A couple of days ago I paid a visit to the dermatologist. The receptionist gave me a faded yellow form and I duly filled in my personal data and a largely incomplete and inaccurate health history. And what was the name again of these pills I am taking daily? The form disappeared into a solid looking metal cabinet spilling over with similar records containing similar half truths. A little later the doctor handed me an unreadable handwritten note that could be exchanged for a tube with pills at the pharmacy a couple of miles down the road.
What is going on? The US spends a whopping 17% of its GDP on health care and, according to McKinsey, around $650Bn more than necessary and more than any other developed country in the world. However, the life expectancy is higher and infant mortality lower in most of these countries. You may find the most sophisticated health care available to those who can pay, but on aggregate the US doesn't compare well. Nearly a 100,000 people die in the US each year of medical mistakes.
There are many reasons for the exorbitant costs, starting with the strange system of care providers passing the cost to insurance companies who pass it on to companies and finally to the consumers, who believe that their company is paying. The relative administrative cost is twice as high as the next country at the bottom of the list (bureaucratic France). Medicare spending and results vary widely among areas with little difference in outcomes, which points to huge inefficiencies. There are no incentives to work more efficiently and that shows. Americans also pay on average 50% more on drugs than other developed countries. Apparently the pharma industry has great a lobby on K-Street. Then of course there is the issue of 46 million uninsured. And the strangely litigious legal system.
Economists rarely agree, but there is consensus that fixing health care is critical to fixing the economy. To highlight this point: according to The Economist, GM spends more on health care than on the steel for its cars. This is a complex beast and more politicians have failed than succeeded in tackling the myriad of issues. But the population is graying and medical costs show worrisome inflation rates. Since 1999 the average cost of a policy for a family of four has doubled. It now equals a full quarter of the median household income. According to a report of Obama's Council of Economic Advisors, any reform that slowed the annual growth rate of health costs by 1.5% would boost America’s economic output by over 2% and increase the average household’s income by $2,600 in 2020. The Obama Administration is tackling health care with top priority and a focus to extend benefits to all, while reigning in the costs.
Here's a place to start: less than 20% of care delivery organizations have electronic patient records. While there are notable exceptions, like Kaiser Permanente and the Mayo clinic in Minnesota (check out their website!), efficiency in this industry has been lagging way behind. I can do all my banking at home or on the road using my iPhone and get cash at any ATM around the world (with the notable exception of Cuba as I experienced last month), without any intrusion of my privacy. Banks around the world are interconnected and information exchange has been standardized for ages. An electronic patient administration, information sharing and data analysis are essential for efficiency improvement. When information is exchanged between organizations instantly and without errors the quality of the treatment will improve. This is especially relevant in emergency situations.
Rolling out large scale projects, like a standardized patient administration, is a daunting task. It is not so much the technology that makes it hard, but the required changes in the business processes, organization structure and, last but not least, the company culture. Add the political sensitivity on top of it and you will see the combustibility of it all. But the urgency should override inertia.
While medical research has made tremendous strides in the last years, there are still many unknowns on the results that drugs in different combinations may have on treatment. Large scale data analysis can provide valuable insights. Using Web 2.0 technology, doctors can tap into the collective wisdom of their peers when dealing with a difficult prognosis. Patients can be automatically reminded of their check-ups and appointments. The same technologies are now bringing about a change in the traditionally paternalistic relationship between doctor and patient. Most people go online to find information about their health. New websites have sprung up that are focused on sharing information and experience about diseases, symptoms, treatments and side effects. Patienslikeme.com and inspire.com already have hundreds of thousands of members actively communicating amongst each other and with the doctors that are participating. Even the pharmaceutical industry is weighing in. Novartis is learning from the effects of their drugs and more importantly trying to understand more before they launch a new drug. They are actively recruiting for clinical trials on these sites. Why wait for your doctor to get your records integrated, organized and analyzed? Both Google and Microsoft are getting into the game and offer DIY tools to manage your health. Microsoft even calls it Health Vault to highlight security and privacy of data.
