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.

Lessons from the US Health Reform that’s Already Failing

It’s not often I bother reading the numerous articles I come across everyday on US health system reform. But Atul Gawande is a man of clear thought and once again proved he understands health – though I don’t agree with him entirely.

In this article he highlights the failure of recent Democrat reforms to address rising costs and quality in health. He then goes on to say that government intervention can lower costs and improve quality just as happened in agriculture in the early 1900’s.

His argument is intriguing for a number of reasons.

Like many commentators he criticises the free-market approach in health yet fails to realize out that health is not a ‘laissez-faire’ market. Anyone with a basic understanding of markets realizes that there is a fundamental imbalance in health. This McKinsey’s report, for example, explains how most health systems lack a rigorous approach for matching clinician supply with demand for health services. This is despite the clinical workforce using around 60% of the $4bn spent on health each year. In what other industry is there a shortage of 60% of market supply?

The agricultural revolution analogy he uses is obviously a loose one. One cannot compare the complexity of health with the farming system of the early 2oth century. Gawande’s purpose is more to demonstrate that top-down reforms can cause effective change.

You might read his story and swell with sudden belief in the power of the progressive Obama administration to deliver the perfect medicine to our ailing system, from the top down. The success of government intervention in agriculture, however, is one example of top-down success against the myriad of failures well documented in change management science. Indeed, health is perhaps the best example of failure to change with every Democrat president sice Roosevelt having tried and failed.

Top-down reform will be necessary in the interim to accelerate change. But long term I firmly believe that less regulation (without completely removing oversight) is what health requires.

Let me give a small example. In the USA they are looking at a new model of primary care. It’s not unlike the superclinics our Rudd government is building. What strikes me immediately is that they are very much ‘models of the moment’. They are attempts to use existing resources and infrastructure to change health delivery. As Einstein said however, ‘you can’t solve a problem with the same thinking that created it’. Here we are trying to use the same structures, albeit in a re-jigged format, to solve the problem!

Indeed, the Rudd superclinics are already failing: see super clinic an expensive joke.

Health System Dashboards and Quick Wins

It’s been nearly 2 months since my last post. So much has happened since.

Last week I attended a health forum with government and health industry leaders from around Australia. It was both broad and enlightening. My contribution was to promote the need for a consumer focus – along the lines of this recent post. I believe this message was well received by all – except those with entrenched interests such as the medical specialist colleges and health bureaucrats.

At that forum it was predicted that the COAG meeting of 2 weeks ago would achieve no significant reform agreements. Indeed this is what happened – although perhaps with good reason. As Kevon Rudd pointed out, this may need time to get right. The cynics would say we’ve had enough time.

My future goal for this blog is to shift towards promoting simple tools that will provide measurable improvement to our health system. These may be medications, IT or process tools that can be implemented at any level. I will endeavour to give some kind of health economic and regulatory rationale for their implementation. I will also try to outline how these incremental changes can shift healthcare back towards a balanced market.

My first quick win is a health dashboard.

The dashboard is a concept familiar to many in other industries, particularly to business analysts. A dashboard collates and displays information, typically relating to performance. In the case of health, the dashboard could display data for a family health clinic, or indeed for a large hospital or even at the national level.

Healthcare is information rich but data poor. The fact that few of our established pieces of health infrastructure use dashboards demonstrates this. I am aware that hospitals use them in some capacity – but only a limited number of staff have access to them. I know that some GP clinics, particularly those run by corporate groups, have software that can extract this type of data – albeit in a limited format such as a summary of Hb1Ac levels for all your diabetic patients.

Healthcare must move from a reactive art towards a predictive model. A great example of this are radiology dashboards in Baltimore. The idea is to provide data for decision support. Only with overview displays can staff quickly foresee changes and gaps that need to be filled.

In Australia dashboards could be easily applied at the primary care, aged care and hospital level. Most of these facilities already have databases with the relevant information. But doctors have few clues about how to make use of this data. We concentrate of the traditional tools of EBM, diagnosis and management while easily losing sight of the bigger picture.

