Unhealthy Industry

From The Australian newspapers’ health section

AT THE COAL FACE: Gabriel James

January 09, 2010

SINCE the introduction of Medicare in 1985 we’ve had more than 20 state and federal health system reviews.

Each identifies lack of money, poor planning and weak primary care as big issues. Each proposes blue-sky goals such as better rewarding of prevention, creating interdisciplinary teams and training more doctors. But what has changed?

If Australian healthcare were a business its stock price would be tumbling. It’s time we recognised that to be sustainable, health must be like any other industry. Instead, our inflexible workforce, burdensome regulation and consumer segregation makes health a nationalised fiasco, with a small proportion of private entities taking the cream.

To continue reading click here.

Does Australia’s health system need to get worse before it can get better?

In 2010, governments across the world will redouble their efforts to reform healthcare. 

Indeed, in most countries, they have been trying for decades. But a recent economic jolt reminded us just how tenuous our prosperity is and has given us a new sense of urgency.

Click here to continue reading my article on Open Forum.

Point-of-Care Testing – A Quick Win Damned by EBM

The decision by our Department of Health not to fund point-of-care testing is a perfect example of how healthcare is stunted by regulation and our concern for evidence in a world evolving faster than we can think – let alone publish systematic reviews.

Point-of-care (PoC) laboratory testing has numerous advantages over the traditional large-scale laboratory systems. The obvious ones  are timeliness and accessibility. According to numerous studies it is cost-effective, and most of those were extremely limited studies that only assessed the actual cost’s of testing – not time saved or travel saved etc. In effect, they were completely distorted studies in terms of cost-effectiveness.

In Australia, where GP’s in remote areas often have to wait 3 days for an INR before adjusting a Warfarin dose, it seems illogical that we can’t give themPoC testing.

It’s detractors suggest GP’s might over-test (as if that doesn’t happen already). I would suggest that the very demands of organising the test in-house, while quick and easy, is still harder than ticking a box and would give GP’s and patients a better sense of the usefulness of their tests.

The last time PoC testing was evaluated by the government was apparently 1997. If they wait another 12 years before the next review I predict we’ll have the ability to buy kits off the internet for home use by then. Only because the government will pay for us to have a doctor do will patients not test themselves.

Yet again, the limitations of bureaucracy and the limitations of trying to evidence-base breakneck speed and complexity means a loss for consumers of health.

Health Care Reform begins with the Individual

It’s great to hear a voice of reason amidst all this mudslinging, particularly in the USA where the possibility of any major reform is dimming by the day. And it comes in the form of an MD who reminds us that ultimately it is individuals that are responsible for their care and that much illness is preventable by better behaviour.

While we focus on the cost of drugs, procedures and insurance, it is easy to forget that we are treating people that are sick for a reason. In Australia, as in much of the USA, our current system is basically like going shopping with someone else’s credit card — no limit, no penalty, no shame. People have very little to discourage them from getting overweight, for example.

Now before you suspect me of promoting draconian fat-taxes and like measures – hear me out. The best guarantee of health in any society are norms and customs that strongly encourage healthy living. These take time, however, to develop, and can easily be lost. Then there will always be those that ignore them anyway. As it stands we have a long way to go before people are fully empowered to aim for better health.

For this reason there is increasing focus on health education. But more can be done. One great suggestion is the idea of an ‘individual health road map‘. This is a plan given to you by your health care provider that outlines all the critical steps required for an individual to maintain, insofar is is humanly possible, their health. For example, a diabetic could be given the standard of care plan for diabetics, and if he/she actually showed up, without fail, to the doctor, the podiatrist, the nutritionist and followed their subsequent recommendations, he would be less likely to require hospitalisation and expensive treatment and society would not shoulder his cost. If he misses these critical steps in his care, he pays, not us.

Obviously, any similar system must be implemented with great concern for people’s well-being – and no-one should ever be refused health care. But as it stands, we have low expectations of individuals and place very little pressure on people to truly live healthy lifestyles. Such a form of insurance may be the best reform yet.

I’m also encouraged to read that another web-based patient support tool is being developed. It’s part electronic medical record, part drug encyclopedia, and part patient chart known as the Pediatric Knowledgebase (PKB).

The PKB integrates the hospital’s medical records with drug-specific decision support generated by clinical pharmacology experts and clinical caregivers and predictive models generated by a hospital’s pharmacometric and informatics team. Forecasting tools evaluate dosing scenarios to be explored via a user friendly interface that front-ends a pediatric population-based PK/PD model. The result is therapeutic drug monitoring for children that uses patient data to help predict outcomes and inform clinical decisions in individual patients.

Patient Genetics and Online Collaboration

Is the future in controlled clinical trials, or IT driven collaborations to share health experiences? The answer is obviously a mixture of both, but patient/industry collaborations are making some very positive steps towards becoming a powerful tool.

This great article from NYTimes highlights some collaborations already formed.

