Inkwell: Authors and Artists
Joe Flower (bbear) Tue 3 Jul 12 10:29
My bet is that the effect will very real, but will be hard to see on the mass level, hard for the Democrats to point to and say, "See? We did this!" Because it will be a slow change, on the pace at which people adjust to new circumstances, absorb the difference, and change their life plans. But very real, yes.
Dave Waite (dwaite) Tue 3 Jul 12 10:39
I'm hoping at the state level, at least the real costs for paying for immediate emergency care will drop drastically as this bill becomes effective in insuring the indagent - isn't that one of the major cost savings associated with the bill?
Joe Flower (bbear) Tue 3 Jul 12 12:36
To the extent that it works and most of the uninsured become covered, yes. It would mean that the hospital is not forced to tack on their expenses to everyone else's bill. But the Republicans are eager to make sure that Medicaid is not expanded, even if the states don't have to pay for it, because blaming and hurting poor people is a principle for them. That and other obstructions may mean that in the end ACA will not cover as many extra people as hoped.
Jane Hirshfield (jh) Tue 3 Jul 12 15:30
(wickett, I am pretty sure you can go back in and EDIT your original review of Joe's book to say whatever you'd now like it to.)
Joe Flower (bbear) Tue 3 Jul 12 15:34
(Actually, she did, except it appears that Amazon removed the URL itself.)
. (wickett) Tue 3 Jul 12 16:43
Paulina Borsook (loris) Tue 3 Jul 12 20:10
joe, op-ed in today's chron by katherine schlaerth, an associate prof at loma linda school of medicine, on some potential law of unintended (negative) consquences from obamacare: http://www.sfgate.com/default/article/What-s-next-from-Obamacare-3680231.php thots?
descend into a fractal hell of meta-truthiness (jmcarlin) Wed 4 Jul 12 11:03
Joe, I just got the August Consumer Reports magazine. There's an article "How Safe is Your Hospital". One startling part of that article is that "No hospital got top scores for readmissions or communication." NONE. The readmission number was for heart attacks, heart failure and pneumonia readmissions within 30 days of discharge. Communication is defined to be explanation of new medications and discharge planning. I would have thought that a few would do well on these measures and was shocked to read CR's findings. Care to comment?
Joe Flower (bbear) Wed 4 Jul 12 11:18
Thanks, Paulina. The article about unintended consequences of Obamacare is by a longtime family physician. She has several concerns: o Not enough physicians, physicians will be even more stretched, pressured to see ever more patients o This will lead to even more over-prescription of narcotics and antibiotics o Electronic medical records are ready for prime time. o ACA diverts funds to prevention from cures, but people won't change their habits. These concerns vary, but they have this core thread in common: They assume that the ACA is implemented, but the system does not respond in any fundamental way, and there are no other big changes going on in healthcare. People tend to see things this way: Here is this influence coming our way, here's what it feels like it will mean to me. People tend not to think about how the system will react to those changes, and what other influences the system is under. This doesn't yield the best analysis. In fact, the system is adapting in some fundamental ways to the ACA. More importantly, it is undergoing some fundamental changes that are more or less independent of the ACA. That is what this book is about.
Joe Flower (bbear) Wed 4 Jul 12 11:24
To meet her concerns individually: > Not enough providers, and the resulting pressures True, even without the ACA, just with the Boomers aging into Medicare years. If the system made no response to this, yes, the existing doctors would be extraordinarily stressed. The real pressure on the system is to use doctors time far more effectively and efficiently. Note, for instance, that she says the uses one-third of her time inputting data. If that is true and average (which I don't necessarily doubt) solve that problem with software that derives its data directly from the actions of the doctors and the direct input of tests and labs and doctors orders, boom, you have 50% more doctors' time. That's just one example. The software, the team systems, and the business models that can do this all exist, and are outlined in the book.
