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Fixin' Healthcare

Tuesday, January 30, 2007

Transformation Of Healthcare - To Transform Is To Reform

Society struggles to maintain the integrity of complex systems while adjusting to changing conditions and shifting needs. Change agents may be aware of the debate over reformation vs. transformation (upper limit hypothesis) but in the heat of battle the objective is to create change. There are always forces that serve to moderate change.

When any system reaches a point of diminishing returns, alternate processes become attractive. Alternate processes may be adjustments to the existing system (reformation) or an entirely new approach (transformation). It is conceivable for transformation to reform and maintain an existing system in a more productive mode.

Reformation of health care is a constant process but the adjustments have not altered the basic course or momentum of the system. And, for the most part, people are satisfied with that process. However, rising costs, increasing incidence of chronic diseases, health problems associated with advanced age and declining health status are creating an unsustainable situation.

Politicians are elected by giving people what they want and people want more health (medical) care. So, the politicians are focused on providing medical insurance to everyone. This will not change the system but it will calm the people. Unfortunately, the problems will continue to grow.

The policy Mandarins are implementing quality indicators to achieve improved care. Early results are encouraging but not overwhelming. It is another adjustment to the current system of medical care.

A more promising possibility is the proposal to establish an electronic medical record. It offers the promise to improve efficiency and effectiveness with cost saving. The possibilities can be greatly enhanced if it is both a health and a medical record, and if the health/medical record is both risk-oriented and problem-oriented. Now, that will be an instrument to achieve improved health status at lower cost.

The establishment of health promotion and preventive health care as the primary system that is applied to everyone throughout society regardless of health status will transform health care. The goal of such a system is optimum health status for every individual and the population. A smaller medical care system will focus upon each individual suffering from disease and trauma. The goal is to restore optimum health.

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Monday, January 29, 2007

Transformation Of Healthcare - All Roads Lead To Lifestyle

The associations of psychosocial risk factors for cardiovascular disease with concentrations of inflammatory markers were examined among 6,814 men and women aged 45 to 84 years. Cynical distrust, chronic stress and depression were correlated with serum levels of C-reactive protein, IL-6 and fibrinogen before and after adjustments for socioeconomic position, behaviors, BMI and diabetes.

Psychosocial factors were associated with higher levels of inflammatory markers, most consistently for cynical distrust. The associations were reduced by 20% to 55% after adjustment for behavioral factors and by 45% to 100% after adjustment for BMI and diabetes, mostly owing to the effect of BMI. No associations remained after controlling for socioeconomic position, behaviors, BMI and diabetes.

In the transformation of health care, all roads lead to healthy lifestyles.

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Transformation Of Healthcare - Listening, Hearing And Understanding

Community based groups are better than medical providers at disseminating health information, promoting health and advocating prevention among immigrants. True enough, but this concept applies to everyone, not just immigrants.

The task is to identify the most credible community based groups and the most effective way for them to provide the most appropriate information. In other words, this is an important and complex issue that goes beyond who delivers information and where it is delivered.

Health promotion and prevention have suffered from an inability to make the core messages interesting, meaningful and effective. Call it marketing, if you will, and all evidence indicates that mass marketing is becoming more segmented.

Health communication is front and center and much more needs to be known about this important field.

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Wednesday, January 24, 2007

Transformation Of Healthcare - The Once And Future Queen

Prevention is not a pipe dream. Solid data and pilot projects exist to demonstrate the effectiveness of prevention for individuals and groups. Healthy People 2010, an extension of Healthy People 2000, is a national benchmark that has been slow to take flight. Its value is that it is there and serves as a guide for local programs and other pilot projects. Take a look at CardioVision 2020, Healthy South Carolina and the Greater Greenville Shrinkdown.

Significant change on a large scale takes time and sustained effort. Much more is ongoing than meets the eye. Partly, this is due to the massive scale and the attention given to the problems of medical care. It was well-put that prevention is still waiting for its Massachusetts moment.

Prevention is the step-sister of medical care. But, like Cinderella, prevention will be queen one day. The transformation of health care will reveal that prevention is not a branch of medical care. Prevention is the primary function of health care and medical care is a related default field to be used when necessary but avoided if at all possible.