While policy makers get excited about performance incentives, they need to first consider a far more simple measure of providing overview.

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: 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.

NHHRC: Medicare Select – What is it?

Our Parliamentary library has a good analysis of Medicare Select for those of you wondering what Option C means in the NHHRC report.

I would like to see this option compared with a ‘healthcare credit card’ system. From the analysis and debates I’ve heard on Medicare select it seems a real sticking point is the lack of flexibility it actually brings. While it would add increased competition to the market, people are ultimately still quite limited in their options of care. In some respects they are more limited. For example, now people can go to virtually any public hospital for treatment. Under Medicare select my superficial understanding is that they would be limited to a chain of hospitals, much like the HMO system in the USA. For this reason many doctors don’t like the concept either.

A credit card system would give every individual a base level of money to spend on health and allow them to spend it wherever they chose. I believe that one reason health literacy is relatively low in Australia is that we don’t need to take responsibility for our health and how we spend on health. Giving people purchasing power would allow them to learn what relative costs are in healthcare.

Clearly though, this system needs a full analysis of its own.

The ‘Wellness’ Phone

NTT DoCoMo Inc. has prototyped and presented a “wellness mobile phone” that can measure body fat ratio, pulse, breath odor, how far the user has walked and give health advice.

This was a joint development with Mitsubishi Electric Corp. and the company assumes that it will be commercialized in the future, although it has not determined a marketing schedule yet. The company’s booth was filled with many visitors who came to try the prototype.

Based on a mobile phone embedded with a touch panel type LCD, it has sensors to measure various types of biometric information. For example, an infrared sensor measures the pulse using via absorption of hemoglobin. For the measurement of breath odor, a gas sensor set at the bottom of the handset has been used (seems very Japanese to me, but sometimes we all need a reminder!).

A pedometer can sense whether a user is walking, running or climbing up or down stairs. Reflecting such situations, the mobile phone calculates the user’s energy consumption accurately, the company said. Along with an application that monitors and shows the user’s health data in chronological order, the company believes the mobile phone will be used in combination with dietary control services and applications related to fitness management, mental healthcare and the like.

The Elements of Influence

Why is influence important?While many of us need to influence others in our work and personal lives, we are aware that bare persuasion doesn’t always work. Influence really means being aware of others needs and leveraging their likes and dislikes to help them act.

From Robert Cialdini interviewd on Smartplanet.

There are six universal principles of influence. If we use them as touchstones, they will allow us to be significantly more successful in our influence attempts. They are:

• Reciprocation. People give back to you the kind of treatment that they’ve received from you. If you do something first by giving something of value—be it more information or a positive attitude—it will all come back to you.

• Scarcity. People will try to seize those opportunities that you offer them that are rare or dwindling in availability. This is an important reminder that we need to differentiate what we have to offer that is different from our rivals and competitors. That way, we can tell people honestly “You can only get this aspect or this feature by moving in our direction.”

• Authority. People will be most persuaded by you when they see you as having knowledge and credibility on the topic. You’d be surprised how many fail to properly inform their audience of their genuine credentials before launching into an influence attempt. That’s a big mistake.

• Commitment. People will feel a need to comply with your request if they see that it’s consistent with what they’ve publicly committed themselves to in your presence. The implication there is to ask people to state their true priorities, commitments and features of the situation that they think are most important. Then align your requests or proposals with those things. The rule for consistency will cause them to want to say yes to what they’ve already told you they value.

• Liking. People prefer to say yes to your request to the degree that they know and like you. No surprise there but a simple way to make that happen is to uncover genuine similarities or parallels that exist between you and the person you want to influence. That person is going to like you more and be more willing to move in your direction.

• Consensus. People will be likely to say yes to your request if you give them evidence that people just like them have been saying yes to it too. I saw recent study that showed if a restaurant owner puts on the menu “This is our most popular item” than it immediately becomes more popular.