Besides looking for obvious technology solutions you would expect a focus on creative sourcing solutions. However less than 3% of all work supported in India comes from this industry (compared to 41% financial services). The US spends $91Bn more than necessary on administration. There is no reason why large parts of the administrative work can not be performed more cost effectively by creating shared services centers in low cost locations. There are already several successful engagements with hospitals in India, that analyze X-rays and lab reports. Google “teleradiology” and dozens of companies offering the service pop up. The next step may be an Indian doctor performing remote surgery. Or if that is too far fetched, the patient can travel to Asia to have the treatment delivered in one of the world class hospitals over there. My son was born at Bumrungrad hospital in Bangkok. He was the only blond baby in a room of 40 dark skinned babies. The doctor who delivered him was educated in Germany. My wife had a huge private room with a seating area and a kitchenette, as well as 24 hour private nurse. This was in 1991 and we were about the first westerners there. Last year this hospital treated 400,000 patients from 150 countries, many covered by their insurance! Cuba has been training world class doctors for the last 40 years and once this country opens, it may become a major destination for “medical tourism”.
Expect major surgery to be performed on health care policies, structures and processes. This has to become a global industry, supported by state-of-the- art technology and operational processes that are being measured and continually improved. And maybe the per person cost one day comes down to Canada's level, which is 50% of the US per capita spending.
Jim Clark tried this in 1998 with Healtheon merged with WebMD. Perhaps the current crisis will motivate all stakeholders to finally make this reform happen!
ReplyDeleteThis appeared in this week's Time:
ReplyDeleteuesday, Jun. 23, 2009
How to Cut Health Care Costs: Less Care, More Data
By Michael Grunwald
Ezekiel Emanuel got a memorable introduction to our haphazard health-care system on his first visit to a cancer ward as a medical student. The white coats were ordering a transfusion for a teenage girl, and since shyness does not run in his family — brother Rahm is President Obama's famously foulmouthed chief of staff, brother Ari a similarly silence-deficient Hollywood agent — he interrupted to ask why. Because she had Hodgkin's disease and her platelets were below 20,000, the team explained. Emanuel still had questions: Was there evidence for that protocol? Don't some hospitals wait until 10,000? Why 20,000? Because that's what we do here, one doc replied.
Now a noted oncologist turned White House health adviser, Emanuel has spent much of his career battling the that's-what-we-do-here mentality of American medicine. "It drives me nuts — the ignorance is overwhelming," he says. "I'm a data-driven guy. I want to see evidence." It turns out that Emanuel's boss, budget director Peter Orszag, is also a data-driven guy, as is Orszag's boss, the President of the United States. They've already stuffed $1.1 billion into the stimulus bill to jump-start "comparative effectiveness research" into which treatments work best in which situations. Now they're pushing to overhaul the entire health-care sector by year's end, and they're determined to replace ignorance with evidence, to create a data-driven system, to shift one-sixth of the economy from "that's what we do here" to "that's what works." (Watch a video about a woman living without health insurance.)
The U.S. spends more on health care than any other country does, and studies have suggested that as much as 30% of it — perhaps $700 billion a year — may be wasted on unneeded care, mostly routine CT scans and MRIs, office visits, hospital stays, minor procedures and brand-name prescriptions that are requested by patients and ordered by doctors every day. Orszag is particularly obsessed with research by the Dartmouth Institute for Health Policy and Clinical Practice, documenting huge regional variations in costs but virtually no variations in outcomes. For example, chronically ill patients in Los Angeles visited doctors an average of 59.2 times in the last six months of their life, vs. only 14.5 times in Ogden, Utah; they still ended up just as dead. Medicare now pays three times as much per enrollee in Miami as in Honolulu, and costs are growing twice as fast in Dallas as in San Diego. Patients in higher-spending regions get more tests, more procedures, more referrals to specialists and more time in the hospital and ICU, but the Dartmouth research has found that if anything, their outcomes are slightly worse. "We're flying blind," says Dartmouth's Dr. Elliott Fisher. "We're getting quantity, not quality." See http://www.time.com/time/politics/article/0,8599,1905340,00.html
I read the first part of your post and smiled, not because it was amusing, it's not, but it's exactly what happened to me yesterday. My "file" I was told, was in storage because I had not been to that doctor in more than three years. So they relied on me to replicate my history on a little white form, confident, I guess, that I knew every thing that they needed to know. Then after ten minutes the nurse practitioner handed me a prescription and a deductible card offered by the drug manufacturer (it might be expensive, she advised). Too bad I couldn't use my HealthVault account to update their records. And too bad I didn't have my laptop on hand so that I could ask her, after a quick search, why I needed a prescription that offers such serious side effects as, well, death. I'll live with my breakouts, thank you. Healthcare reform, it can't happen soon enough!!
ReplyDeleteVery imformative article. 650 Billion is a hell lot of money. Electronicaly recording of medical record is becoming more and more common these days as it make the records more accessible. But EMR`s have some cons and pros as well. I agree with lwild that some times the prescribe medicine could go terribly wrong.
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