Tuesday, August 28, 2007

Are you worthy of health insurance and high-value care?

Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? Note that this is the first post of a four-part series.

Let’s start with health insurance. It seems to me that the American Capitalist model currently considers three groups as worthy of having at least minimally sufficient healthcare coverage: Those with adequate financial resources (employees with employer-based insurance and the wealthy); older adults (receiving Medicare, at least until the program defaults); and the poor (who receive Medicaid). But even with these “worthy” groups, only those with the financial means have regular access to high-priced healthcare providers (such as “boutique clinics” and expensive specialists who refuse Medicare and Medicaid) versus overworked and underpaid primary care physicians and community/public health centers. And some argue that these groups should be further restricted to only those people who take good care of themselves (e.g., drug addicts, smokers, alcoholics, over-eaters, etc.) are undeserving and should lose their coverage.

On the other hand, our form of capitalism considers the tens of millions of working poor, undocumented aliens and others without adequate financial means as unworthy of health insurance. These “unworthy” adults go without needed care, including preventive and routine care, such as mammograms, pap smears, or screenings for colon cancer. Almost half of uninsured individuals will not seek care when they have a medical problem, compared to just 15% of insured individuals. They also have worse health outcomes, including breast cancer have 30 to 50% higher mortality rates, colon cancer have 50 to 60% higher mortality rates; and a 37% higher mortality rate from accidents. If they have chronic conditions, they are almost twice as likely to visit an emergency department or be hospitalized as insured patients because the lack of routine care means their chronic conditions are often poorly managed, increasing the likelihood of serious, acute complications. And once hospitalized, they receive treatment for acute needs but probably don’t receive appropriate follow-up care, resulting in worse health outcomes over the long term. Uninsured children also lack access to care and experience worse health outcomes. [The above contains snips from the CalHeatlhReform web site.]

Interestingly, the great equalizer is our failure to deliver high-value wellcare and sickcare consistently to anyone, no matter how wealthy one is and how much insurance coverage one has. Safe, effective, appropriate and timely care—delivered efficiently and affordably—is rare in America. Problems with poor care quality and waste are endemic, and our nation has been doing little to gain and use the scientific knowledge and information tools needed change things around. For example, as discussed on our Wellness Wiki :

