Health: Where to from here?

This is truly THE global question today. But just as the Nobel peace prize committee has established itself as a questionable zeitgeist, I fear many health reform commentators are doing little more than talk. This beckons a general comment about two important recent developments, and a personal statement about the future of this blog.

There have been two announcements that made me sit up and take notice of late. Actually, make that three.

The first was from Dr. Ezekiel Emanuel in a speech to the Medical Group Management Association annual conference in the USA. I quote, “The problem in the system (healthcare) is not that we don’t have the right technologies,” said Emanuel, chair of bioethics at the National Institutes of Health, in addition to being the older brother of White House Chief of Staff Rahm Emanuel. “It’s how we connect with patients.”

That statement – how we connect with patients – sums up what I believe is the unstated need central to healthcare reform. Too many people are approaching things from an economic or systems focus when ultimately, everything depends on patient needs. This truism deserves more explanation.

Emanuel went on to speak of increasing this connection by making healthcare accessible in non-office settings including online. He also advocated such things as non-physician care when practical, on-site health clinics at large worksites and even a return to house calls.

This leads onto the second and third developments of late. The second is that NEHTA announced a shift in strategy on Australian health records. Realizing that a national centralized behemoth was never going to happen this century, they’re turning to industry to tout their wares. This is a great and sorely needed shift.

The third was a lonely voice crying in the medical training wilderness of Australia.

It comes from Michael Moore, not the doco-joker, but former ACT health minister. He says Australia’s medical colleges should hand over responsibility for training specialists to universities.

Now chief executive of leading advocacy group the Public Health Association of Australia, Moore said the change would lead to more trainees, easing fatigue loads. He said overworked doctors could thank the closed-shop attitude of their supervising colleges for ensuring trainee numbers “aren’t too high”.

“The training and control of who gets into the specialist programs is in the hands of colleges and it’s a poor system because it clearly suits the colleges to have fairly restrictive entrance,” he said. “If they maintain a relatively poor supply and a high demand, obviously they’re going to make more money. The logical system would be to take the training completely away from the colleges and move it to universities.”

This surely suits the current governments reform agenda. They are clearly frustrated by the closed-shop attitude of several medical colleges. The question is how this can be done?

These last two changes both point back to the first: health reform should begin with, and target, areas where patient needs can be met. Other changes will then follow more easily. If we go after big and immovable targets we will fail. but if treat health as the dynamic marketplace it is, and meet patient needs, the resistant stakeholders will be forced to follow lead. The introduction of patient controlled records and the broadening of medical training are key steps in this direction.

I want to finish by apologizing for my lack of posts in recent weeks. While busy with other things, I’ve also had some time to think about where to spend my time in the near future and am considering wrapping up this blog. Or at least rolling it up into something more specific such as a tool for research/reports on advancements in primary health management. I see little value in generating more gas around this roaring healthcare fire and hope to capture and funnel this heat towards building something worthwhile.

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.

Pharma backed Medical Education Under Fire

From FiercePharma:

Continuing medical education (CME) has been bastardized by pharma funding, an HHS inspector general told Congress, and needs a complete overhaul. Lewis Morris, chief counsel for the HHS office of inspector general, said that industry doesn’t just shape the courses, it has also used CME to promote off-label uses. And Morris was just the first of several witnesses expected to criticize industry-funded CME during a Senate Committee on Aging hearing.

Pharma-backed CME has grown by leaps and bounds. Dow Jones reports that industry funding for medical education has more than tripled over the past 10 years to $1.2 billion. That’s more than half the courses many doctors are required to take to stay current. “CME has become an insidious vehicle for the aggressive promotion of drugs and medical devices,” said Dr. Steve Nissen (photo), the Cleveland Clinic cardiologist who rarely minces his words.

But others–including PhRMA–protest that the industry can offer the best, most up-to-date info on new treatments, and that drugmakers are an important part of medical education. Dr. Thomas Stossel of Harvard Medical School–who has started an organization balking at the current backlash against pharma funding and doc payments–told the committee that companies make an important contribution to scientific understanding of disease. “I want the best information. I don’t care who pays for it,” Stossel said (as quoted by Dow Jones). “The nonprofit societies just can’t get up to speed fast enough.”

The hearing is just the latest salvo in an ongoing battle over how much pharma funding is too much, and whether all financial ties between industry and doctors, academia, and CME should be disclosed. Medical schools and hospitals have established conflicts-of-interest policies, some of which are so strict they don’t even allow reps to hand out logo notepads. Drugmakers have promised to disclose payments to doctors, and some have bowed out of CME funding. This particular Senate committee is considering legislation that would require companies to disclose doc payments. The debate is far from over.