Inkwell: Authors and Artists

    
My bet is that the effect will very real, but will be hard to see on
the mass level, hard for the Democrats to point to and say, "See? We
did this!" Because it will be a slow change, on the pace at which
people adjust to new circumstances, absorb the difference, and change
their life plans. But very real, yes.
  

    
I'm hoping at the state level, at least the real costs for paying for
immediate emergency care will drop drastically as this bill becomes
effective in insuring the indagent - isn't that one of the major cost
savings associated with the bill?
  

    
To the extent that it works and most of the uninsured become covered,
yes. It would mean that the hospital is not forced to tack on their
expenses to everyone else's bill. But the Republicans are eager to make
sure that Medicaid is not expanded, even if the states don't have to
pay for it, because blaming and hurting poor people is a principle for
them. That and other obstructions may mean that in the end ACA will not
cover as many extra people as hoped.
  

    
(wickett, I am pretty sure you can go back in and EDIT your original
review of Joe's book to say whatever you'd now like it to.)
  

    
(Actually, she did, except it appears that Amazon removed the URL
itself.)
  

    

Yes. Yes.
  

    
joe, op-ed in today's chron by katherine schlaerth, an associate prof
at loma linda school of medicine, on some potential law of unintended
(negative) consquences from obamacare:

http://www.sfgate.com/default/article/What-s-next-from-Obamacare-3680231.php


thots?
  

    

Joe, I just got the August Consumer Reports magazine. There's an
article "How Safe is Your Hospital". One startling part of that
article is that "No hospital got top scores for readmissions or
communication." NONE.

The readmission number was for heart attacks, heart failure and
pneumonia readmissions within 30 days of discharge.

Communication is defined to be explanation of new medications
and discharge planning.

I would have thought that a few would do well on these measures
and was shocked to read CR's findings.

Care to comment?
  

    
Thanks, Paulina. The article about unintended consequences of
Obamacare is by a longtime family physician. She has several concerns:
  o  Not enough physicians, physicians will be even more stretched,
pressured to see ever more patients
  o  This will lead to even more over-prescription of narcotics and
antibiotics
  o  Electronic medical records are ready for prime time.
  o  ACA diverts funds to prevention from cures, but people won't
change their habits.

These concerns vary, but they have this core thread in common: They
assume that the ACA is implemented, but the system does not respond in
any fundamental way, and there are no other big changes going on in
healthcare. People tend to see things this way: Here is this influence
coming our way, here's what it feels like it will mean to me. People
tend not to think about how the system will react to those changes, and
what other influences the system is under. This doesn't yield the best
analysis.

In fact, the system is adapting in some fundamental ways to the ACA.
More importantly, it is undergoing some fundamental changes that are
more or less independent of the ACA. That is what this book is about.
  

    
To meet her concerns individually:

> Not enough providers, and the resulting pressures

True, even without the ACA, just with the Boomers aging into Medicare
years. If the system made no response to this, yes, the existing
doctors would be extraordinarily stressed. The real pressure on the
system is to use doctors time far more effectively and efficiently.
Note, for instance, that she says the uses one-third of her time
inputting data. If that is true and average (which I don't necessarily
doubt) solve that problem with software that derives its data directly
from the actions of the doctors and the direct input of tests and labs
and doctors orders, boom, you have 50% more doctors' time. That's just
one example. The software, the team systems, and the business models
that can do this all exist, and are outlined in the book.
  

    
> EMRs not ready for prime time

This is true of many major systems, as we have discussed above and as
I detail extensively in the book. To the extent that systems shift from
being strictly fee-for-service to being paid in one way or another for
outcomes and the health of populations, they will ditch systems that
get in the way of clinical care in favor of systems that optimize it.
The legacy software providers in the field now will adapt or die.
Seriously — here are the top 8 computer companies circa 1980: IBM,
Burroughs, UNIVAC, DEC, NCR, Control Data, Honeywell, Hewlett Packard.
By 1990 all of them had gone bankrupt, been bought out and scaled down,
or had fundamentally changed their product lines and business models
and been born again. We will see the same thing in the health IT
business within this decade. It will be expensive, wrenching, and
difficult, but it will happen.
  

