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Archive for October, 2009

Conversations about Healthcare Reform have fomented conversations about patient outcomes.  Here are some interesting readings on this topic:

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Jack Wennberg is a pioneer in using data to study clinical outcomes and geographic variations in treatment patterns.  He finds that where you live determines the amount of care you will receive, and that more care does not correlate to better outcomes.  Alix Spiegel on NPR takes a look at Wennberg’s work, and what it might say to us today:

In 2003, there was an enormous landmark study published by a Jack Wennberg protege named Elliott Fisher, who works at Dartmouth College. Fisher compared Medicare recipients with similar levels of sickness in areas throughout the whole United States. Fisher looked at places where elderly people used relatively few health care services and compared them with places where elderly people used a lot of health care services.

“The patients in the high-spending regions were getting about 60 percent more care; 60 percent more days in the hospital; twice as many specialist visits,” Fisher says. “And yet when we followed patients for up to five years, if you lived in one of these higher-intensity communities, your survival [rate] was certainly no better, and in many cases a little bit worse.”

Her conclusion?

… Fisher and other researchers estimate that almost one-third of the care given in our country today is that kind of care — care that isn’t really helping people.

The United States spends more than $2 trillion on health care every year. So the cost of that 30 percent unnecessary care annually? $660 billion.

imagesAtul Gawande also drew on the the work of Fisher and Wennberg in his must-read article appearing in the New Yorker in June.  Gawande, a prolific writer as well as a Boston area surgeon and Harvard professor, visited McAllen, TX–the second most expensive health care market in the country.

Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.

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Congress

Robert Pear and David Herszenhorn at the New York Times tell us that the Congressional Budget Office (CBO) has returned the Senate Finance Committee’s legislation for Healthcare Reform:

The much-anticipated cost analysis showed the bill meeting President Obama’s main requirements, including his demand that health legislation not add “one dime to the deficit.” Indeed, the budget office said, the bill would reduce deficits by a total of $81 billion in the decade starting next year.

The numbers from the CBO are not reassuring to those who have dug the trench and are willing to defend their constituencies against imposed healthcare reform.  Dennis Smith at the Heritage Foundation argues that

The Congressional Budget Office preliminary estimate of the Senate Finance Committee’s work is a devastating revelation. The bill is a platform for an enormous jump in federal spending, and yet it still leaves 25 million Americans without health insurance. The gross cost of new federal outlays increased from $738 billion to $829 billion. Meanwhile, the Baucus bill will accelerate, contrary to the president’s rhetoric, the government’s “takeover” of the health care sector of the economy.  Nearly half of the individuals who gain insurance will be through Medicaid, a poorly performing program that is insulated from any serious systemic improvement. Expanding Medicaid, a welfare program, is not health care reform.

There are other ways to frame the findings. The government plan surveyed by the CBO will “go unnoticed” by most Americans, writes Ezra Klein at the Washington Post:

The verdict? It will look a lot like our old health-care system.

Unless you’re uninsured, or on the individual market, this bill is not expected to affect you. CBO estimates that 29 million Americans who would’ve otherwise been uninsured will be covered. That’s a very big deal. Five million Americans who would otherwise have been left to the individual market will find a better option. And 3 million Americans who would’ve otherwise been in employer-based health insurance will be on the exchanges or, in some cases, on Medicaid. The insurance exchanges are projected to serve 23 million people come 2019, and 18 million of the members will be low-income and on subsidies.

That leaves 245 million non-elderly Americans who will pretty much be in the exact place they would’ve been otherwise.

Finally, as expected, the government planned legislation doesn’t go far enough for others.  To force action on the healthcare issue,  Nicholas Kristoff suggests that the members of Congress’ insurance patterns mirror the national demographic

I propose that if health reform fails this year, 15 percent of members of Congress, along with their families, randomly lose all health insurance and another 8 percent receive inadequate coverage.

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Empowering Patients

Yesterday this article in the Atlantic by Clayton Christensen and Jason Hwang came across our desks. You probably recognize these fellows as the authors of The Innovator’s Prescription.  book_tip_sm(In case you haven’t been following Christensen’s rise to cult figure status, he is also responsible for the ubiquitous use of the word “disruptive” by anyone hoping to convince you they have a decent idea.)  Christensen and Hwang propose that we encourage patients to become more educated partners in health management. They point to the the strong communities for diabetics as a nascent, but successful, model and find that there are correlations between educated patients/better care/lower costs:

“Already, advances in scientific knowledge and medical technology are enabling some patients to monitor their health and control their own diseases. Insulin-dependent diabetics, for example, quickly learn how to manage their blood glucose levels at home by matching their insulin dosage to changes in their diet and physical activity. Many diabetics have also joined online communities to share information and advice, sometimes viewing each other as more trusted advisors than their own doctors. Diabetics who take their health in hand in this way find that the cost of care decreases dramatically, while the quality increases: it’s far more effective than relying on experts whom they may see only every few months.”

There are other voices ahead of Christensen and Hwang on the “patient empowerment” front (although not many as visible or as articulate). For instance, Diabetes Mine, started by Amy Tenderich, has been an online resource for people dealing with diabetes for four years and may be a front-runner in the field.   E-Patient Dave is a terrifically interesting blog written by a man who took on his cancer (and the medical establishment) and “stomped it.”  He then took his experience, expanded it, shared it, and has now commercialized it with a new business.

At the Medicine 2.0 Conference: http://epatientdave.com/

At the Medicine 2.0 Conference: http://epatientdave.com/

You can find Dave’s voice among others working in the “Participatory Medicine” arena at e-Patients.net. We liked a guest posting at this site by Amy Romano:

What if we could help a large population of highly motivated, influential health care consumers become empowered, engaged, equipped, and enabled? And what if they could develop these skills while they were healthy –before they face life threatening illnesses or need to manage chronic conditions? What if transforming the way these consumers participated in their care could reduce the burden of one of the most costly conditions in our health care system and improve the health of millions of people each year?

It’s all possible – if we make maternity care more participatory.

To be more informed about the participatory medicine movement, E-Patient Dave recommends a short video advertising an E-Patient Conference happening this fall in Philadelphia.  (You can also find Jason Hwang at this conference.)

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