Back from Canada

I recently returned from our annual trip to rural Quebec, a refreshing break from everything (including the internets!). Eli’s post below, about resource-intensive approaches to infection prevention that seem so attractive compared with the hard work of basic hand hygiene, reminded me of a conversation I had over dinner with a Canadian family friend. He asked for details about the current political debate over Medicare, and I explained how one side is interested in restructuring the program from a defined benefit plan to a defined contribution plan, thereby shifting the risk of future increased health costs from the government to the individual.

“What happens when you need care that you can’t afford?” he asked. I pointed out that medical illness and the associated costs were a common cause of personal bankruptcy in the United States. He sat in stunned silence for a few moments before ending our discussion with, “Well, that’s barbaric.”

Happy Canada Day 2012!

A few myths about the Canadian system can be found here. A couple salient facts are found in the graph from the post below—longer life expectancy for half the per-capita investment. It isn’t just Canada, either. The U.S. is super-terrific at spending tons of money to achieve slightly worse outcomes than the rest of the industrialized world.

Awaiting the Supreme Whatever

Will they overturn the Affordable Care Act, or just part of it? How will it affect us as patients and providers? How will it impact public health and prevention efforts (the Prevention Fund is already vulnerable, as we know)? Whatever happens, we have a lot of things to fix, because clearly we’re doing it wrong. Maybe we aren’t screening enough people for MDROs.

Source: OECD

If Air Travel Worked like the US Healthcare System

Somehow, this makes me like air travel for the first time in 10 years...



h/t @IrfanDhalla via @picardonhealth

Healthcare reform explained. The Kaiser Family Foundation video

Cokie Roberts explains all or at least a little

Sorry about the earlier video; this one should work on iDevices. -e

How many chickens for a 7-day linezolid course?

Like many, I’m intrigued by the health care reform proposal recently put forward by a Nevada Senate candidate. The proposal calls for a return to the barter system for health care delivery. There are only a few problems. One recent analysis concluded that basing such a system solely on chickens would be impossible, given the sheer number of chickens required.

Another shortcoming--what to do about adverse events and nosocomial infections? Shouldn’t a patient also receive goods or services if he or she is harmed during the delivery of health care? I can see it now…returning home after a hospital stay complicated by a nosocomial infection, you discover that the hospital has sent someone over to paint your house…

"Lessons of a $618,616 death"

I arrived at the gym tonight with nothing to read. Given that 30 minutes on the bike can seem like eternity, I went to check out whatever was left behind by those smart enough to bring along some reading material. I found only two recent but ragged magazines--BusinessWeek and Entertainment Weekly. My heart sunk--I was facing eternity on the bike. Then the BusinessWeek cover caught my eye: Lessons of a $618,616 death. The cover story was written by Amanda Bennett about her husband, who died after a 6-year struggle with kidney cancer. After his death, she read all 5,000 pages of his medical records, analyzed every medical bill, and tells the story of his illness in an incredibly honest way. She describes some of the fundamental flaws of the US healthcare system, the bizarre workings of the insurance industry, the moral hazard of having good insurance, and the desperation of the terminally ill that leads to a spare-no-expense mentality even when the odds of success are very, very small. In the end, she feels guilty about the fact that the resources spent on trying to save her husband could have vaccinated a quarter million children, yet she admits she would do it all over again. The entire article can be read online here. It's a must-read.   

Aneurin Bevan

"... no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means."

—Aneurin Bevan, In Place of Fear

I suspect many in the US will have never heard of Aneurin Bevan. I recently came across his name while reading the obituary of Michael Foot. In the wake of England's Labour Party landslide victory in 1945, Bevan was appointed Minister of Health, charged with starting the new National Health Service and asked to solve the nation's housing shortage. He was the youngest member of the cabinet. His "National Health Service Act of 1946" did not come into force until July 1948 after great fights with the conservative party and a showdown with the BMA.

It has been interesting to read the postmortem stories and talks of battles ahead. What I'm struck with are the similarities and differences between Britain's fight in 1945 and ours. Tough economic times, major housing issues (bombs vs foreclosures), landslide victory for one party and the long duration of the battle for universal coverage. At the same time, England's left nationalized healthcare and ours maintained a free-market system which will now be challenged by the "free-market" right. Oh, well. It hasn't even been a year...or has it been 65?

