Tuesday, February 10, 2009

Disease Prevention as Cost Avoidance

Steven Woolf, in a Commentary in JAMA (February 4, 2009) looks at the potential for cost avoidance with prevention and screening and makes the valid point that "it makes sense to invest in a well-defined package of preventive services". President Obama recently made the point, while speaking about the recovery bill that preventive services can save money for the nation in the long run. While this focus on health and prevention is laudatory, I worry about this becoming an excuse to blame patients who are unsuccessful in trying to modify their lifestyles.

Most successful prevention starts with making very difficult lifestyle changes. Exercising, eating right and stopping smoking have major effects on health and health care costs but are often unsuccessful. Only 5 - 10% of those who try to stop smoking on their own succeed. Only 5% of those who try to lose weight actually lose weight and keep the weight off. With 90 - 95% failure rates for these lifestyle changes, the danger to avoid is punishing people for those failures and blaming them for the nation's high health care costs.

People can do everything right and still get sick. The question "what did you do to yourself?" is often asked when someone is ill even thought the implication is of guilt on the part of the patient.

The focus on prevention is good but has to be combined with support of those people who get sick despite their best attempts. Illness is not optional and even those who try and lose weight and exercise can get sick and need care.

Monday, February 9, 2009

Heatlh IT - The Promises and Dangers

President Obama is convinced that a 20 billion dollar investment in Health IT (as is present in the house version of the recovery bill), can save money and improve care. An article entitled, "Clinical Information Technologies and Inpatient Outcomes" in the Archives of Internal Medicine supports that view by stating that hospitals with automated notes and records had fewer complications, lower mortality rates and lower costs than hospitals without the newer health information technology. I agree!

But lest you think that this technology is only positive, think about the downside of electronic records of any sort. Have you ever tried to correct a mistake in a billing record for a utility company? Electronic media never seems to die and resists change. A mistake in your medical record stating that you have a disease that you don't really have can remain forever and can be difficult to remove.

Electronic medical records have also been designed to foster physician use so they have purposely allowed for whole sections to be entered with a simgle keystroke. Why bother to write your own history when you just agree with another doctor's history? Just hit the key and it appears as your own. After all it is faster and the information is the same! Well often the information is not the same and incorrect records gets repeated over and over in multiple notes.

Privacy is perhaps most troubling as the ability of medical records to be shared by medical professionals also makes the loss of confidentiality easier.

We need updated health information technology but we need to be careful about its proper design and use.

Friday, February 6, 2009

Data About Doctors: A New Court Ruling Creates Controversy

Much like the children of Lake Wobegon, all doctors, to their patients, are above average. It is time to give you another secret of medicine: Some doctors did graduate at the bottom of their class and some doctors are not as good as others. How do you know if seeing your doctor will result in quality care? It isn't easy.
Depending on your point of view, a new decision by the Federal Appelate Court either makes the already difficult job of compiling, analyzing and reporting on physician specific data even harder or prevents misleading data from being reported. The decision is that the US Department of Health and Human Services is not required to release data on 40 million patient cases involving 700,000 physicians under the freedom of information act.
The data is physician specific Medicare claims data which is billing data, not medical records. Thus physician groups are worried that it can be interpreted in misleading ways and may breach confidentiality. Payers are arguing that while imperfect, the data still will move us forward in understanding individual physician practice patterns and allow for better decision making.
I know that both sides are partially right and that the issue will not go away.
This is just one scene in a multi-act play and we have not even reached intermission. I am sure that we will continue to move forward with increasing information available on individual physicians. The challenge will be determining the right measurements for physician quality and gathering the information in a way that maintains the integrity of the data while always maintaining doctor-patient confidentiality. There are no easy answers.

Tuesday, February 3, 2009

Ultrasound as Physical Exam: Costs and Benefits

Will hand-carried ultrasounds be the new stethoscope, being used by every doctor as often as they take your pulse and listen to your heart sounds? The editorial "Should a Hand-carried Ultrasound Machine Become Standard Equipment for Every Internist?" in the American Journal of Medicine suggests that we are heading in that direction. According to the editorial the ultrasounds are "reasonable in cost, and highly accurate" and "have already increased the safety of many procedures". So what are the problems?

Who will train physicians so they know how to interpret what they are looking at?

Will it be like a stethoscope and therefore there will be no separate charge for its use? I am not sure physicians paying between $9,000 and $40,000 for the equipment (although costs will probably go down) would want to forgo payment for its use.

If there is an extra charge and it is used as routinely as a stethoscope, what will it actually cost an individual patient, how will it impact insurance premiums, and how will it impact the amount we pay in taxes that goes towards health care costs?

For all this money will it actually improve the outcomes of care?

The hand-carried ultrasound may improve care and if that is the case let's prove that with proper studies and start using it. Let's just not ignore the fact that we will need to be as creative in determining a payment system for it as were the doctors and engineers who have invented it.

Illness and Death are Not Optional

Prevention doesn't work! Prevention does work! Which is it? It turns out that an article in American Medical News entitled "Keeping Prevention in Perspective" confirms what I have believed for a long time. That is that prevention is oversold, mainly by scaring fundamentally healthy people. At the same time some prevention is undersold and should be used more. While some preventive steps are extremely helpful to maintaining an active, happy lifestyle, only a few have been shown to statistically decrease mortality. The difficulty is knowing which measures are really critical and which are more discretionary. Here are some key bits of advice:
  1. The most important thing one can do to stay healthy is to pick your parents carefully. What, you say that you can't pick your parents? Then you are stuck with your parents genes and you have to act to make the most of what you have.
  2. Make sure that you have a primary care doctor who will take the time to discuss prevention with you so that you can really understand requirements and options
  3. Listen to the messages through the media but don't overreact to the scare tactics or under react to the important messages.
  4. Do your own research, talk to your friends and if you are really ambitious, look at the US Preventive Services Task Force (USPSTF) recommendations to read what your doctor is reading (or should be reading)
  5. Lastly, just live your life in moderation and don't focus too much on your health. After all, life is a uniformly fatal disease and it should not be wasted by worrying.