American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tuesday, January 29, 2013

Where is the health care crisis?

So here's my beef. At the recent Forbes Healthcare Summit there was a lot of focus on speakers and vendors offering very cool new tech, from future "Tricorders" that can diagnose multiple diseases, is non-invasive, and hand-held; personal genomics, where data from your own genome is cheap and easy to get and can be integrated with clinical knowledge to produce better care; targeted therapies for various diseases, using the specific biology of a patient and her disease to design a treatment.

All of these are awesome, but really have little impact on our most pressing health care problems.

In the U.S., we manage to deliver a triple-whammy: health care that is less effective than in other nations, is only available to limited numbers of people and costs a ton. There are a number of factors that go into this, most of which are historico-cultural.

Since the end of World War II, we have insured people largely through employers, setting up a system where those who can least afford it to find insurance on the open market. Obamacare, which is largely insurance reform rather than health care reform, takes some steps toward patching this problem, but not solving it. Health care exchanges will probably make privately-purchased insurance more affordable, but when you're not making money, the price difference isn't significant.

We have social safety nets developed during the Depression and the late 60s and early 70s. These are supposed to protect our most vulnerable, and do to a degree. Medicare--government insurance for the elderly--has been wildly successful. It's relatively easy to work with, but from a doctor's and patient's perspective. But it does cost a ton, of which more later. Medicaid--public insurance for the poor--has had some hits and misses. It has managed to largely protect mothers and children, but generally leaves out any other poor people. It's also poorly-funded, something that Obamacare will try to rectify, but there will be barriers, more of which later.

We talk up prevention but we largely don't mean it. Many insurance companies and employers are starting to discover the cost-savings of prevention programs, but prevention is still less favored than treatment, and in the long run, treatment is more expensive, both in dollars and lives.

The key to many of these problems is to improve access and delivery of primary care, and to set up at least minimal care guidelines (that is, rationing). Like much of American industry, health care has been driven by capital and innovation, and has produced what earlier generations would call miracles. But these successes are outweighed by the failure to focus on the social aspects of health care, especially public health and cost.

When capital for innovation comes largely from health care costs paid for by employees and insurers, the cart has driven the horse. Innovative care gets paid for after-the-fact, without significant evaluation as to cost-effectiveness and efficacy. A new heart procedure, for example, may be found help individual patients for a brief time, but if studied long-term, may be found to be too expensive and lead to flat or poor outcomes. But we learn that after it has been implemented. The immediate results seem great, the bills get paid, and no one's the wiser. Except that we can't afford it, and patients suffer for it.

This same trend drives the urgency of doctors to specialize. Specialists get to use the new toys, the ones that make the money. There is no systematic way in the U.S. to evaluate treatments for their medical and social utility, their cost-effectiveness. The ability has existed for decades, the will has not.

Many Americans tend to be fiercely independent and suspicious of government intervention in their lives. But the only way to have real health care reform is cooperation, and probably some top-down structure.

It's true that individual insurance companies have economic incentive to cut costs. On the ground this gets very messy. Each insurance company behaves differently. If I want to get a test for a patient, the hoops I need for approval require completely different processes for each company. In the office, this leads to untenable waste, undoable work. It creates a dis-incentive for doctors to order tests, although I don't know how that plays out in real life. Limitations on care should be on the basis of evidence, not inconvenience.

Electronic health records, seen as a critical step in improving communication, prevention, and cost of care don't even communicate with each other. Rather than make data sharing easier, EHRs often create enormous, wasteful, useless records designed so that every entry meets the requirements of every insurer. Hospital discharge reports and letters from specialists have become useless and unreadable.

We have what is probably the most technology-intensive health care system in the world, and it has produced overall lousy results. Our focus should turn toward providing better, evidence-based and cost-effective care to more people. I really want a Tricorder, but I'm willing to hold off for a few decades to get our house in order first.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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