    
> ACA diverts funds to prevention from cure, and people won't change

There are two parts to that sentence and as far as I can tell neither
is true. The ACA does not actually "divert" funds away from cures in
any way that I can think of. It does emphasize preventive measures, and
mandate that they be free to any covered patient, to encourage their
use. And that is built on the well-demonstrated notion that prevention
will drive down the costs on the "cure" end.

I would respectfully suggest that being a doctor in the conventional
health system would give one no basis on which to declare that people
won't change. Of course they don't change if the doctor simply
instructs them to lose weight, stop smoking, cut down on their
drinking, or change their diet. Most doctors have never seen a full-on,
serious, well-constructed preventive healthcare program — and most of
the personnel in such programs are not doctors. The idea that people
won't change in the face of such serious well-constructed programs is
refuted by the many examples throughout the book of different
populations, funded in different ways, dropping their healthcare costs
by being better cared for and becoming healthier without any
extraordinary will power or shift in human nature. The notion that
"people won't change" (with the implication that an emphasis on
prevention is a waste of money) is simply provably false.
  

    
> Consumer Reports ... "How Safe is Your Hospital" ... "No hospital
got top scores for readmissions or communication." NONE.

Haven't seen it, but I am not surprised. Even our best institutions
have problems. Johns Hopkins is famous for poor communications, and its
re-admit stats have been about average. In the book I cite Don
Berwick, the founder of the Institute for Healthcare Improvement and
until recently Obama's appointee for running Medicare and Medicaid:

He spoke repeatedly at industry functions, arguing for higher-quality
standards and practices. On December 4, 2003, at IHI’s annual meeting,
he delivered the talk that would become a classic, “My Right Knee.”
Knowing that his knee would have to be replaced soon, he laid out five
requirements he would demand of any medical institution that would do
his surgery:

  o  1. Don’t kill me (no needless deaths). 
  o  2. Do help me, and don’t hurt me (no needless pain). 
  o  3. Don’t make me feel helpless. 
  o  4. Don’t keep me waiting. 
  o  5. Don’t waste resources, mine or anyone else’s.

Berwick felt that every patient should be able to make exactly such a
demand. But given what he knew of the medical establishment, he was not
at all sure that he could find any institution in the United States
that could deliver on those five promises. This is striking, coming
from a doctor who was probably as intimately aware of how healthcare
institutions work as anyone alive: “Given my requirements, it is not
clear that any health care institution in the United States will want
to take me on as a patient.”

Many institutions have been making great progress, but all
institutions still have to make big changes to be ready for the Next
Healthcare.
  

    


i much prefer that your model of the world (adaptive systems changing for
the general benefit) than that of the loma linda prof's feeling that things
will just get worse along the lines they have been worsening.

an ill-formed set of concerns, presaged by remarks made by julie and the
estimable <wickett>:

- mysterious chronic illness (such as MS, cfs, fibromyalgia, etc) are
actually far more common than is realized --- and these are managed (if at
all) through tending and care. yet discussions of how to provide the kind of
care those of us who suffer from such need dont seem to enter into the
current discussions of the healthcare mess and how to fix it.

- i really worry about the loss of solo practitioners.

- combing these concerns into one personal example in addition to my other
maladies i have neurologically-driven odd chronic pain probs --- and it had
gotten to the point in 2007 where i had to reserve a wheelchair at airports
coming and going in order to attend my mother's funeral (thank you, ADA!).
this experience so freaked me out i decided i needed to throw everything at
getting better: so a variety of pt, pilates, chiropractic, ultrasound, cold
laser, contrast baths, therapeutic massage, and acupuncture brought about
huge positive changes; no wheelchairs in sight five years later and i have
-gained- 1/2 inch in height (less spinal compression).