For example, in June this year, the Belgian pharmaceutical company UCB announced a partnership to build an online epilepsy community with PatientsLikeMe, among the first private companies to develop a platform for data sharing by patients. PatientsLikeMe, based in Cambridge, has as members tens of thousands of patients who contribute detailed information about their diseases, drugs, doses and side effects. Mark McDade, UCB’s chief operating officer, said the regulatory approval process should be changed to incorporate not just safety and efficacy but also measurements on how drugs affect patients’ lives — data that is now slow and expensive to collect.

Genetic companies have also taken up patient-driven research. The Silicon Valley company 23andMe, for example, started a program this summer called “Research Revolution.” People can buy a stripped-down version of 23andMe’s genetic service, which gives people DNA information on ancestry and risk for certain diseases, for $99 and then contribute their genetic data toward research into the disease of their choice (NYTimes).

Innovation opinions by McKinsey

McKinseys had a few good articles on innovation posted yeasterday. I’d recommend them for a read – and particularly the comments below each article which are quite insightful and perhaps better in content terms also.

This article, on how economic downturns drive innovation was quite controversial. I found one of the comments by a Paul Hamann quite insightful:

Here’s three big ideas for innovation resulting from this recession:

1. Medicine will become an application of computer science. This innovation will finally end the health care crisis and expose the incompetence of most doctors. That’s why the Obama administration won’t compromise on linking physician compensation to outcomes. It’s also why they won’t cap malpractice awards. That’s 17% of GDP finally subject to competition. Info Tech companies will take most of it. Google and Intel will do well. They already are.

2. Computers will become carbon-based instead of silicon, resulting in unlimited compute cycles that are nearly free. This advance will result in absolute ubiquity. It will also enable NP-complete problems to be efficiently solved. That will lead to enormous leaps in engineering and science.

3. The distinction between mobile phone, desktop, and server will go away. We’ll see hardware and Linux-based OS’s become interchangeable across the three categories. This innovation will ultimately benefit Google and end Microsoft’s dominance in software. It will also give a huge boost to the open source movement, benefiting developers and niche software providers. Finally, it will severely disrupt the economics of cloud computing. After all, every new technology gets over-hyped. It’s already time to ask what the cloud computing bust will look like.

I included all three of his points for completeness, but can only comment about the first. It’s a fairly broad sweep but there is some truth in it. It’s by no means an original idea, with the likes of Clayton Christensen and the author of ‘Supercrunchers’ (name?) predicting the exposure of doctors incompetence when health goes truly digital.

The next question for doctors is then how to best prepare for this from an educational perspective. Do we just wait for the innovation? Or should we begin to change our ways of practising medicine in anticipation?

I believe many doctors already are adapting as patients gain access to knowledge and tools they never had previously. As I’ve suggested before, we are becoming more like health managers than health teachers.

The Dangers of Mixing Medications

Well known to geriatricians, the dangers of mixing medications are significant with around 21% of the elderly reportedly on a bad combination of drugs. CHOICE seems unsure who to blame citing historical, practice and industry factors. I would say the blame should fall squarely on no one.

We have very little data on real-life interactions of medicines and must therefore go with automated warnings on GP’s desktops and criteria such as Beers. CHOICE suggests pharmacists need to get more involved – particularly as allied health acquire more prescribing rights.

The practical experience of anyone that’s spent more than a few days in any public hospital says that until patients are given better information and control over what medication they are on, why and where they get it from, we will continue to be in the same situation.

The Choice article does offer some great tips (primarily for clinicians), however, that we should apply in the meantime.

Mobile Phones make us Dumb

Lot’s of older people might have said it, but who would have believed it? Now there is some evidence.

A Monash University study of more than 300 children aged 11-14 found that those who made more voice calls per week had faster reaction times but performed less accurately on memory tests and associative learning tasks. Students who frequently used SMS text messaging also demonstrated shorter response times and less accurate responses.

“The use of mobile phones is changing the way children learn and pushing them to become more impulsive in the way they behave,” says study author Professor Michael Abramson of the Department of Epidemiology and Preventive Medicine.

US Politicians to Ban Drug Ads

Direct to Consumer, as it is known, is when pharmaceutical companies market their wares to the public. It is only allowed in a few countries like the USA and New Zealand, and with restrictions.

But a move is on to limit or ban them altogether. This NYTimes article explains the politicians motivations.

On the whole, I agree with the arguments presented there. To me it is another wake up call for the healthcare industry as it seeks new ways to interact with consumers and begins to realize it’s future lies more in wellness/prevention and personalised medicine than blockbuster products.

Rebuilding our Corporate Reputation

As a current health care industry employee I am often confronted by negative aspersions about the industry, particularly pharmaceutical companies. Amongst the younger generation of industry employees the sense is that this negativity is only going to increase in the short term. So the importance of building a slid understanding with society is paramount in my view.

This McKinsey piece offers some great insights, examples and strategies for doing good PR (membership required). One feature I felt very attuned to, particularly in light of my first comment about young people, is the need to do “social attitudinal” segmentation studies. In general, the studies they cite found that consumers felt large companies focused too much on PR and lobbying, and not enough on dialogue with them! I think this is a great message, particularly for those in corporate affairs within health care – and perhaps a question Obama’s staff must be asking themselves in the face of increasing backlash over his health reform plans.