Joe Flower (bbear) Wed 4 Jul 12 11:32
> EMRs not ready for prime time This is true of many major systems, as we have discussed above and as I detail extensively in the book. To the extent that systems shift from being strictly fee-for-service to being paid in one way or another for outcomes and the health of populations, they will ditch systems that get in the way of clinical care in favor of systems that optimize it. The legacy software providers in the field now will adapt or die. Seriously here are the top 8 computer companies circa 1980: IBM, Burroughs, UNIVAC, DEC, NCR, Control Data, Honeywell, Hewlett Packard. By 1990 all of them had gone bankrupt, been bought out and scaled down, or had fundamentally changed their product lines and business models and been born again. We will see the same thing in the health IT business within this decade. It will be expensive, wrenching, and difficult, but it will happen.
Joe Flower (bbear) Wed 4 Jul 12 11:41
> ACA diverts funds to prevention from cure, and people won't change There are two parts to that sentence and as far as I can tell neither is true. The ACA does not actually "divert" funds away from cures in any way that I can think of. It does emphasize preventive measures, and mandate that they be free to any covered patient, to encourage their use. And that is built on the well-demonstrated notion that prevention will drive down the costs on the "cure" end. I would respectfully suggest that being a doctor in the conventional health system would give one no basis on which to declare that people won't change. Of course they don't change if the doctor simply instructs them to lose weight, stop smoking, cut down on their drinking, or change their diet. Most doctors have never seen a full-on, serious, well-constructed preventive healthcare program and most of the personnel in such programs are not doctors. The idea that people won't change in the face of such serious well-constructed programs is refuted by the many examples throughout the book of different populations, funded in different ways, dropping their healthcare costs by being better cared for and becoming healthier without any extraordinary will power or shift in human nature. The notion that "people won't change" (with the implication that an emphasis on prevention is a waste of money) is simply provably false.
Joe Flower (bbear) Wed 4 Jul 12 11:49
> Consumer Reports ... "How Safe is Your Hospital" ... "No hospital got top scores for readmissions or communication." NONE. Haven't seen it, but I am not surprised. Even our best institutions have problems. Johns Hopkins is famous for poor communications, and its re-admit stats have been about average. In the book I cite Don Berwick, the founder of the Institute for Healthcare Improvement and until recently Obama's appointee for running Medicare and Medicaid: He spoke repeatedly at industry functions, arguing for higher-quality standards and practices. On December 4, 2003, at IHIs annual meeting, he delivered the talk that would become a classic, My Right Knee. Knowing that his knee would have to be replaced soon, he laid out five requirements he would demand of any medical institution that would do his surgery: o 1. Dont kill me (no needless deaths). o 2. Do help me, and dont hurt me (no needless pain). o 3. Dont make me feel helpless. o 4. Dont keep me waiting. o 5. Dont waste resources, mine or anyone elses. Berwick felt that every patient should be able to make exactly such a demand. But given what he knew of the medical establishment, he was not at all sure that he could find any institution in the United States that could deliver on those five promises. This is striking, coming from a doctor who was probably as intimately aware of how healthcare institutions work as anyone alive: Given my requirements, it is not clear that any health care institution in the United States will want to take me on as a patient. Many institutions have been making great progress, but all institutions still have to make big changes to be ready for the Next Healthcare.
Paulina Borsook (loris) Wed 4 Jul 12 18:41
i much prefer that your model of the world (adaptive systems changing for the general benefit) than that of the loma linda prof's feeling that things will just get worse along the lines they have been worsening. an ill-formed set of concerns, presaged by remarks made by julie and the estimable <wickett>: - mysterious chronic illness (such as MS, cfs, fibromyalgia, etc) are actually far more common than is realized --- and these are managed (if at all) through tending and care. yet discussions of how to provide the kind of care those of us who suffer from such need dont seem to enter into the current discussions of the healthcare mess and how to fix it. - i really worry about the loss of solo practitioners. - combing these concerns into one personal example in addition to my other maladies i have neurologically-driven odd chronic pain probs --- and it had gotten to the point in 2007 where i had to reserve a wheelchair at airports coming and going in order to attend my mother's funeral (thank you, ADA!). this experience so freaked me out i decided i needed to throw everything at getting better: so a variety of pt, pilates, chiropractic, ultrasound, cold laser, contrast baths, therapeutic massage, and acupuncture brought about huge positive changes; no wheelchairs in sight five years later and i have -gained- 1/2 inch in height (less spinal compression). * none of this 'healthcare' was paid for by my insurance (i consider myself very forturnate to have my get-hit-by-a-truck insurance at under $500/month) so the system doesnt 'know' that my taking proactive and preventative steps has saved 'the system' money (can walk and carry things; am not on pain meds; dont need homehealthcare attendants, etc etc) * i chose the practitioners who i felt got me and the idiosyncracies of my condition; none of these were part of any group and no one was dictating their methods. * it seems to me (from reading propaganda handed out by ucla and cedars- sinai) that while there is recognition that CIM (complementary and integrative medicine) can really help with chronic illness and can save money (because other kinds of nasty interventions arent required) there is less funding for it and research into it as evidence-based medicine, than there is funding for fussing about with bright shiny new molecules and genetic intervemtions, which are both intellectually sexy and promise potentially renumerative IP. thots?
