Healthcare: Inform before Reform

by Benjamin Atkinson on June 18, 2009

Listening to the recent discussions about healthcare reform causes me to suspect a general ignorance about important aspects of health and healthcare. I implore anyone who may be involved in formulating policy or promoting reform to consider the following sources for their accumulated wisdom and timely ideas.

In my next few posts, I’ll take up several healthcare issues I believe have been overlooked.

  • The Enigma of Health, by Hans Gadamer – This was my first philosophical survery of medicine. I highly recommend it. A Gadamer gem: We don’t experience health, only its absence.
  • Medical Nemesis, by Ivan Illich – Time for a socio-political examination of medicine. This text is a rich treatise on the reduction of the individual’s autonomy and the usurping of important societal roles by the medicolegal juggernaut, that is our healthcare system, today. Illich called it…in 1973.
  • The Birth of the Clinic, by Michel Foucult – This is the quintessential history of modern medicine. Foucult masterfully traces the historical and cultural evolution of the medical arts.
  • Worried Sick, by Nortin Hadler, MD – A physician and top-notch researcher discusses critical flaws in several popular tests, procedures and drugs. He also identifies systemic flaws in U.S. healthcare and proposes a novel schema.
  • The Innovator’s Prescription, by Clayton Christensen, et. al. – Healthcare can be made efficient and effective. Innovation is the key, specifically business model innovation. This book outlines many excellent ideas for reforming the business of healthcare.

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Born Autonomy

by Benjamin Atkinson on July 20, 2008

I delivered a baby 4 days ago. Gideon was 10 pounds, 1 ounce and 22.25 inches long. He and his mother are doing great.

I’m not a health care professional. I’m Gideon’s father.

My wife and I chose to have our 3 boys at home. Her third labor was so quick that our midwife arrived 5 minutes after the baby.

Apart from my fumbling with the umbilical cord, which was looped about Gideon’s neck, the birth was as expected…empowering and enriching.

My experiences convince me that healthy pregnancies should become healthy births apart from the medical profession. There is simply no scientific evidence supporting medical intervention in a healthy pregnancy. Yet, women in the U.S. have been taught that a normal birth is performed in a hospital. Why?

The health care costs for our last delivery was $2500. A spontaneous vaginal birth in a hospital will cost $8000 to $12,000 depending on the hospital service area. Why, when soaring medical inflation has seeped into our collective conscience, do we pay more for unnecessary care?

I’ll explore these questions in the next few posts and attempt to lay a foundation for my contrast of the anti-medicine and anti-medicalization philosophies.

Right now, I need to burp a baby.

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An Employer Health Solution

by Benjamin Atkinson on June 17, 2008

I’ve found some very good information in Dr. Nortin Hadler’s new book, Worried Sick.

For instance, when considering an individual’s risk of dying early (before the average life expectancy), 75% of the risk is accounted for by socioeconomic status and job satisfaction. 25% of the risk is accounted for by all other risk factors.

In the U.S. we spent about $2.3 trillion on healthcare in 2007.

I would like to issue a challenge to U.S. businesses: Stop spending money on health plans.

Instead, make your work more meaningful and rewarding. I suspect your employees will be healthier for it.

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Cardiac Stents, Angioplasty, By-Pass…virtually worthless.

by Benjamin Atkinson on June 16, 2008

My readings on individual autonomy and decision-making have been interrupted by the arrival of: Worried Sick: A Prescription for Health in an Overtreated America by Nortin Hadler, MD, an elegant guide for the medical layperson and an excoriating refutation of many of medicine’s modern “miracles”. Many of the conclusions in this book would be easy to ignore, if the author were some anti-establishment quack or a disciple of Mary Baker Eddy. However, Nortin Hadler is held in high esteem for both his clinical practice and academic research. I’ve read most of his work and can attest that Dr. Hadler has the intellectual horsepower, epidemiological expertise and the driving passion to tackle the sickening aspects of our healthcare system.

Here’s the money quote from Chapter 1: The Heart of the Matter:

“I submit that interventional cardiology and cardiovascular surgery have written one of the bleakest chapters in the history of Western medicine. If there was never another CABG or angioplasty performed or stent placed, patients with heart disease would be better off. Clearly, all this is missing the forest for the trees. There is something basically wrong with the theory that calls for violence to the offending, occluding plaque. To abandon the theory would shut down interventional cardiology, nearly all cardiovascular surgery, and many surgical supply houses and biotechnology firms. It would dramatically downsize hospitals in the United States and free up over $100 billion annually. And that’s just the direct costs…”

Crazy, huh? Wait until you read his review of the literature (shudder). Dr. Hadler offers not only provocative opinions, but an accessible, yet thorough, analysis of the research. Almost half of this book’s mass is supplementary reading and discourse about the design and torture of relevant biomedical studies.

Equipped with the depth of knowledge, the breadth of experience, and the lack of membership to The Club of Cos, Hadler is able to address critical medical issues confronting society. Anybody who hopes to change healthcare for the better, or who wishes to better care for themselves, should dive into Worried Sick.

