Q. and A. about Health Care Reform

By Shawn Vuong


This week Dr. Holm writes a short Q & A about the current health care reform and debate.  It's a nice concise summary of the basic problems of the reform, and I have nothing to add.  Hopefully, we find a workable and solid solution to our healthcare system problems.  So without further ado, the Health Care Reform Q & A.  
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By Richard P. Holm MD


Q. Do we really need health care reform?


A. The answer is a clear yes, because of ACCESS and COST issues:
1. Without reform, insurance companies will remain free to increase profits by cherry-picking only the well people, leaving too many Americans without access to health insurance. What’s more, many people will continue to be unable to change jobs for fear of losing insurance. These are problems of ACCESS;
2. Without reform, health costs will continue to rise, and health insurance will become more unaffordable for many businesses, let alone many individuals. Unchecked, by 2017 Medicare will bankrupt social security. This is a problem of COST.




Q. Why is US health care twice as expensive as any country in the world?


A. There are many reasons, which is why this is so hard to fix. Here are the most significant.


1. Payment for health care rewards hospitals for making available and encouraging the most expensive technology which does not necessarily improve care;
2. Physicians, especially in the emergency rooms have every reason to order the most complete and often most expensive tests or treatment because the patient wants it; the hospital wants it; and there is a risk of law suit if every test or treatment is not done and something bad happens. This again, does not necessarily improve care;
3. Patients expect the most expensive care for their family and for themselves, someone else is paying for it. Studies show the most expensive does not necessarily mean the best care;
4. Too often we do not have our personal doctor directing care, but have turned to that which is specialist driven. This kind of care can become very disjointed and very expensive.




Q. Will the solutions working their way through Congress right now solve the access and cost problems?


A. Both problems are being addressed. Ethically, I believe the access problem must be solved first. Although the more complex challenge of reducing health care costs will require a great deal of political will, it is a problem that also must be solved.


Both parties, of course, are playing their political hands with this issue, but I believe that without health care reform the consequences will be too dire for the any of us to tolerate. Our Washington leaders will have to find a way to make it happen.

Impossible To Fix

By Shawn Vuong

Medicine demands perfection. Nobody wants their loved one to die of something that could have been caught earlier on a blood test or CT scan.

So, a lady with a headache comes into the ER. The ER doctor knows that this headache is probably a tension headache or a migraine headache. The ER doctor also knows that the odds of this lady having a brain tumor are low, very low. Although every other ER doctor in the state would order a CT scan for every headache case that comes to the ER (due to the fact that they are scared of litigation brought against them, not because they think every headache warrants a CT), this ER doctor decides it is close to the end of his shift and he doesn't want to waste time ordering the CT scan this lady probably doesn't even need. So, he sends her home with some migraine medication.

Well, thanks to Murphy's Law this lady ends up permanently injured due to a malignant brain tumor. So because of this devastating turn of events, the family files a malpractice claim against the ER doctor.

Thanks to the teachings of a very wise law professor with significant expertise in tort law, I know what's coming next.

The doctor will be asked if it is the 'Standard of Care' to order a CT scan for a headache patient. Although medical literature may say that it is not the best practice to order a CT for every headache patient, and although every other ER doctor in the nation is ordering CT scans for fear of medical malpractice litigation, it IS considered the 'Standard of Care' just because every other ER physician is doing it. Right or wrong. Thus, this ER doctor will likely lose this malpractice case.

How do we as a profession change this? Obviously, a group of ER doctors cannot just follow the medical literature and stop ordering CT scans for every headache. This will just increase the chance that they will be successfully sued in a malpractice case. So, in reality, no ER doctor will stop ordering unnecessary scans. The more the 'Standard of Care' deviates from what the medical literature considers the best medical practices, the more of a disservice physicians are providing to patients. Yet, the legal climate prevents the doctors from changing the way they practice from the 'Standard of Care' due to fear of litigation.

This sounds impossible to fix.

-- Please note that this article is not trying to say ER doctors should not order CT scans for headaches. I have no idea if you should or not, I am not a licensed physician. This hypothetical scenario was merely thought up to help illustrate the problem with defensive medicine.

Good Medicine

By Shawn Vuong

This week Dr. Holm talks about the over-use of medications. Sometimes, patients are on too many medications and there are many factors (or maybe the combination of these factors) that could be the culprit. As medicine continues onward so does drug and pharmaceutical research. This will only aggravate the over dependence on drugs we see today. Every day researchers and scientists discover more genes, cell markers, and biochemical pathways to target with new drugs.

As medicine becomes more and more advanced, we may see a decrease in pharmaceuticals. But I predict patients may actually be on more as research shows that therapies which include a combination of old and new drugs work best. What can we do about this over abundance of drugs? The patients can question their physician on why they need certain medications. Doctors can also help battle this by practicing good medicine.