The current efforts at medical care reform may be the initial movement in that direction. They will collapse under their own financial weight without having improved health status. Perhaps, then, the perspective on health will swing but it will not come in the form of a Eureka moment. More than likely it will come as a slowly rising tide.

Meanwhile, there is a lot of work to be done.

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Tuesday, January 23, 2007

Transformation Of Healthcare - Think It, Do It

Do you believe in magic? Well, maybe not magic exactly but what about wishful thinking? Wishful thinking and fantasy are common threads in a culture and they sustain individuals in some important ways. Lucky charms; true, true and (un)related; faith in an outcome unseen. Positive outlook and optimism depend upon faith and wishful thinking to some extent.

Optimism tends to be self-fulfilling. Optimistic people generally have better health and live longer. On the other hand, high expectations carry greater risk for disappointment. But, if expectations are always low, achievements and outcomes are limited.

"The harder I work, the luckier I get".

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Monday, January 22, 2007

Transformation Of Healthcare - Expectations, Hope, Inspiration, Motivation, Humility

Today even more than in ancient times healthcare involves mystical elements. Some might refer to this as the art of medicine and others might call it wishful thinking. Fear and expectations associated with illness, disease and injury stimulate the need for mystical elements. The human spirit needs hope to generate the inspiration and motivation that are essential for good health. However, it is best to remember that expectations have many sharp edges.

The "medicine man" and "witch doctor" knew a lot about fear and expectations. They often made good use of knowledge about culture and human nature to create desired objectives. Priests and ministers have their methods for dealing with fear and expectations. But, science and technology in the 20th Century have elevated expectations to new heights without comparable attention to the disappointments.

Nothing has changed the culture more than science and technology but human nature remains human nature. The unknown is no less immense, mysterious and daunting even as expectations soar. It is a marketer's dream but it is expectation without soul where demand exceeds need.

The paradox is that diseases have been reduced or eliminated but other health problems have arisen in their place. The irony is that modern medicine can sustain but not cure these chronic problems, which contributes to their rapid expansion in scope and severity. The tragedy is that the public commitment to expectations for modern medicine masks the need for broader and more sustained prevention. This is a situation more in need of transformation than reform.

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Saturday, January 20, 2007

Transformation Of Healthcare - The Goals Determine The Task

The Director of the Agency for Healthcare Research and Quality (AHRQ), Carolyn M. Clancy, M.D., spoke on September 27, 2006 to the Symposium on Remaking American Medicine. Her remarks noted a close relationship between the themes of Remaking American Medicine and the mission of AHRQ to improve quality, safety, efficiency and effectiveness of health care.

The four themes are:
  • Involving patients and their families in their own care is a key element to improving health care quality.
  • Encouraging health care providers to collaborate and learn from each other how to improve the quality of health care, fostering transparency and inspiring creative solutions.
  • Encouraging partnerships between patients and providers in designing quality health care solutions to help ensure more efficient and effective delivery of health care.
  • Recognizing that nothing can be achieved if the concept of transparency is not fully embraced by health care institutions. This is the cornerstone to remaking American medicine for all.
A survey conducted by the Kaiser Family Foundation and AHRQ reported that more Americans (51%) are dissatified with the quality of health care than those who say they are satisified (41%). Further, more Americans indicated they understand the term "medical error" and 43% say preventable medical errors occur "very often" or "somewhat often" when they seek care from a health professional.

The following points from the survey were presented as evidence that Americans are taking steps to improve the quality of care they receive.
  • 83 percent ask their doctor questions about their health or any treatment that he or she has prescribed.
  • 70 percent report that they check the medication given by their pharmacist against the doctor's prescription.
  • 54 percent bring a list of all their medications to a doctor's appointment.
  • 45 percent report bringing a friend or relative to a doctor's appointment to help ask questions.
  • One in three Americans say they or their family member has created a set of their medical records to ensure that their health care providers have all their medical information.
Dr. Clancy expresses satisfaction that consumers and patients have become more informed and empowered. She adds that patients, families and clinicians need to create a partnership to achieve the best quality care.