I’ll tease out some other insights from Dr. Hadler over the next few days. Stay tuned.

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Problem 3: “Mammonistic” Temerity of the Insurer

by Benjamin Atkinson on May 7, 2008

So far, we’ve seen the reduction of an individual’s life to discrete functions he/she wishes to control. From there to the physician, where discrete functional deficits are corrected, in exchange for society’s dollars and the individual’s autonomy. However, it is inside the insurers where de-individuation is completed. Once reduced to a claim number, all pretense of patient care may be dropped. These organizations are not evil, for that is the property of an individual. Nor are the people working at insurers particularly evil. Health insurers are simply focused on costs and shifting costs. There is no place, albeit no systems, for supporting patient autonomy, or provider autonomy, in most cases.

It’s easy to point to the insurers as the source of all that is wrong with healthcare. However, this is the height of hypocrisy. Our society, we the people, demanded this social insurance system, and any who condemn one or another stakeholder are ignorant, unless they admit their own complicity. And if we are party to the wrongs, we must bear up under the task of setting things right. And insurers have at their disposal a way to set things right.

Medical underwriting and adverse selection are topics beyond the purview of this short treatise. Regardless of the financing strategies that politicians manage to bungle, the most vital roles for insurers don’t change. Yes, if we have universal coverage we can create more accurate actuarial models. Yes, if we all embrace healthcare consumerism, we’ll pay more out-of-pocket expenses, but possibly control prices. However, the financing debate is moot without first drawing in stark relief the goals of patient autonomy and quality. If we can begin working on the solutions below, insurers can become more focused on coordinating the best care (You know. The care that increases the autonomy of the patient.), and less focused on simply shifting costs. How would this work?

As providers’ perspectives shift toward autonomy and effectiveness, quality will become more visible. The insurers cost-containment goals will be met by helping patients coordinate care among the best providers. For example, a patient is diagnosed with a serious kidney problem. Today, the generalist will refer the patient to a specialist based on professional/personal relationship or health plan networks. As for quality, it’s a crap shoot. But, if we are working with physicians who have made explicit their treatment protocol and outcomes metrics, the right docs are easy to find. The insurer has an opportunity to save money by making those connections happen. To get the patient to the right specialist it might cost $10,000 in transportation/lodging. Is it worth $10,000 to save a kidney? I’ll leave that for the actuaries. (If it were my kidney and my money, I’d know the answer.)

And, in the example above, specialist care will be limited to the acute episode. Once resolved, the specialist and generalist can agree or collaborate on the maintenance protocols, including the patients preferences. Soon, the patient may require only occasional support from an extender. Eventually, the individual is once again under self-care, having learned how to cope with any residual impact on life functions.

The insurer’s new role will be effective only if the individual performs their part (Solution Group 1), and the provider performs their part (Solution Group 2). Until then, the insurance companies have little opportunity to offer real solutions. The original medical relationships, patient and doctor, is where the solutions begin. We can stop beating up the insurers until we make advances, and improve the dialog, at the point of care.

Solutions to Problem 3:

  1. Harnessing the power of rules-based medicine, insurers must become the evangelists and coordinators of quality care.
  2. Insurers must foster a new kind of network, the crowd-sourced care network and build pathways from specialist to self-care.
  3. Insurers must abandon P4P until real outcomes (not process) metrics are being collected from defined (repeatable) treatments.

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Problem 2: Unmitigated Gall of the Physician

May 5, 2008

Woe to the physic, caught between the role of healer and the role of dealer. The individual’s reduction of the life experience is subsumed and amplified by a medical community that offers an escape from every corporeal challenge. This criticism is not directed at the medical profession, in general, only at the irresponsible purveyance of [...]

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Problem 1: Colossal Hubris of the Individual

April 30, 2008

In August 2006, the National Association of Health Underwriters issued a white paper listing key current and future healthcare cost drivers:

Aging Population
Pharmaceutical Costs
New Technologies
Behavioral and Lifestyle Choices
System Inefficiencies
Medical Malpractice
Cost-Shifting
Increases Utilization

Such factors dominate the discussion about cost in healthcare. However, all of these are either ancillary to, or predicated upon, the more fundamental motive driving demand [...]

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Epistemological Foundation for Healthcare Reform

April 29, 2008

To truly effect change in America’s healthcare system, stakeholders must address deeply-rooted beliefs and behaviors. Without change at this level, all manner of novel financial schema, medical nostrums and patient consumerism will lead to neither higher quality nor lower costs. Our current crisis evolved as our culture evolved, and no governmental fiat will reverse this [...]

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The Starting Point: Patient Autonomy

April 28, 2008

To be a member of the Club of Cos, one must first understand Ivan Illich’s meaning. He coined the epithet to describe the complex of provider, payer and pharma. This club is built upon systems that reduce the individual’s autonomy. Without restoring autonomy to the individual, no effectual healthcare reform will take place.
So, this diary [...]

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