing faster than we can pay for it. In this way, I do agree with KevinMD –that if we’re going to redesign our health care system, we can’t just copy Canada or France–their systems are struggling just as ours is.

But there is one area where things are markedly different. (You knew where this was going, right?) Cost . In the US, we’re spending 16.0% of GDP on our healthcare system, where the next closest country in this survey, Germany, comes out at 10.2%. Now you say to yourself, “Self, that’s only 5.8% difference!” But that difference ends up being hundreds of billions of dollars (and $3,410 per person). And you look at percent uninsured, and New Zealand is our closest competitor, at less than 2%. We’re up at 16%.

So you look at all this survey data, where the United States is clearly in the middle of the pack (along with everyone else), and don’t you seriously have to wonder, “Then what the hell are we paying so much for?” If we’re not the fastest to get elective surgery (that award goes the Germans), and we’re not the most likely to see 2 or more specialists (again, Germany wins that one), and yet we’re the most likely to have people report forgoing care because of cost, and the most likely to have a problem with coordination of care (getting lab results or medical records sent to another doctor), again, where’s the money going?

For what we’re paying for, our health care system should be winning every single poll, every single year. What a disgrace.

4 Comments »

Health Care Is A Right : click for the one-minute video.

“I strongly support universal, single payer, government-provided or government-funded health care. It doesn’t mean that the government runs it. It can have competition among the different providers. But I just think that we’ve long since reached the stage that it’s immoral to put people in a situation where they cannot get the medical care
they need because their incomes aren’t high enough. I think that it ought to be a matter of right. And our current system just doesn’t work. It’s way too expensive. The quality of health care is excellent for those who have enough money to buy the very best, but lower-income and low-middle-income Americans are not getting good health care, and so many now cannot afford the private health insurance that they’re going without insurance – millions and millions of people. And I think that to eliminate the incredibly ridiculous costs of all of this unnecessary paper work, and different standards from different insurance companies, it is time to have universal health insurance.”

41 Comments »

I received more comments on my Planned Parenthood post than any post in a long time. Thanks! A bunch of people had questions about minors and sexual activity and reporting–first, you have to check with your own state, as it varies per state.

This is a list of when physicians must report sexual activity among their patients (for California). Often I’m told that patients (teenagers) know about these rules and will generally lie or not answer the question about their partner(‘)s age because of this. Also, in some jurisdictions, I’m told that the area does not believe that mandatory reporting is good for its community, so physicians will technically report to the police, but the police never act on it; in this way, physicians are not breaking the law.

5 Comments »

I’m reminded of the stupidity of HIPAA today, as I walked into a nurses’ station where all the medical charts are, dressed in a tie and slacks (no white coat or name badge) and no one asked me a thing.

Dressed appropriately, you could do this in any hospital in the United States and no one would question a thing.

HIPAA does not protect anyone’s privacy, it just makes a paperwork hassle for you and your doctors.

10 Comments »

KevinMD (love to love his blog, love to hate his health policy!) has never really explained himself as to why he agrees with John Stossel that HSAs will make any type of dent in our health care costs, and Shadowfax takes them both to task for it .

The acutely ill do not make health care decisions and are not responsive to costs. I repeat.
The acutely ill do not make health care decisions and are not responsive to costs.

Just like Shadowfax says–the guy possibly having a heart attack, or the incredibly sick patient with pneumonia who’s going to the ICU is not in any position (or state of mind) to determine if he should get the generic or the brand name antibiotic; if he should have a foley catheter placed; if he should have heart surgery or just stenting.

And one other point to add to Shadowfax: The Most Important Health Care Graph:

Us fairly healthy folk cost next to nothing for the health care system. Deciding whether we need a chest xray or not is like taking a grain of sand from the beach.

4 Comments »

During my OB-Gyn rotation, I’ve been working with the great staff of our local Planned Parenthood , and let me just say: Planned Parenthood rocks.

I will admit, fully ignorant of Planned Parenthood beforehand, I thought I’d be doing abortion evaluations. Planned Parenthood equals abortions. That was the extent of my knowledge. I spoke with friends–well-educated, public health-type friends, and that was their same response. “So, did you do any abortions today?”