The Department of Health Human Services is directing attention to providing useful, understandable information on the quality and price of health care.
  • Connect the System = health information systems that can quickly and securely communicate and exchange data.
  • Measure and Publish Quality = define benchmarks for what constitutes quality care and link process to outcomes.
  • Measure and Publish Price = calculation of cost for the process that constitutes quality care.
  • Create Positive Incentives = reward those who offer and those who purchase high-quality, competitively priced health care.
Dr. Clancy's remarks define some of the essential components involved in "remaking American medicine" to improve the quality of medical care for those who seek assistance with illness, disease and injury. When she uses the term "transforming our nation's health care system" in the same context, she barely scratches the surface of what is needed to accomplish what is a much broader task.

Medical care is far from the most effective, much less efficient, means of achieving and maintaining optimum health status and optimum mental, emotional and physical function. Health promotion, healthy lifestyles, prevention and rehabilitation are the components of health care that are a higher order than medicine for transforming health status in America.

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Sunday, January 14, 2007

Transformation Of Healthcare - Mirror, Mirror On The Wall

The chorus calling for change in the healthcare system is so loud that it seems like one voice. On closer inspection, however, there is revealed to be many issues and many advocates divided among the issues. Among the advocates there is sympathy for all the issues but no common agreement for establishing priorities.

Policy makers have approached healthcare reform in a piecemeal fashion. Financial adjustments intended to save money have been unpopular and generally unsuccessful. Actions that influence certain aspects of health care delivery, such as the Medicare drug benefit, are popular but it remains to be seen if there is a corresponding improvement in health status.

Compassion and politics are directing many of the proposed healthcare reforms. Universal, single payor health insurance should solve some of the acute financial problems suffered by some individuals. Initially, most providers would experience increased income. Most people would be happy, at least for a while. But, it is the same medical care system and evidence is accumulating that overall health status is declining in America regardless of health insurance.

An agenda of eleven principles outlining reform of healthcare in America has been presented by national associations representing physicians. Number ten is as follows: "Sufficient funds must be available for public health and other essential services to include, but not be limited to preventive services, trauma care and mental health services".

A recent article in the Wall Street Journal described an effort by Virginia Mason Medical Center in Seattle to lower cost and achieve comparable or improved outcomes. They succeded but created a financial strain for the hospital. Another report in the January 16th issue of the WSJ described the negative responses experienced by a Chinese physician who practices prevention and lowers cost but creates financial problems for the hospital.

There is no evidence whatsoever that healthcare providers in America oppose, circumvent or undercut prevention. It is far more likely they believe prevention will make no difference in their practices. Many do not believe that prevention will be effective beyond a minor role. Thus, the rank at ten of eleven.

"Transformation of healthcare" is a phrase to convey broadening of perspective in regard to change in healthcare. Its purpose is to emphasize the goal of optimum health status and optimum mental, emotional and physical performance. Process in healthcare cannot be ignored but process is not a goal, and process is subject to change.

The concept of healthcare transformation is based upon an understanding of health consisting of two related but unequal divisions. The larger division and the one of primary importance is wellness, prevention and rehabilitation. Wellness and prevention applies to every adult and child in America without exception. Medical care is the other division and it applies to each person in America who suffers with illness, disease and injury. After successful medical care people will continue through rehabilitation to their optimum health status.

Subsequent posts on this blog will explore the many considerations that might be involved in the transformation of healthcare. The Lifestyle Chronicles will be incorporated into this concept. Undoubtedly, medical care reform will proceed at its own pace but America needs a new approach to health and this will help reform medical care.

Let's build it and make them want to come.

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Wednesday, January 10, 2007

The Lifestyle Chronicles - One Size Fits All

It is true that diagnostic tools are available that can detect disease at the early, asymptomatic stage. There is much to be learned about the natural course of diseases detected at earlier stages but the logical assumption is that early detection increases the effectiveness of prevention.

The other side of the coin is that tests for early detection involve cost and some are quite expensive. If multiple tests are utilized, the expense can be high. Then, there is the problem of false positive and false negative results.

Centers have been established to utilize these technologies but they are not ready for prime time. Unless the information serves as motivation to practice prevention or a way to measure progress or to determine whether to utilize specialized therapeutic procedures, the energy, attention and resources would be better spent implementing a broad based healthy lifestyle.