Atul Gawande - Interview

Recently, Atul Gawande sat down with Rahul Parikh, MD in Salon.com to discuss healthcare reform, checklists and music. It's an interesting discussion on changing the healthcare system and improving quality including the need for better data. The interview occurred before the Massachusetts Senate election, so it seems at times like it was written decades ago when there actually was hope for healthcare reform. Final note: I agree that Radiohead ruled at some point, but as far as ruling the day, perhaps Spoon or Super Furry Animals should have been mentioned. (Thanks John Cole)

Atul Gawande - The Checklist Manifesto

Dan has commented several times on Atul Gawande's New Yorker articles (here and here). As he stated, his writing is highly influential both politically in Washington and in driving patient safety. Those who like his articles and books will be excited to know that he has a new book coming out next week titled "The Checklist Manifesto." You'll be even more excited that you can hear him now on APIC's website and see him July 12th at the New Orleans APIC conference where there will be an "exclusive book signing at the premier conference for infection prevention education." I was going to comment on the fact that SHEA might be considered the premier conference by some, but then I realized SHEA's meeting will be going away in a few years, so it's probably not worth mentioning...

I'm sure we'll write more about his newest book when we've had a chance to read it. In the meantime, I will be sitting next to my fireplace hoping Santa finds it in his heart to place a copy in my stocking.

Healthcare reform and cost containment

Back in May I flagged an article by Atul Gawande. That piece, which put McAllen, Texas on the map (but not in a good way), illustrated nicely the consequences of the perverse incentives built into the fragmented U.S. healthcare system. The article became required reading in the White House during the debate over healthcare reform.

Dr. Gawande has another article in the New Yorker this week, this one addressing strategies for cost containment. Although failure to more aggressively curb costs has been a common criticism of the current reform bills, Gawande argues that pilot programs such as those included in the bill (including one that would penalize hospitals with high infection rates) are the most promising long-term approach to cost containment and quality improvement.

He uses the history of U.S. agricultural practices as an analogy, arguing for a form of positive deviance writ large--establish small-scale pilots around the country, and expand or replicate those that are successful. The process would be guided by government but not with big comprehensive mandates.

I agree with that general approach to quality improvement and infection prevention, and I think we are already seeing how certain interventions that clearly work (e.g. the central-line associated bloodstream infection prevention bundle) are being more widely adopted. What we desperately need is more funding to quickly study competing approaches and determine what works best.

Labor Day reading

An interesting piece in The Atlantic, written by someone who lost his father to a hospital acquired infection. He ties poor infection control practices to the structure of our health care system, and provides his own proposal for reform at the end of the piece. Whether you agree or not with his prescription (I happen not to agree), the piece is thoughtfully written and makes several important points.

One particular issue that I’ve thought about lately has to do with how the structure of a health care system influences the risk for hospital acquired infection. I agree that incentives for infection prevention (and disincentives for higher infection rates) are important. But is there any evidence that countries with similar living standards but different health care systems have markedly different nosocomial infection rates?

I’m asking this not as a hypothetical, but because I honestly have no idea. I’ll need to find time to search for published data on this, unless someone can enlighten me in the comments section (and no, I’m not talking about rates of one specific drug resistant organism from one country to another, but overall nosocomial infection rates, which of course leads to big issues of standardized definitions, risk adjustment, etc.).

Sigh

When will the media stop inviting a serial liar to misinform the public about healthcare reform? There are a lot of smart people out there with important things to say about making our system better. She is not one of them.

Improving health care: A double-edged sword?

An article in today's Salt Lake Tribune focuses on the Intermountain Health System, which is widely known for its focus on electronic medical records and informatics to improve the quality of health care. The article points out a paradoxical impact. By using their rich databases to the improve the quality of care delivered, Intermountain has allowed insurers to reap big savings while the hospital system actually lost millions of dollars since fewer services are required when complications are avoided. Unfortunately, bad care begets more care which begets revenue.