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By Richard P. Holm MD

The other day an 80 plus year old woman came into my office visiting from another state and asked if she could get off some of her pills. “I take too many,” she said, and I agreed with her. We stopped ten of the fourteen she was taking.

We live in a pill-taking society. Some of this probably comes from the human tendency to find an easier way to do things. If we have a choice whether to walk or ride to work, we will likely ride. If we have a choice whether to exercise or take a pill to lower blood pressure for example, we will likely take the pill. A pill is easier than a lifestyle change. And there are other forces also encouraging too many pills.

Some significant medical conditions just call for it. Sometimes it takes two to five drugs to get blood pressure down, or control a diabetic’s blood sugar or help a weak heart pump better. If you happen to struggle with a combination of these or other conditions, you can end up taking a smorgasbord of pills.

Clearly drug companies work very hard to convince doctors and patients that drugs work for almost every ailment. And think about how providers are asked by patients to solve a new problem each time, and how simple and pleasing to give a pill to satisfy their needs.

We have a culture with an inclination to over-rely on drugs and over-play their benefits, but what is worse, we under-play their risks. This is a fact: the more drugs, the higher the likelihood for a significant side effect or a dangerous interaction between medicines.

I am not saying that all medicines are bad, and I’m not encouraging you to stop taking your medicines without careful direction by your doctor. The next time you see your provider, however, ask her or him to review the pills you take and try to get the number down. That would be good medicine.

Are Two Heads Better?

By Richard P. Holm MD

Collaboration is a fancy word, which means two heads are better than one. It's the buzzword that always pops up when physicians are talking about Physician Assistants (PAs) and Nurse Practitioners (NPs). I believe that the art of collaboration, or knowing when and who to call for help, is about the most important and difficult challenge any PA, NP, or MD faces everyday. 

Take for example the isolated over-busy practitioner who knows a lot about everything, but not enough about the specific problem troubling that individual patient. Hopefully that care provider has enough experience and depth of knowledge to recognize when to ask for help and collaborate with someone who knows more. Two heads can be better than one.

There is another side to that story. Last month Mr. X had a complicated problem and I sent him to the specialist in another community. Before he returned, three other specialists were consulted by the first, each adding another test, and medicine, and expense. I was faxed copies of all these consults, but basically kept out of the loop until the patient returned to my office. Here's a time when the big picture had been lost while focusing on all the tiny parts. Sometimes one head is better than four.

Many experts say that the cost and access problems we have with our health care in the US are because care is so fragmented. All the parts are not speaking to the whole. 

In this time where it is likely major health care reform will occur, we must be very careful to construct a system that would encourage care that starts with a medical home. This would be when one very well trained primary care MD, PA, or NP would know when to refer, when not to refer, and expect a return of responsibility for the patient.
Collaboration is the name of the game.

Expensive High-Tech Medicine

By Richard P. Holm MD

In this country the health care system is sick. There are 47 million uninsured people and the number is rising; med students as well as PA and Nurse Practitioner students are choosing fields other than primary care; and the massive numbers of baby-boomers are getting old. Worst of all, we cannot seem to get a handle on the spiraling cost of health care.

Why is it that in this country health care costs are twice as high as the rest of the developed world? Experts explain that it comes from the excessive use of high-tech medicine, which yields only minimal benefit at a very high price.

It seems that much of the spiraling expense comes from excessive and unnecessary use of imaging such as CT scans and MRI; from very high-priced and borderline-helpful types of radiation and chemotherapy for cancer; and from costly techno-heavy procedures that are not proven to significantly improve the patient's condition.

Others have explained that the out-of-control cost of care is due to over-ordering these items since the patient and family expect and demand the latest and greatest, and threaten a lawsuit if the doctor is reluctant, or anything goes wrong.

But alas, insurance companies and the government have tried desperately to get a handle on these costs and have not been able to control the ever-escalating expensive technology. All efforts with preauthorization and oversight have simply not worked.

The solution must begin with patients being financially encouraged to seek proven methods for diagnosis and treatment. Also, everyone must have access to a primary care provider, which means we must find a way to encourage students into this field. Finally the provider must not be pushed by patient, lawsuit, or financial incentive for unproven technology. Value and quality should be the watchwords, and high-tech methods should be used only when it is part of that equation.

The health care system in our country is sick, and the cure should start with a primary care doctor, not with a CT scan.

Tom Daschle for Health and Human Services Advisor

By Shawn Vuong

Well its pretty much official, our own Tom Daschle will be the secretary of HHS.  What does this mean for doctors and patients in South Dakota?  What does this mean for doctors and patients nationwide?  

Some don't believe Daschle is the right man for the job.  They may be worried about his past voting history, his history of partisan politics, or even his wife's job as a lobbyist that may play in conflicts of interests.  Others think he's perfect.  Either way you look at it, he's going to be a key component of the healthcare reform that America is about to see.  