  • Medical treatment causes between 80,000 and 250,000 deaths a year usually due to physician mistakes and negative drug effects--including unnecessary surgeries, medication errors, diagnostic errors, infections, and negative effects of drugs—which ranks the U.S. 15th out of 19 countries in deaths potentially preventable with excellent medical care. The total cost of medical mistakes, including medical costs and lost production, totals $17 to 29 billion a year. Furthermore, at least 30 percent of all direct health care outlays are the result of poor quality care, consisting primarily of overuse, misuse, and waste, with $2 billion being spent annually in excess medical costs alone. All this means our government's annual bill for healthcare spending significantly exceeds that of other nations, and could reach $4 trillion by 2015, with one of every five dollars being spent in our country on healthcare.
  • Our “practice variation” problem means that more care and higher spending are not associated with better outcomes, and may, in fact, result in worse outcomes. A patient could be hospitalized for nine days in one part of the country and three in another for the same diagnosis, and those differences would have no impact on outcomes. In other words, more expensive care isn’t necessarily better care.
  • Over 44 million people in the U.S. lack access to primary healthcare, even though such care is essential for improving outcomes and controlling costs by being patients’ first point of contact with the healthcare system, as well as their main source of preventive and essential care.
  • Compared to other industrialized countries, the U.S. is among the least likely to have extensive clinical information systems or quality-based payment incentives, the least likely to provide access to after-hours care, and the most likely to report that their patients often have difficulty paying for care.
  • The total Medicare debt will require over 90 percent of projected federal income tax revenues by 2075. And healthcare costs for promised medical benefits to retiring public employees — and estimated $1 trillion — have not been budgeted and is a looming disaster. Aging baby boomers are in for a rude awakening: Medicare is insolvent.
  • Nearly 40 percent of physicians have manipulated insurance reimbursement in order to give their patients needed care by exaggerating patients' symptoms to allow for longer hospital stays, and changing patients' diagnoses for billing purposes. In addition, providers are growing so frustrated with the reimbursement rates that receive from health plans that they are starting to sever ties with those plans. The low rates have an additional negative effect: They force providers to increase patient rosters, resulting in shorter office visits, longer waits, and growing dissatisfaction among patients.
  • There is simply not enough information about the quality of care — outcomes data about what works and what doesn’t — to enable them to make appropriate decisions. Their decisions, therefore, are based on limited or poor quality information. In other words, those who pay for and receive healthcare don’t have the knowledge they need to make informed decisions.
  • An estimated half of all surgical operations and other medical procedures lack strict scientific evidence of their effectiveness and safety, and common procedures are prescribed that are not proven effective — up to 85 percent lack adequate scientific validation. In other words, healthcare providers often don’t know what treatments work best for a particular patient. And even when good information is available to support healthcare decisions, it often isn’t being used to improve care quality because the unaided human mind, no matter how competent, simply cannot focus on all the necessary details nor possess all the knowledge needed for continually making the best clinical decisions.
  • A growing body of research in mind-body medicine not only demonstrates an undeniable interplay between biomedical, psychological, and social factors, but points specifically to a causal link between mental/emotional problems and many physical illnesses. This means that medical practitioners must somehow be certain a patient’s bodily symptoms are not significantly influenced by psychological problems, even though few have the knowledge to make such determinations.
  • Knowledge about prescription medication safety and effectiveness is sometimes lacking. The Center for Drug Evaluation and Research is described as being broken. In a rush to approve drugs, a powerless FDA has been unable to assure that drugs it approves are safe and effective despite clinical trials.
  • Billions of U.S. tax dollars are spent each year on research and hundreds of billions are spent on service delivery programs. However, relatively little is spent on, or known about, how best to ensure that the lessons learned from research inform and improve the quality of health and human services and the availability and utilization of evidence-based approaches. And there has been resistance in the healthcare industry to use scientific knowledge to help decision makers improve their performance.
  • Obtaining the knowledge to improve decision-making requires a commitment to ongoing clinical outcomes research and a focus on continuous quality improvement — things that our healthcare industry has largely avoided. If studying clinical outcomes was given the same degree of attention as optimizing financial gains and resource utilization, we would have much better knowledge for supporting diagnosis and treatment decisions.

I contend that the only way to improve healthcare quality and control costs—and sustain these benefits well into the future—is for our highest priority to focus on obtaining and using clinical knowledge wisely by rewarding the use of evolving evidence-based knowledge to support decisions about how best to prevent health problems and treat them cost-effectively. Such solutions would overcome devastating effect of today’s healthcare “knowledge gap” and broken economic models.

Sadly, this is not the case. While our society considers certain people worthy of having health insurance, we consider no one worthy of receiving high-value care. So, why don't we deserve it?

I believe there are many reasons for this. One is our failure to invest adequately on the science of evidence-based medicine and health information technology. Another is political pressure from those with a stake in maintaining the status quo because they gain financially from a low-value, error-prone healthcare system in which ignorance and misaligned incentives dominate. Our system considers them worthy of high income and profits, while the healthcare consumer suffers. This is a model for disaster.

I suggest the solution start with a shift in the way we think of “worthiness.”

First, we ought to consider all Americans and other legal residents as being worthy of adequate health insurance coverage. This is the realm of universal healthcare and there are different models for paying for such care, which should be examined and compared. Unfortunately, the idea of universal healthcare runs counter to the American Capitalist model and its “free market” principle. So, the very idea of universal healthcare requires national debate about the goodness of our economic system and how our society determines human worth and deservingness.

Since people’s addictions, emotional problems, poor lifestyle choices, etc. worsen their health and increase costs, we ought to change the things in our society that promote these kinds of problems, rather than simply dismissing these people as unworthy. We could, for example, do such things as:
  • Replace advertisements of foods laden with harmful fats and sugars, cigarette smoking, alcohol drinking, etc with adds promoting healthy eating and living
  • Make unhealthy foods more expensive than healthy ones, along with increasing the tax on tobacco and alcohol
  • Offer better health and wellness education and social programs and incentives for healthy living
  • Prove better “compliance counseling” to help people manage chronic conditions m ore effectively.

Second, we should consider all Americans and other legal residents as being worthy of high-value (safe, effective and efficient) care. This means transforming our current healthcare system into one that focuses on eliminating waste, errors, over-treatment, under-treatment, inappropriate treatment, ineffective interventions, dangerous medications, etc. It also means doing a better job with prevention and other aspects of well-care.