Joe Flower (bbear) Thu 5 Jul 12 09:49
Hey, Paulina! One of the core modes of thought of the book is that when people discuss how to fix healthcare, they almost inevitably try to come up with some massive system change: This is how healthcare should be! This one way! Yet most industries or economic systems have much more variety of business models to meet different kinds of customer needs. So should healthcare. Though there are certain new modes that are rising to prominence, such as comprehensive healthcare systems that do most of their business on a risk-based model of one kind or another, there will be (I believe) a far greater variety of business models in the future of healthcare than today's. People with these "mysterious chronic illness (such as MS, cfs, fibromyalgia, etc)" tend to be ill-served by fee-for-service medicine, which will only provide specific services that can be reimbursed at a remunerative level as they are demanded. The notion that providing some service now will prevent the patient from deteriorating to the point where they will need greater services later has no place in the economics of a fee-for-service system especially when the system will get reimbursed for the greater services later! Despite that best intentions and compassion of the individuals who run them, economic systems have a kind of relentless ruthlessness. They simply cannot afford to do things that will not fuel them with more money. They are not going to chase after people with such mysterious chronic illnesses and really work to devise the best program of help for them. A system at risk for the costs of your health over time would act quite differently, because the potential costs of such diseases are much larger than those of other people. When you are at risk, people with big costs are not sources of profit, they are sources of cost. You make money by reducing the costs. You actually reduced the system's costs with all your efforts. But you are unusually smart, active, and educated in your own behalf. If I were the CFO of a system at risk for the health of thousands of people, I would read your story and think of the other 99% of people in your situation who are not so active and intelligent, and will end up costing huge amounts if we don't figure out how to find them and help them now.
Joe Flower (bbear) Thu 5 Jul 12 09:59
> CIM vs. shiny new molecules This is similar. You mention "propaganda handed out by ucla and cedars- sinai." By certain measures, those are the two most-expensive fee-for-service systems in the country. The important thing to note is that the complementary/alternative medicine approach to chronic illness is so much cheaper than other approaches, especially than "bright shiny new molecules and genetic interventions." Again, the "cheaper" part flips both ways: In a fee-for-service system, that reads as "labor intensive, with lower or no reimbursement." In a system at risk for your health, that reads as "so much higher on the cost/benefit scale that we should try every CIM approach possible before moving onto more expensive and invasive approaches." The same possible approach shows on the radar completely differently in systems with different economic underpinnings. And indeed as some systems across the country are shifting to a more at-risk economic model, we are seeing a fairly rapid rise in incorporating CIM techniques.
Joe Flower (bbear) Thu 5 Jul 12 10:13
> I really worry about the loss of solo practitioners. I chose the practitioners who i felt got me and the idiosyncracies of my condition; none of these were part of any group and no one was dictating their methods. I hear your concern for a loss of variety in what would be available for people with these "mysterious" illnesses. I am not quite so concerned, for two reasons: First, the reason we are seeing fewer solo practitioners is not because it's becoming illegal or anything, but because is has become so difficult actually to make a living that way. In the book I detail various ways (such as the Ideal Medical Practice, the Medical Home model, and direct-pay primary care) that sole- and small-practice docs can do better by being better docs. Second, the standardization of medicine applies most strongly in areas like diabetes care in which there really is a known, clear checklist: If you are not doing X, Y, and Z (keeping track of blood sugar level, giving nutritional counseling, regularly checking feet and eyes, for instance), then you are not doing good medicine. Nor can one think of people with diabetes for whom it would be a good idea to neglect those things. Parts of medicine in which there is no clearly established "best practice" pathway, in which what works for a particular patient may not work for another, are of course not subject to such pressures to standardize. The "mysterious chronic illness" category is a prime example. I know that systems can be slow to get this right, as we have seen in some examples you and I know of. But the tendency in large at-risk systems will be to try to develop individual doctors who specialize in these difficult areas, and let them try what works. I have seen this in Kaiser, for instance, in the difficult area of inter-gender issues.
