We start 2010 with some paradigm shattering news:
January 15, 2010 – The U.S. Food and Drug Administration announced today stunning results from tests on Beleva, the much-heralded "wonder drug" destined to revolutionize human health worldwide and reduce U.S. healthcare costs alone by an estimated $1.2 trillion annually.
Five years of rigorous clinical trials have conclusively demonstrated that taking Beleva orally prevents most cancers, controls appetite, reduces body fat, aids circulation, promotes restful sleep, eliminates joint and back pain, increases energy and sexual drive, optimizes blood pressure, cures depression and other serious mental disorders, improves mood, increases bone density and cures the common cold, among other things.
Believe it! Say goodbye to rising health care costs. Get The Drift for the complete story. 
"We have great potential. Anything we do for primary care is going to be an improvement, because we're doing it all wrong now."
- family medicine physician/educator
Practically no one thinks the "primary care parade" discussed in Part One of "Goodbye, Hello: Framing the Future of Primary Care" is sustainable in the future. With almost every stakeholder vested in the status quo, what happens next?
The are at least two ways of thinking about the future: probability and desirability. Part Two, "Bending the Possibility Arrow," explores alternative models and where we might be headed. It's on the web today, and available in hardcopy next week.
Balancing the Medical Imagination
"The logic of increasing longevity, increasingly prevalent chronic conditions, and increasingly sophisticated (and expensive) pharmaceutical and medical products and interventions points to the possibility of health care systemic overload and bankruptcy. Such considerations may make more urgent the argument in favor of balancing the medical imagination with a sociological one, recognizing the limits to medicine, and contributing to a political climate in which medical and pharmaceutical spending are reset in a more rational proportion to investment in action on social determinants of health."
- American Journal of Public Health, November 2009
"Today I see within us all the replacement of complex inner density with a new kind of self-evolving under the pressure of information overload and the technology of the 'instantly available.' A new self that needs to contain less and less of an inner repertory of dense cultural inheritance - as we all become 'pancake people' - spread wide and thin as we connect with that vast network of information accessed by the mere touch of a button."
- Richard Foreman, playwright
Program evaluation can often become a prison - a straightjacket of metrics, forms and community indicators that we ask our community partners to adopt in assessing their performance. In a formal evaluation exercise, people can end up counting and accounting, rather than doing and learning.
Based on our experience, we think evaluation should be a prism - a means of dispersing light into its constituent spectral colors, or a rainbow of perspectives. We should reflect on evaluation together, weaving the language of counting and accounting with the language of local knowledge, stories, history and shared cultural mores and rituals. This argues for more of a collaborative, portfolio approach to evaluation, rather than relying solely on one formal evaluation matrix developed by the funding agency.
- From SLHI's Weave the People report
Will be impossible for approximately 350,000 Arizonans who will be dropped from the Medicaid program's rolls if Governor Brewer's proposal to ask voters to rescind Prop. 204 is successfully implemented and limits program eligibility to 33-36 percent (with a variety of exceptions) of the federal poverty level from the 100 percent it is today.
If you are an individual in this group that would be dropped from coverage, you have income of approximately $330-$910 per month. If you're a family of four, you have income of approximately $665-$1850 per month. Arizona Senate leader Bob Burns says you just have to make health care a priority and "take care of yourself." Assuming you will have to pay for a roof over your head, clothing and food, transportation, etc., you can check today's prices for health care services, do the math and quickly see the problem. You won't have any money for health care, period.
So what will you do? You'll delay care until you really need it, then you'll show up at the ER or some other location like a community clinic, where care will somehow be provided - and far more expensively than what timely, preventive care costs. But in most instances it won't be free. The costs will be shifted to those who do have coverage, health insurance premiums will rise, employers will pass along the extra costs to their employees or drop coverage altogether, more people will become uninsured, and the cycle will be repeated.
While we debate the pros and cons of balancing the budget through cuts to entitlement programs like AHCCCS, we need to pay attention to the potential ripples through the entire health care system. Meanwhile, we need to continue to press for real health care reform, which unfortunately doesn't resemble anything that is likely to come out of Washington in the near future. That's a subject we'll be exploring in the days and months ahead.
Physicians in a variety of specialties spend considerable time consulting with patients on the identification and treatment of medical issues. In the case of neurology, for example, about 90 percent of all new outpatient visits are coded as "consultations." If you're a physician seeing someone for the first time who may have a complicated disease like MS or Alzheimer's, clearly you're going to spend an hour or more with them initially to determine the best course of action.
Now Medicare, in its infinite wisdom, has taken the chainsaw approach to cost cutting by eliminating consultation services as a benefit for all federally funded programs. Reduction in payment for existing consultation codes further devalues cognitive services (actually talking with and examining patients) and provides incentives for more physicians to look for ways to code things as interventions and procedures - one of the chief contributors to rising medical costs. In the words of one prominent Valley neurologist, "It is far easier for me to do a mindless procedure and get paid more than it is to do a consultation. We are definitely not going in the right direction for health care reform, and I increasingly fear for anyone with a difficult or rare medical condition."
Ironically, the feds are interested in giving physicians $40K or more over multiple years to implement electronic health records, and then unilaterally devalue consultation services and potentially reduce the salaries of some physicians by $40K-$50K annually. It’s no wonder that many physicians take a dim view of Medicare "reform."
If You Were Paying for Medical Care Yourself
Wouldn't you be interested in getting the best value for money spent? In an interesting study documented in the Annals of Internal Medicine, the authors reviewed over 2,000 peer reviewed articles on new innovative therapies that included both cost and benefit in their analyses. While most of these increased cost and benefit, there were a few that saved a significant amount of money in exchange for a very small decrease in quality: savings from $122 to $12,000 in exchange for losses in
quality-adjusted life years of about eight hours to one week. Examples included doing percutaneous coronary interventions vs. more expensive open heart surgery, watchful waiting for inguinal hernias instead of routinely operating on them, and using drugs to treat reflux disease with symptomatic heartburn instead of laparoscopic surgery.
The point is that it's possible to get good outcomes with cost-saving innovations, even if those outcomes are slightly less effective than more expensive options. But will your doctor routinely inform you of the cost benefit of various options? No, primarily because you are not the one paying the bill. Instead, there is a "race to the top" in medical innovation, as plans pay for ever more expensive high tech innovations (and pass it along to you in the form of higher premiums). In other parts of the economy, consumers know the tradeoffs between cost and quality, and make purchasing decisions accordingly.
Given our fixation on getting a grip on stratospheric health care costs, maybe it's time we think of ways to give consumers the option of spending far less money in exchange for giving up a slightly greater benefit. Perhaps then we would see who is really interested in "bending the cost curve."
January 2010
Balancing the Medical Imagination