In conclusion, let me say that I strongly believe our country could afford to deliver high-value care to all our citizens and others (including undocumented workers and their families) if we replaced:

• Waste & inefficiency, ineffectiveness, greed, ignorance, secrecy and misaligned incentives, which benefit an “economically worthy” few

… with …

• Efficient, safe & effective, economical, scientific knowledge-based, transparent, and appropriately incentivized wellcare and sickcare for all.

Anything less is lunacy!

Click here for part 2.

Friday, August 10, 2007

Developing a sound strategy for fixing the healthcare crisis

For the past couple of weeks, I’ve been engaged in an interesting discussion on the Unity08 web site forum at www.unity08.com/node/1820. This grass-roots (bottom-up) political movement, which I recently discovered, “...is committed to presenting a third presidential ticket and platform – one that addresses the issues and challenges of the 21st Century – to the American voters in 2008.”

I’m not pushing a political agenda here, but do want to invite the readers of this blog to see what we’ve been discussing (and join in if you wish) as we attempt to develop a platform promoting a value-driven, evidence-based, consumer-centric universal healthcare system.

Here’s my introduction to the topic “Curing Healthcare: Developing a sound strategy for fixing the healthcare crisis”:

I'm thankful that healthcare consumers are finally becoming aware that our healthcare system is seriously ill. But few are aware how broken the system really is, how incredibly complex the problem is, the many shortcomings of the predominant solutions being proposed, and the strategies & tactics that hold real promise for fixing the system.

We see the U.S. healthcare system as being on the verge of collapse: Millions cannot afford health insurance; care quality is inferior compared to many other nations, while our costs are highest by far; there is little incentive to deliver cost-effective treatments and little knowledge of what constitutes high-value care; healthcare providers are squeezed financially and are unable to spend adequate time with their patients because arbitrary rules control costs without regard to quality of care; the insurance and payment models are seriously disturbed; emergency rooms are over-crowded; many of our veterans don't receive adequate care; competition between providers is misdirected; new health insurance plans put consumers at serious risk; medical malpractice suits are rampant and professional insurance is through the roof; and so on.

Bottom line is that our healthcare system is widely acclaimed for its technological hardware, yet ranks embarrassingly low in performance, access and fairness. Can it be reformed to benefit all stakeholders?

We believe the answer is yes.

My associates and I—who include doctors, nurses, counselors, patients, researchers, policy makers, economists, and others—have spent many years studying these problems and creating a sound blueprint for solving the healthcare crisis. The strategy we propose offers 20 useful tactics for changing broken healthcare policies and practices by focusing on such things as wellness, value creation (i.e., care quality improvement and cost control), consumer/patient empowerment, reforming current economic models, delivery of personalized medicine, interdisciplinary collaboration, conducting better research to develop practice guidelines and identify dangerous medications and procedures, changing the way providers compete, supporting first responders in emergencies, understanding the mind-body connection, understanding the benefits and risks of complementary and alternative approaches to care, and using innovative information technologies to aid decisions.
The post above has led to discussions of important issues you may find interesting.

I'm going to be away for the next two weeks and look forward to resume blogging upon my return.

Be well till then ...

Friday, August 03, 2007

Knowledge, Standards and the Healthcare Crisis: Part 11 (conclusion)

In my previous post [click here for first in series], I began answering the question: What has to happen for good data to become useful knowledge that leads to ever-better and more affordable care?

I discussed why we often require large pools of diverse, non-redundant data to generate reliable/valid information that supports good health and healthcare decisions. I made the case that diagnostic, treatment method, and clinical & financial outcomes data standards should be defined by determining the specific pools of data we need to guide clinical decisions. These standard data pools should include every possible piece of data that might affect the reliability (dependability) and validity (accuracy) of a person's decisions. And the data pools should evolve on an ongoing basis via a thorough evidence-based process of collaborative scientific scrutiny in which data may be prudently added, deleted or modified.

These standard data pools should be used to obtain information over people's entire lifetimes to improve diagnostic and treatment decisions by depicting important trends, associations and cause-effect relationships of health-related signs (e.g., lab test results and vital signs), symptoms (e.g., self-reported physical and psychological problems), and the factors that influence them (e.g., exposure to disease and psychosocial stressors). Furthermore, any information systems used to gather, analyze, disseminate and report these data should be extremely flexible, convenient, and useful.