* none of this 'healthcare' was paid for by my insurance (i consider myself
very forturnate to have my get-hit-by-a-truck insurance at under $500/month)
so the system doesnt 'know' that my taking proactive and preventative steps
has saved 'the system' money (can walk and carry things; am not on pain
meds; dont need homehealthcare attendants, etc etc)

* i chose the practitioners who i felt got me and the idiosyncracies of my
condition; none of these were part of any group and no one was dictating
their methods.

* it seems to me (from reading propaganda handed out by ucla and cedars-
sinai) that while there is recognition that CIM (complementary and
integrative medicine) can really help with chronic illness and can save
money (because other kinds of nasty interventions arent required) there is
less funding for it and research into it as evidence-based medicine, than
there is funding for fussing about with bright shiny new molecules and
genetic intervemtions, which are both intellectually sexy and promise
potentially renumerative IP.

thots?
  

    
Hey, Paulina!

One of the core modes of thought of the book is that when people
discuss how to fix healthcare, they almost inevitably try to come up
with some massive system change: This is how healthcare should be! This
one way! Yet most industries or economic systems have much more
variety of business models to meet different kinds of customer needs.
So should healthcare. Though there are certain new modes that are
rising to prominence, such as comprehensive healthcare systems that do
most of their business on a risk-based model of one kind or another,
there will be (I believe) a far greater variety of business models in
the future of healthcare than today's. 

People with these "mysterious chronic illness (such as MS, cfs,
fibromyalgia, etc)" tend to be ill-served by fee-for-service medicine,
which will only provide specific services that can be reimbursed at a
remunerative level as they are demanded. The notion that providing some
service now will prevent the patient from deteriorating to the point
where they will need greater services later has no place in the
economics of a fee-for-service system — especially when the system will
get reimbursed for the greater services later! Despite that best
intentions and compassion of the individuals who run them, economic
systems have a kind of relentless ruthlessness. They simply cannot
afford to do things that will not fuel them with more money. They are
not going to chase after people with such mysterious chronic illnesses
and really work to devise the best program of help for them.

A system at risk for the costs of your health over time would act
quite differently, because the potential costs of such diseases are
much larger than those of other people. When you are at risk, people
with big costs are not sources of profit, they are sources of cost. You
make money by reducing the costs. 

You actually reduced the system's costs with all your efforts. But you
are unusually smart, active, and educated in your own behalf. If I
were the CFO of a system at risk for the health of thousands of people,
I would read your story and think of the other 99% of people in your
situation who are not so active and intelligent, and will end up
costing huge amounts if we don't figure out how to find them and help
them now.
  

    
> CIM vs. shiny new molecules

This is similar. You mention "propaganda handed out by ucla and
cedars-
sinai." By certain measures, those are the two most-expensive
fee-for-service systems in the country. The important thing to note is
that the complementary/alternative medicine approach to chronic illness
is so much cheaper than other approaches, especially than "bright
shiny new molecules and genetic interventions." Again, the "cheaper"
part flips both ways: In a fee-for-service system, that reads as "labor
intensive, with lower or no reimbursement." In a system at risk for
your health, that reads as "so much higher on the cost/benefit scale
that we should try every CIM approach possible before moving onto more
expensive and invasive approaches." The same possible approach shows on
the radar completely differently in systems with different economic
underpinnings. And indeed as some systems across the country are
shifting to a more at-risk economic model, we are seeing a fairly rapid
rise in incorporating CIM techniques.
  

    
> I really worry about the loss of solo practitioners. I chose the
practitioners who i felt got me and the idiosyncracies of my condition;
none of these were part of any group and no one was dictating their
methods.

I hear your concern for a loss of variety in what would be available
for people with these "mysterious" illnesses. I am not quite so
concerned, for two reasons:

First, the reason we are seeing fewer solo practitioners is not
because it's becoming illegal or anything, but because is has become so
difficult actually to make a living that way. In the book I detail
various ways (such as the Ideal Medical Practice, the Medical Home
model, and direct-pay primary care) that sole- and small-practice docs
can do better by being better docs. 