Everyone is in need of primary prevention regardless of diagnostic tests. It is a healthcare issue and it does not have to be a medical issue. Contemplating, structuring and implementing a healthy lifestyle is proactive and it increases the probability of achieving and maintaining optimum health status and optimum mental, emotional and physical performance.

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Tuesday, January 09, 2007

The Lifestyle Chronicles - Transformation Of Healthcare

There is entirely too much energy and resources wasted fixing blame when the only purpose served is punishment. When punishment is the objective, the systematic nature of problems are not well understood and the reponses are not solutions. There is no purpose served fixing blame in the US healthcare system when it has reached a state where just about everyone is a victim.

The US healthcare system is a misnomer. It is multiple systems and systems within systems. There was no intelligent design. It is generous to call it a system. If anything, it is an example of accelerated evolution with rapid mutations. Arguably, emotion prevails more than logic and misdirected business interests are more common than anyone cares to admit. Attempts at reform end up so far off target that no one wants to claim them.

Universal health insurance is a compassionate and a political response to the financial aspect of this problem. As such, it is understandable. This past summer I was involved in a minor accident and ended up in an emergency room. There was no injury but the bill was $3,500. My insurance covered it but I shudder to think of someone in a similar situation with no insurance.

Universal health insurance is an immediate necessity. But, please, do not call it healthcare reform. Many of the problems in the healthcare system will be aggravated by additional insurance coverage. And, insurance has proven to be notoriously unreliable as an instrument for reform.

Perhaps the notion of reforming healthcare should be superceded by something we could call the transformation of healthcare. The concept of transformation conveys a more accurate impression of the task. Nothing will be solved by tinkering with the current system. An entirely new approach is necessary. A good start would be to recognize that medical care is a division of healthcare and the overarching goal of healthcare is optimum health status with optimum mental, emotional and physical performance.

I do not give the current crop of Republicans credit for elevating the role of personal responsibility. It has been my understanding from childhood that a basic value of America is personal freedom and freedom of choice. There is no personal freedom without personal responsibility and there is a corresponding community responsibility. To be sure, numerous groups have tried to claim these values as their own, and American society has pushed the limits of these values to ridiculous levels. But, there they are for better or worse.

I have resisted the thought of creating systems to change or reform systems. Perhaps my inclinations are insufficient to the task of transforming healthcare. Lambrew and Podesta proposed the creation of a "Wellness Trust". It is an intriguing concept that should be created in the same act that establishes universal health insurance. I don't expect to hold my breath waiting for such enlightened action from the same crowd that claims personal responsibility and gave us Medicare Part D.

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Sunday, January 07, 2007

The Lifestyle Chronicles - Prolonging Life's Persistent Problems

What were the circumstances that resulted in the prescribing of an antidepressant for you?

My mother died and I had difficulty dealing with the loss.

I see, when did that happen?

Ten years ago.

And, you have been on the medication since that time?

You have been taking a medication for heartburn for several years. Does it provide relief?


Does the heartburn reoccur?

Whenever I stop taking the medication.

And, you are about 75 pounds overweight. What happens when you stop eating junk food, start eating more vegetables and fruit, walk 30 minutes each day and lose weight?

The heartburn goes away.

Do you continue to need the medication.


The Democrats are concerned about prices of drugs and want the government to negotiate lower prices for Medicare beneficiaries, but not which drugs are covered. There are some who believe the only way to get big savings and discounts is to steer patients to certain preferred drugs.

The prescribing of drugs is out of control. Negotiating lower prices is a bandage that ignores the basic problem. Physicians and the public need to be involved in a massive and intense campaign to reduce the prescribing of drugs.

Drugs are perceived to be quick and easy solutions to life's persistent problems. More often than not, drugs are a solution that prolongs the problem.

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The Lifestyle Chronicles - Leap And Learn

Namaste Charter School in Chicago is commited to the physical, social and academic well-being of their students. They believe that academic achievement is dependent upon regular physical activity and good health. The school incorporates physical activity and nutrition into its rigorous curriculum. Parents receive training in nutrition and have access to a weekly farmers market set up in the school. The principal of Namaste is an alumna of Teach for America.

