As both the temperature and the budget crisis heat up in our desert home, we prepare for our two-month summer hiatus from Thinking Out Loud with a reminder of the importance of hope in our individual and common lives.
The Czechoslovakian playwright and politician, Vaclav Havel, put it well: "The most important thing of all is not to lose hope and faith in life itself." For Havel, "Hope is a dimension of the spirit. It is not outside us, but within us." Distinguishing hope from optimism, he reminds us that "Hope is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."
If so, SLHI has the perfect position for you: Associate Director, Arizona Health Futures. Deadline for applications is July 17.
"Many people in medicine don't see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue."
- Atul Gawande, MD in The New Yorker
Here is part of an actual quote from a major private health insurance company for providing coverage to an Arizona small business with seven employees:
You do the math. Total annual health coverage premium for this small business: $245,078.88!
There are significant financial obstacles to making major investments in quality improvement within a production-based [health care] payment system that fails to pay for quality while paying for defects. What profit is there in cutting your inpatient readmission rates if you depend on those readmissions to fill up your beds and surgical suites? The business case for quality improvement is a hard sell unless there are major changes in the way we pay for health care. Paying for value, paying for quality - that's the challenge facing the system today.
- from SLHI, Collaborate to Compete
for adults in acute care is currently under consideration for "re-design" as part of the state's massive budget reduction efforts. A workgroup recently compiled, reviewed and validated utilization data and trends in order to determine what services might be eliminated or trimmed back. They came up with almost $30 million in potential savings, which included offsets due to costs of avoidable alternative treatments and adverse outcomes. You can read their preliminary report here.
Frankly, we were impressed with the thoughtfulness of the process. No one wants to eliminate things like emergency dental services, genetic testing, orthotics or gastric bypass surgery, but the workgroup clearly made a concerted effort to prioritize services based on prevalence, need and likely impact, and came up with a defensible list. No doubt things will change as the result of a public hearing, legislative input and final submission to CMS, but it's a good start.
We can talk until we're blue in the face about maintaining necessary health care services and providing people with a comprehensive set of benefits, but the reality is that we cannot continue to provide everything to everybody all of the time without transporting ourselves into some kind of economic death spiral. We will have to ration care one way or the other, so we might as well try to be "rational" about it.
Consider the case of Ted, an 82-year-old widower who lives on an annual fixed income of $24,000. He has developed cancer of the liver, which has spread to his lungs. His doctor recommends a new drug that, while not offering a cure, has the potential of extending his life anywhere from six months to two years. The cost of the drug is $8,000 per month of treatment.
Now, Ted happens to live in a parallel universe where every U.S. citizen is required to sign up for Medicare, which operates under a strict national budget and pays for a defined package of services with co-pays based on personal income and financial assets. Publicly financed services are rationed on a transparent and explicit set of criteria derived from mountains of cost effectiveness research, physician input and oversight, consumer town halls and surveys, and a regulatory and appeals process crafted by lawyers on steroids. It's generous, but it has its limits: it won't cover expensive medications that do nothing to restore health, it won't pay for hip transplants for 85-year-old golfers, it won't pay for intensive life support in cases that are determined to be medically futile, and so on.
Who decides: Government or patients and their physicians? Read more in this month's The Drift.
That's the title of a recent report from the California HealthCare Foundation that describes a shift in diagnosis, monitoring, and treatment from physicians to mid-level clinicians and consumers, offering less costly and more convenient options.
To cite just one of many examples, five years ago manufacturers introduced cholesterol screening devices that generated results in the physician's office and cost about $5,000, plus $50 per test. "Two years ago, these respective costs had fallen to $1,200 and $20, and are now $400 and $10. Patients can have their provider perform a cholesterol test, which entails an average copayment of $28 and a total cost to the insurer of about $90. Or they can buy a non-prescription, reliable, easy-to-use test kit at the drugstore or online for around $10 and self-administer it at home. Results are available in 15 minutes."
Meanwhile, mid-level clinicians are using algorithms for evidenced-based medicine that, when combined with patient data, can produce a reliable diagnosis or treatment recommendation. One example: some urgent care clinics are using stand-alone, algorithm kiosks for fast and reliable preliminary diagnoses of patients who may have an uncomplicated urinary tract infection. Interestingly, urinary tract infections "account for about 8 million medical visits annually, 1 in 10 of which are managed in emergency departments."
You can imagine how these innovations are being received in some medical and regulatory communities. What is patient empowerment and cost effective medicine in one quarter is inferior medicine and lower revenue in another.
If you're one of the roughly 1-2% of people who are so stressed out from losing your job, bankruptcy, foreclosure, divorce or some other calamity that you can barely function, you may have Post-Traumatic Embitterment Disorder (PTED).
According to the German psychiatrist who identified and named PTED, everybody has to cope with life's negative events, but people with PTED are so embittered and suffer from intrusive thoughts and memories that they are consumed by an intense desire for revenge. In short, these are people who may get a shotgun and return to the workplace to kill those who they think did them in. They are immune to treatment. The world has to change, not them. "Revenge is not a treatment."
But what is the difference between really horrible, indefensible behavior and "sickness?" At what point is an individual responsible for his or her behavior, or helpless in the grips of a deep and severe mental illness? Psychiatrists are considering whether to add PTED and who knows what other exotic mental disorders to the next iteration of Diagnostic and Statistical Manual of Mental Disorders (DSM-V), due out in 2012. When the DSM was first published in 1952, it listed 112 mental health disorders. The current version, DSM-IV, lists 374 disorders in a mind-numbing 886 pages.
Are we heading in the right direction here? Yes, if we actually can identify people who desperately need help and pursue effective treatments. No, if we are simply continuing to medicalize human behavior and absolve others for taking responsibility for their own willful actions.
They do it in bed. They do it in school. They do it in restaurants, walking down the street or in cars. Texting, that is. The American teenager sent and received an average of 2,272 text messages per month in the fourth quarter of 2008 - almost 80 messages a day and more than double the previous year.
"The phenomenon is beginning to worry physicians and psychologists, who say it is leading to anxiety, distraction in school, falling grades, repetitive stress injury and sleep deprivation." It's apparently not worrying Verizon and AT&T, however. We're talking serious revenue growth here.
But what are they texting about? Not much, as far as some of us can tell. But then, we're not up on the code: CU 2moro, WAI (what an idiot), U8 (you ate?) TISL (this is so lame). It's a creative combination of acronyms, phonetic transcriptions and graphic placeholders for emotions and other mental states. Parents aren't supposed to "get it." That's precisely the point.
Oh for the days when people spoke in complete sentences with subject and verb agreement, and actually thought of what they wanted to say before they committed it to paper or screen! It's humans versus machines, and guess who's winning.