Second, the standardization of medicine applies most strongly in areas
like diabetes care in which there really is a known, clear checklist:
If you are not doing X, Y, and Z (keeping track of blood sugar level,
giving nutritional counseling, regularly checking feet and eyes, for
instance), then you are not doing good medicine. Nor can one think of
people with diabetes for whom it would be a good idea to neglect those
things. 

Parts of medicine in which there is no clearly established "best
practice" pathway, in which what works for a particular patient may not
work for another, are of course not subject to such pressures to
standardize. The "mysterious chronic illness" category is a prime
example. 

I know that systems can be slow to get this right, as we have seen in
some examples you and I know of. But the tendency in large at-risk
systems will be to try to develop individual doctors who specialize in
these difficult areas, and let them try what works. I have seen this in
Kaiser, for instance, in the difficult area of inter-gender issues.
  

    
just wanted to put my concerns on the record, tis all.

i realize the research aspect of healthcare is different from the provision
of it (i.e. the search for the shiny patentable molecule vs. how could we
provide acupuncture on a 3X/weekly basis for folks with chronic pain).

as an aside, i have many many kaiser  horrorstories (including deaths and
neardeaths) so to me it is not a model of anything.

but i digress.
  

    
>kaiser horrorstories

There are probably more per covered person for other healthplans,
they're just not as well publicized.  But in CA at least, everyone
knows the name Kaiser, it's the healthplan and the hospital, so it's
easy for everything lousy that goes on there to get attached to the one
name.  The blame gets parcelled out differently when it was
experienced at hospital x or provider's office y or pharmacy z funded
by health plan a and pharmacy benefit plan b.
  

    

probably true. but then i generally use practitioners who are soloists (even
for my conventional meds) so...


another doomsday reaction from the CIM community about obamacare
(just an fyi)


http://www.anh-usa.org/what-the-supreme-court-decision-means-for-
integrative-medicine/
  

    
> kaiser horrorstories

I agree with <debunix> that the Kaiser horror stories are simply more
visible because of its unified nature, and its salience in California.
In addition, when I hear a Kaiser horror story, I ask what year that
happened. Kaiser seems to have significantly improved in many ways over
the last decade.
  

    
> doomsday reaction from the CIM community

I am uncertain about a number of the premises of that article. That
HSAs combined with catastrophic insurance are doomed by the
legislation, and will only increase if people willingly opt out? What I
have been hearing from insurance executives is an expectation that we
will see more of them. I will have to keep an eye out for a better
explanation of this. The article's description of the government
demanding only "full coverage" is, I believe, incorrect. The exchanges
are supposed to be set up by the states, and there are a number of ways
to set them up, with the major difference being how wide a variety of
plans will be allowed (Utah and Massachusetts exchanges, both already
operating, represent the two extremes). I could be wrong on this, but I
believe that a major strain of what I am hearing from the insurance
industry and the employer healthcare consultant industry is an
increasing shift of a titrated amount of financial risk to the
consumer/patient. Which translates into co-pays, deductibles, and
consumer-directed health plans (CDHPs), which consist  of exactly this
combination of high-deductible health plans with HSAs. This is the
first time I have heard anyone claim that such plans would be in some
way restricted or even discouraged by the ACA.  
  

    

>  doomsday reaction 

People fear change. Some REALLY fear change. Factoring out that fear
from legitimate concern is hard but worthwhile when it's possible.
  

    
i think people in the CIM community feel -every- move by tptb makes their
professional and financial lives worse --- never mind that this may not be
the case. so i think what you are hearing is worry based on lots of past
experience. i cant think of any of my practitioners who have had good
experience with either insurance corps or healthcare systems.

this community of patients also may be folks who -dont- have conventional
insurance but -do- cough up, say, to see a CIM practitioner as needed. so to
them this maybe feels like lots of $ shelled out to entitied they dont like
for medicine they dont want
  

    
Restating something I just sent in email.

Please don't use any of my posts on the well as content for your
professiona publishing, even if you're giving away the book and
claiming no monetary profit.

I am happy to be interviewed with specific questions for a known
target publication if I am the appropriate person for the topic;
however my posts on the well are a part of a conversation and not
a contribution to a publication.