I was so far, far off base it’s not even funny. * In fact, it may sound ironic, but I’m pretty confident when I say this: No matter what your feelings are about the subject, there would be more abortions performed in this country if Planned Parenthood didn’t exist. Let me explain.

The patients I’ve seen have been, in general, young, healthy women, ages 12 to 26. They come in primarily for three things:

1. annual exams (pap smears, breast exams, etc.),
2. sexually-transmitted infection (STIs) diagnosis and treatment,
3. and birth control.

I see patients of all socio-economic statuses, but most are immigrants or lower-middle class women. Their health knowledge runs the gamut, from the highly educated 12 year-old I saw today, who curiously asked “how exactly do the birth control pills work ?” to the 23 year-old who shrugs and answers questions with a dull, empty look on her face. Almost every single one uses some form of birth control.

This makes sense. Over 90% of women of childbearing age use some sort of contraception method. I quickly became aware that my male gender has allowed me to pass through medical school (and life!) totally ignorant of all of this. My patients came in using almost everything–condoms, the pill, the patch, Nuvaring, Depo–and I was left perplexed. What a humbling role reversal–this was one of the first times it’s been so painfully obvious that my patients are more informed about their health and medicines than me. (This also made me realize that I generally assume I generally know more about medicine than my patients.) Not that the pharmacology or physiology is at all complex or difficult–just that the topics had never really come up before. Birth control was birth control was birth control.

I’ve been having a fantastic time at Planned Parenthood–I’m able to perform a number of pelvic exams and get a good sampling of “normal variation,” and probably the harder part–I’m able to talk very candidly with my patients about their sexual health. It’s great practice just to get used to figuring out how to talk about “sexual activity” and “sexual intercourse,” because it certainly takes practice. You have to unlearn (or at least disengage) the typical social cues in your head that encourage you to avoid the subject or the word, especially since almost none of my patients have had any complaints or concerns with their sexual health. It’s great to see patients in an environment where discussing sexual health is the norm, as it also helps bring a level of normalcy to the encounter.

We give out a ton of contraceptives every day. Condoms, pills, patches, rings, shots. And none of the patients I’ve seen are taking these medications for anything other than preventing pregnancy. They are sexually active, almost always with one, monogamous partner, and they do not want to get pregnant. And by enrolling these largely uninsured teens and young women in California’s Family PACT program , we’re able to provide them with free contraceptives and reproductive health services.

55% of pregnancies in the US are unintended, and of these, 43% are live births, 43% are terminated electively, and 13% end in miscarriage.

All the women I see in clinic are sexually active. And most are working or middle class at best by income standards (the average 2 bedroom apartment in the area runs you at least $1400 a month), most are uninsured, and most do not have another source of medical or reproductive care. And none want to get pregnant.

Now just take away Planned Parenthood, add in the costs to see a health care provider and pay for contraceptives, and imagine how many more of my patients would become pregnant. Keeping everything else the same, you’d find many more women in the difficult position of considering an elective termination of pregnancy.

I am far from zealot or activist–as I said before, I knew nothing before a few weeks ago–but I’ve been incredibly impressed with my short time there, and I’m hoping I’ve educated you as to what Planned Parenthood does in your community, since I was woefully ignorant myself.

*Planned Parenthood provides reproductive health services, annual female gynecologic evaluations, breast exams, pap smears (and management and followup of abnormal pap smears), the HPV vaccine, STI testing including HIV, emergency contraception, vasectomies, patient education–the list goes on and on.

58 Comments »

I’ve got to meet this shadowfax gent; his politics are simply astounding . He also points out that no one is asking for a national health service, which Kevin loves to complain about ; Catron too , and Medpundit as well. I’ll triple link my old damn post: NHS Isn’t NHI .

A government-run health care system is not the same as a government-payor financed health care system. Read basic health policy. Thanks.

1 Comment »

Follow-up on my Green Medicine post ; there’s a very easy way to reduce the usage of supplies in the hospital: PATIENTS, QUIT GETTING SICK!

No, seriously–if you care about the environment, take your medications and follow-up with your outpatient doctor regularly; you’re less likely develop common diseases that require admission, paperwork, and supplies to diagnose and treat you: congestive heart failure, COPD exacerbations, pneumonias, heart attacks, strokes–the list goes on and on.

2 Comments »