To get a good idea of what's in store for us, I plan on reading "Critical: What We Can Do About The Health-Care Crisis" by Daschle.  The book came out Feb 2008, and I think its going to be the outline of what's to come.

Doctors Feeling Gloomy?

By Shawn Vuong

Yesterday I was talking about my worries of becoming a bitter doctor.  But why do doctors loose morale?  Today, Sarah Rubenstein of the WSJ gave me some insight on this matter.

Here are some of the bracing findings from 11,950 primary care docs and specialists who responded to the survey:

94% said the time they’ve devote to non-clinical paperwork in the past three years has increased. 63% said the paperwork has meant they spend less time per patient.

82% said their practices would be “unsustainable” if proposed Medicare pay cuts were made.

78% believe there is a shortage of primary care docs in the U.S.

49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

60% would not recommend medicine as a career to young people.

42% said professional morale is either “poor” or “very low.”

17% rated the financial position of their practices as “healthy and profitable.”

6% described morale of their colleagues as “positive.”

Wow, if that isn't depressing I don't know what is.  Paper work, a shortage of doctors, and low morale possibly through low reimbursements, insurance controlling care, and less doctor-patient time.  I may be wet behind the ears in the world of medicine, but I can tell you one thing, I am going into medicine to take care of people.  If a primary care physician told me that all the paper work they do keeps them from seeing the patient, I'd dodge primary care like the plague.  Many other medical students already are dodging away from primary care.

A couple questions come to mind after reading this.  First and most obvious question, how do we fix this?  Also, since Dr. Holm is a family doctor himself, I would like to know what his general opinion is on this article.  Is morale really low here in South Dakota?  Are family physicians here feeling the pinch of administrative work, low reimbursements, and insurance control?

Healthcare Costs Part 1

By Richard P. Holm MD

Maybe it was ten years ago I heard a political reformer pose the question: What if we paid for groceries like we pay for health care in the U.S.& how different would it be? He described buying groceries where there would be no reason to look for a bargain, but rather motivation to buy the most expensive items, and everybodys basket would be filled to the brim.

I think there is still some truth to the comparison, because in this world of third party payers for health care, the consumer is still not driven to look for value. Rather it seems the employer who buys the insurance has to do that. But in 2008 there are some changes we would have to make to the grocery-store/health-care comparison.

Now you find that there are only three grocery stores in the state, and you have to go to the store your employer chose. Upon arrival to the store you find a very elaborately decorated and expensive building, the carts are robotic, the aisles are wide and beautiful, and there are way more managers than checkout people, due to government beaurocracy.

Looking around you realize that every customer in the store seems to have a different way of paying for the food. One person has a plan where all the food is free, once he reaches his deductible, but it pays only for certain food, and he cant figure out what that is, except to know that generic beans are always paid for. And then there are customers who have managed care advisers walking around the store with them pointing out which food is not available to them. What's more, there are many people outside the store that can't get in.

It is not a perfect metaphor but it makes one point very clear the system is a mess. In this age of healthcare reform, please be pro-active and contact your Washington legislators.

Tough Questions About Death & Dying

By Shawn Vuong

In Dr. Holm's latest post, "When Should the Heart Stop Beating," some interesting questions are brought up.

1. When is a patient too old or too sick to receive expensive procedures?
   
2. How can we pay for expensive healthcare for so many people?
   
3. If we take away the "easier death" of an abnormal heart rhythm, how will people die?

These are extremely difficult questions, that I do not think many people are ready to discuss. But these are important topics for families, and are a hot topic in medicine. 

One factoid that has been cruising around the medical blogosphere for quite sometime now, is that 5% of our population spends approximately 50% of our healthcare dollars.  How can this be?  Some believe it is all of the expensive treatment we utilize at the end of life.  This time is a very difficult for the family, they may want everything done for their loved ones, when its obvious to the clinical team that there is just not much more anyone can do.  But more often then not, the clinical picture is in a "gray area."  How does a doctor decide that the act of performing surgery or giving the treatment may be worse for the patient than the benefits gained?  The Happy Hosptalist sums up the cost effectiveness of this problem quite nicely.   

How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:

Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site [sic] of the big picture and do things to patients because they can. Because they lose sight of the big picture.  And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.

As a patient and a family member, you may be thinking "Why do these costs even matter? We want everything done for me (or my family member) because that's the right thing to do."  Researchers at Dartmouth argue that more interventions and aggressive treatment do not necessarily prolong patient's lives, and by doing less you may be "sparing patients the agony of unnecessary tests and reducing the risk of hospital borne infections."

The end-of-life decisions are not decisions for cost-effectiveness, insurance companies, or even doctors to make.  The patient and their family ultimately have to decide what is the best route for them. But I hope families realize, they can let their loved ones pass away with peace and dignity without demanding every possible intervention. 

When Should the Heart Stop Beating?

By Richard P. Holm MD

In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.

Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast. 

He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.

It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven. 

The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.

The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.

Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?