The answer to the question above, however, doesn't end here.

My quest for an answer began in 1981 as I started my clinical psychology practice. I asked myself back then: How can I obtain and use every important piece of information-about a person's mind, body, actions and environment-for the continuous improvement of the care I deliver?

This quest led me on a 25 year journey across a myriad of knowledge domains, including evidence-based medicine, psychology, the mind-body connection, conventional and complementary and alternative care, wellness, practice guidelines and pathways, decision support, knowledge management, health information technology (HIT), RHIOs and HIEs, outcomes research, public health, performance metrics, transparency, health insurance, competition between providers, the business of healthcare, economic models, politics, and so on.

The more I learned, the more I realized that what was needed is a way to define, validate and manage an enormous variety of data-across all consumer demographics, health problems/diagnoses, treatment methods/procedures, and professional disciplines-for people's entire lifetimes.

We understood that managing these data is a daunting task, which requires:

  1. Gathering extensive sets of diagnostic, intervention (both well-care and sick-care processes), and outcomes (clinical and financial) data from both controlled studies and everyday practice
  2. Sharing these data with research scientists and clinicians to establish and evolve evidence-based guidelines
  3. Disseminating the guidelines to practitioners and consumers, along with useful educational/instructional materials they understand
  4. Tracking the use of the guidelines and reasons for variance (i.e., why certain recommendations were not followed)
  5. Evaluating outcomes data relevant to diagnoses and interventions
  6. Enabling anyone to participate in the process, even if they have low bandwidth and occasional connectivity
  7. Using cost-effective HIT and filling in existing gaps
  8. Providing reliable and valid decision support tools
  9. Empowering consumers to act responsibly and make wise choices
  10. Fostering collaboration between providers, researchers, public health agencies, etc.
  11. Supporting first responders and emergency room staff in disaster situations.
So, my colleagues and I invented an economical health information architecture that facilitates collaboration between loosely connected persons, as well as innovative decision aids. We also wrote a blueprint for a "Patient Life-Cycle Wellness System" and an Evidence-based HealthCare Decision Support System flowchart that describe a patient-centered, whole-person, birth-to-death strategy for continually improving care and wellness throughout the healthcare continuum.

Our strategy focused on building health science knowledgebases and using them with evidence-based decision-support tools by:
  1. Collecting data about a patient, the patient's problem, the treatments rendered and the outcomes using different HIT tools. These data include clinical and financial outcomes, variance data, as well as patient and provider data.
  2. Sending the date to research databases, stripped of patient identifiers, where scientists and other knowledge workers access, study and discuss the data collaboratively by (a) using analytic tools to find patterns in the data; (b) challenging one another's interpretations of the data, and the assumptions and predictions they make; (c) building clinical models reflecting diagnostic and associated treatment processes; and (d) sharing and evolving these models.
  3. Validating or the invalidating the intervention-recommendation models. The validated models are supported by the scientific evidence showing that particular interventions are safe, effective, and efficient when used to treat particular types of patients with particular health problems in particular situations. The invalidated models have scientific evidence that shows when particular interventions are not safe, effective, and efficient when used to treat particular types of patients with particular health problems in particular situations; so they are useful for determining when not to use a certain intervention.
  4. The validated and invalidated intervention-recommendation models become evidence-based practice guidelines, which are stored in health science knowledgebases. Each evidence-based practice guideline is associated with reference and instructional materials, which are also stored in the knowledgebases.
  5. The evidence-based practice guidelines and related materials in the science knowledgebases are disseminated to authorized stakeholders, where they are stored locally and accessed for use in the decision support tools.
  6. The decision tools send data about the care process and outcomes to the research databases, which is used to create new and modify existing practice guidelines. This is an ongoing feedback loop leading to continually improving guidelines and outcomes.
My answer to original question-What has to happen for good data to become useful knowledge that leads to ever-better and more affordable care?-is, therefore: We ought to (a) transform the current healthcare system to align it with the Patient Life-Cycle Wellness System blueprint and (b) build health science knowledgebases that are used with evidence-based decision-support tools. This strategy would help overcome the knowledge gap and promote continual improvements in the quality and efficiency (value, cost-effectiveness) of care delivery.