Healthcare reform and infection prevention

From an excellent piece in the NEJM, by Dr. Nicole Lurie, that nicely links healthcare reform, infection prevention and the public health:

"Early detection of a new infectious disease—and potentially the survival of those who are infected—requires that sick people have access to the health care system and receive early treatment. Delays in seeking care can lead to delays in the recognition and control of an epidemic and in the treatment of patients. Indeed, experts have hypothesized that one reason the mortality associated with the current epidemic of swine-origin influenza A (H1N1) virus (S-OIV) was so high in Mexico is that many people delayed seeking care, in part because of its cost. In the United States, lack of health insurance is a key reason for delays in seeking care; health care reform that results in universal coverage would facilitate earlier detection of new diseases, enable disease-control efforts to be instituted, and alleviate the population’s vulnerability that is attributable to delayed care."

Read the whole thing here.

Whither utilitarianism?

In an OpEd piece in this morning's Wall Street Journal, Betsy McCaughey attacks Ezekiel Emanuel, an oncologist and medical ethicist at the NIH, for his view that in making medical decisions physicians should not only take into account the needs of the individual patient but those of society as well. She argues that this is a dangerous way to think. But it's ironic coming from a woman who when not attacking health care reform is writing and speaking about the dangers of multidrug resistant organisms. If physicians made decisions purely on the basis of the need of the patient without regard to a greater collective good, then the entire concept of antibiotic stewardship would be abandoned. With that thinking doctors should prescribe the most potent and broad-spectrum antibiotic in every case without concerns for the development of antibiotic resistance that reduces our ability to have effective antibiotics for the future. As I see it, the thoughtful physician often thinks of the impact of decisions beyond his or her patient. And that's really no different from how a thoughtful human should approach life in general. The real argument in the healthcare reform debate, which underlies the tension between the views of McCaughey and Emanuel, is whether health care is a public good or whether it's a commodity. Unfortunately, the United States can't seem to figure that out.

New frontiers in stupid

My previously expressed cynicism about the healthcare reform “debate” appears warranted, as the discourse reaches new depths of stupidity and disingenuousness. My favorite recent example comes from the Investors Business Daily. In an editorial opposing Obama’s healthcare reform, that paper argued that a UK-style system would result from Obama’s proposals, and that such a system would consign to an early death none other than Stephen Hawking, the world renowned physicist who suffers from Amyotrophic Lateral Sclerosis. Mr. Hawking “wouldn’t have a chance in the U.K.”, his life deemed “worthless”, the paper breathlessly reported.

One small problem: Stephen Hawking lives in the U.K., and the N.H.S. has helped keep him alive, by his own report.

….and here’s some bonus stupid from Betsy McCaughey, who has taken a break from spreading disinformation about infection prevention in order to spread what AARP accurately describes as “flat-out lies” about Obama’s healthcare reform plans

Do we really need healthcare reform?

If you are sitting on the fence about whether this country needs healthcare reform, see this story from NPR. Then make a donation to Remote Area Medical (RAM). By the way, a gallery of patients and providers accompanying the NPR story shows a number of students from the Virginia Commonwealth University School of Dentistry who donated their services to this event. I practice at VCU and what makes me proudest of this institution is it's long and deep commitment to the poor.

Don't Get Sick (if you want to stay insured)

Another piece, in Slate, on the odious practice of rescission.

Restrictions May Apply

I enjoy This American Life, and have been listening to each weekly podcast while I walk to work. This week’s show was entitled “Fine Print”, and covered several unrelated topics wherein reading the fine print turned out to be crucial.

One segment of the show hits pretty hard, and is directly relevant to health care reform—it covers, in a very moving way, the health insurance industry practice of “rescission”. For those of you who live in a developed nation with a sane health care system, “rescission” is a practice whereby an insurer can revoke your health care insurance policy after you become ill, based upon a careful review of your application for any evidence (even minor, technical evidence) that you incorrectly or inaccurately completed your application.

A must-listen for any of you who think our health care system isn’t in desperate need of reform. Click on this link, then “full episode”, and go to 35:22 in the broadcast to listen.