Paulina Borsook (loris) Thu 5 Jul 12 11:12
just wanted to put my concerns on the record, tis all. i realize the research aspect of healthcare is different from the provision of it (i.e. the search for the shiny patentable molecule vs. how could we provide acupuncture on a 3X/weekly basis for folks with chronic pain). as an aside, i have many many kaiser horrorstories (including deaths and neardeaths) so to me it is not a model of anything. but i digress.
paralyzed by a question like that (debunix) Thu 5 Jul 12 11:22
>kaiser horrorstories There are probably more per covered person for other healthplans, they're just not as well publicized. But in CA at least, everyone knows the name Kaiser, it's the healthplan and the hospital, so it's easy for everything lousy that goes on there to get attached to the one name. The blame gets parcelled out differently when it was experienced at hospital x or provider's office y or pharmacy z funded by health plan a and pharmacy benefit plan b.
Paulina Borsook (loris) Thu 5 Jul 12 11:37
probably true. but then i generally use practitioners who are soloists (even for my conventional meds) so... another doomsday reaction from the CIM community about obamacare (just an fyi) http://www.anh-usa.org/what-the-supreme-court-decision-means-for- integrative-medicine/
Joe Flower (bbear) Thu 5 Jul 12 11:49
> kaiser horrorstories I agree with <debunix> that the Kaiser horror stories are simply more visible because of its unified nature, and its salience in California. In addition, when I hear a Kaiser horror story, I ask what year that happened. Kaiser seems to have significantly improved in many ways over the last decade.
Joe Flower (bbear) Thu 5 Jul 12 11:58
> doomsday reaction from the CIM community I am uncertain about a number of the premises of that article. That HSAs combined with catastrophic insurance are doomed by the legislation, and will only increase if people willingly opt out? What I have been hearing from insurance executives is an expectation that we will see more of them. I will have to keep an eye out for a better explanation of this. The article's description of the government demanding only "full coverage" is, I believe, incorrect. The exchanges are supposed to be set up by the states, and there are a number of ways to set them up, with the major difference being how wide a variety of plans will be allowed (Utah and Massachusetts exchanges, both already operating, represent the two extremes). I could be wrong on this, but I believe that a major strain of what I am hearing from the insurance industry and the employer healthcare consultant industry is an increasing shift of a titrated amount of financial risk to the consumer/patient. Which translates into co-pays, deductibles, and consumer-directed health plans (CDHPs), which consist of exactly this combination of high-deductible health plans with HSAs. This is the first time I have heard anyone claim that such plans would be in some way restricted or even discouraged by the ACA.
descend into a fractal hell of meta-truthiness (jmcarlin) Thu 5 Jul 12 11:59
> doomsday reaction People fear change. Some REALLY fear change. Factoring out that fear from legitimate concern is hard but worthwhile when it's possible.
Paulina Borsook (loris) Thu 5 Jul 12 12:08
i think people in the CIM community feel -every- move by tptb makes their professional and financial lives worse --- never mind that this may not be the case. so i think what you are hearing is worry based on lots of past experience. i cant think of any of my practitioners who have had good experience with either insurance corps or healthcare systems. this community of patients also may be folks who -dont- have conventional insurance but -do- cough up, say, to see a CIM practitioner as needed. so to them this maybe feels like lots of $ shelled out to entitied they dont like for medicine they dont want
J. Eric Townsend (jet) Thu 12 Jul 12 17:53
Restating something I just sent in email. Please don't use any of my posts on the well as content for your professiona publishing, even if you're giving away the book and claiming no monetary profit. I am happy to be interviewed with specific questions for a known target publication if I am the appropriate person for the topic; however my posts on the well are a part of a conversation and not a contribution to a publication.
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