A report from the American College of Sports Medicine shows the most physically active middle school students more often have better grades. The link between physical activity and academic performance was most significant when children met Healthy People 2010 guidelines for vigorous activity 20 minutes at least three days a week.

Changing the culture and society will not be easier than reforming medical care, but changing the culture and society will improve health status and performance of the population far more than reforming medical care. Isn't that what health policy is all about?

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Friday, January 05, 2007

The Lifestyle Chronicles - Of Mice And Men

Neil Postman in his book, "Amusing Ourselves To Death", describes modern culture as constant entertainment. It is a culture distracted by triva where social interaction has given way to private preserve. Public conversations are sound bytes. Information is out of context and often with inappropriate association. Technology is revered as a simple means for fast solutions to problems.

Technology is a machine and a process. Technology creates an intellectual and social environment influencing human behavior. For Postman, television is the dominant technology that has created modern culture.

Within this culture and over a short period of time, technology has created medical care and oriented society to illness and disease. Medical care has become a metaphor for health.

But, now, what is health? More medical care? Medical care (health) insurance for everyone? A free get out of jail card?

Here comes that Kafka feeling all over again.

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Thursday, January 04, 2007

The Lifestyle Chronicles - Learn And Live

What is the most consistent basis for a long life?

"The one social factor linked to longer lives in every country where it has been studied is education. It is more important than race; it obliterates any effects of income.

And, health economists say, those factors that are popularly believed to be crucial - money and health insurance, for example, pale in comparison.

Giving people more Social Security income, or less for that matter, will not really affect people's health. It is a good thing to do for other reasons but not for health.

Health insurance, too, is vastly overrated in the policy debate.

A few extra years of school is associated with extra years of life and vastly improved health decades later, in old age."

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Wednesday, January 03, 2007

The Lifestyle Chronicles - Join Your Neighbor, Raise A Barn

Does the health care system contribute to poor health?

That question has troubled me for over 30 years. Initially, my concern centered upon errors of comission and omission. The incorrect diagnosis, the drug reaction, the complication from surgery, inappropriate therapy, incorrect triage. Mistakes that are the nightmares of healthcare providers.

On the other hand, the limits of capability, experience and knowledge are reached all too soon. There is more to know than is known. One of the prices to be paid is the current limitation upon the science and the art of health care. This is reality and the challenge is to determine where and how to push the frontier to improve health status.

During my lifetime health care has been transformed into medical care. And, medical care has become a business. Medical care is focused upon illness, disease and injury, and the process is refined and expanded by business. Middlemen, highly specialized practitioners, peripheral practitioners and technologies abound.

The medical care system finds and treats an expanding array of diagnoses, often without definitive or favorable outcome. Panels of experts change the standards and up the ante for more diagnostic screening and additional therapy. "New and improved, the best in town, we treat more of these than anybody else." Additional medical care opens the door for more mistakes.

The public is focused upon complaints, ailments, illness and disease. Everyone wants their share of individual attention, which includes the most advanced diagnosis and therapy available regardless of cost. The medical care consumer almost always expects more than can be delivered. Furthermore, no individual ever believes they should pay for the bad luck of being sick.

The majority of medical problems are not the result of bad luck or faulty genes. The majority of medical problems are preventable and they cannot be cured by means of medical therapy. Welch, Schwartz and Woloshin are correct when they describe sickness as an epidemic of diagnoses.

Yes, the medical care system does contribute to poor health. Medical care is a process and like the MTA of Kingston Trio fame, you can never get off. That is, unless someone remembers the objective is improved health status. Evidence based medicine is an oxymoron.

Forget about reforming medical care and pursue a transformation of health care. When medical care is the junior partner in the health care system, health status will improve and the financial crisis will have passed.

Let's keep an eye on the West Virginia Medicaid project. They may not be right on all accounts but at least they are doing something. This will take time and it will undoubtedly require mid-course corrections. Meanwhile, other models such as the project for prevention in Rhode Island will come along, and please don't forget Mike Huckabee and Healthy America.

America needs to go to boot camp. Americans need to be inspired to a higher cause. Drawing and giving strength to the community is the most productive pathway to improved health status. It is time to take control of life. No more victims.

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