Friday, June 4, 2010

The Human Side of Doctor-Patient Relations - NYTimes.com

When D., a woman in her mid-30s, learned that she was dying from complications of AIDS, she fully expected that her life would end in much the same way it had been lived: homeless, alone and among strangers.

If it hadn't been for Dr. Jason K. Alexander, a medical student at the time, she might have been right.

Two years earlier Dr. Alexander, along with four other classmates, had created a project that paired medical students with patients who were dying alone. "We wanted to reach out to patients who had been shunned, the people others didn't want to deal with," Dr. Alexander recently recalled.

The program, which also helps family members who are struggling with terminally ill loved ones, was part of an innovative new center for humanism at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in Newark. The center offers four-year scholarships for students with outstanding academic and community service records.

D. was one of the program's first patients, a woman who years earlier had been rejected by her own family. "She was angry at first," Dr. Alexander said, recounting his initial visit with her. "She was dying, but she took the opportunity to attack me, a medical student who had walked into her room and said that he was just there for her to talk."

Dr. Alexander was about to leave when he remembered the advice of his faculty adviser: let the patient guide the conversation. "I surrendered to her anger and told her that we didn't have to talk, that I would just sit in the room with her." After several minutes of trying "to embrace the deafening silence," Dr. Alexander heard a noise coming from where D. was sitting. "I saw tears rolling down her eyes," he said remembering the moment. "She began sobbing that she was scared and had no one."

That visit would be the first of nearly daily conversations between Dr. Alexander and D., meetings that would continue several months until her death.

The school's initiative, started with a $3.2 million grant from the Healthcare Foundation of New Jersey, is part of what many believe is an expanding movement in medical education: a growing emphasis on the human side of medical care. Leaders of this "humanism movement" have come from both the general public and within the ranks of medical education. And although they have focused on issues like patient-centered care, physician professionalism, clinics for the uninsured and disaster relief, nearly all have agreed on one thing: the importance of supporting what they believe are the natural, but often suppressed, ideals and inclinations of those who chose to pursue a career in medicine.

"I believe there is a yearning among physicians to practice this way," said Sandra O. Gold, president and chief executive of the Arnold P. Gold Foundation. The nonprofit organization has financed the bulk of the movement's initiatives in the last two decades, with more than $15 million in grants for research, lectures and conferences. "But everything that is happening to doctors dissuades them from these humanistic ideals," she said.

More ...

http://www.nytimes.com/2010/06/03/health/03chen.html?hpw

Critics Question Study Cited in Health Debate - NYTimes.com

In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.

Wasteful spending — perhaps $700 billion a year — "does nothing to improve patient health but subjects you and me to tests and procedures that aren't necessary and are potentially harmful," the president's budget director, Peter Orszag, wrote in a blog post characteristic of the administration's argument.

Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.

The maps made reform seem relatively easy to many in Congress, some of whom demanded the administration simply trim the money Medicare pays to hospitals and doctors in the brown zones. The administration promised to seriously consider doing just that.

But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country's best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government's Medicare program. Measures of the quality of care are not part of the formula.

For all anyone knows, patients could be dying in far greater numbers in hospitals in the beige regions than hospitals in the brown ones, and Dartmouth's maps would not pick up that difference. As any shopper knows, cheaper does not always mean better.

Even Dartmouth's claims about which hospitals and regions are cheapest may be suspect. The principal argument behind Dartmouth's research is that doctors in the Upper Midwest offer consistently better and cheaper care than their counterparts in the South and in big cities, and if Southern and urban doctors would be less greedy and act more like ones in Minnesota, the country would be both healthier and wealthier.

But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts. Also, nurses in Houston tend to be paid more than those in North Dakota because the cost of living is higher in Houston. Neither patients' health nor differences in prices are fully considered by the Dartmouth Atlas.

The mistaken belief that the Dartmouth research proves that cheaper care is better care is widespread — and has been fed in part by Dartmouth researchers themselves.

The debate about the Dartmouth work is important because a growing number of health policy researchers are finding that overhauling the nation's health care system will be far harder and more painful than the Dartmouth work has long suggested. Cuts, if not made carefully, could cost lives.

Looking in detail at Dartmouth's evidence helps show why.

More ...

http://www.nytimes.com/2010/06/03/business/03dartmouth.html?hpw

Tuesday, June 1, 2010

Disease Management Care Blog

An ongoing resource for information, insights, peer-review literature and musings from the world of disease management, the medical home, the chronic care model, the patient centered medical home, informatics, pay for performance, primary care, chronic illness and health insurance

http://diseasemanagementcareblog.blogspot.com/

Soaring costs force Canada to reassess health model - Yahoo! News

Pressured by an aging population and the need to rein in budget
deficits, Canada's provinces are taking tough measures to curb
healthcare costs, a trend that could erode the principles of the
popular state-funded system.

Ontario, Canada's most populous province, kicked off a fierce battle
with drug companies and pharmacies when it said earlier this year it
would halve generic drug prices and eliminate "incentive fees" to
generic drug manufacturers.

British Columbia is replacing block grants to hospitals with fee-for-
procedure payments and Quebec has a new flat health tax and a
proposal for payments on each medical visit -- an idea that critics
say is an illegal user fee.

And a few provinces are also experimenting with private funding for
procedures such as hip, knee and cataract surgery.

It's likely just a start as the provinces, responsible for delivering
healthcare, cope with the demands of a retiring baby-boom generation.
Official figures show that senior citizens will make up 25 percent of
the population by 2036.

"There's got to be some change to the status quo whether it happens
in three years or 10 years," said Derek Burleton, senior economist at
Toronto-Dominion Bank.

"We can't continually see health spending growing above and beyond
the growth rate in the economy because, at some point, it means
crowding out of all the other government services.

"At some stage we're going to hit a breaking point."

MIRROR IMAGE DEBATE

In some ways the Canadian debate is the mirror image of discussions
going on in the United States.

Canada, fretting over budget strains, wants to prune its system,
while the United States, worrying about an army of uninsured, aims to
create a state-backed safety net.

Healthcare in Canada is delivered through a publicly funded system,
which covers all "medically necessary" hospital and physician care
and curbs the role of private medicine. It ate up about 40 percent of
provincial budgets, or some C$183 billion ($174 billion) last year.

Spending has been rising 6 percent a year under a deal that added C
$41.3 billion of federal funding over 10 years.

But that deal ends in 2013, and the federal government is unlikely to
be as generous in future, especially for one-off projects.

"As Ottawa looks to repair its budget balance ... one could see these
one-time allocations to specific health projects might be curtailed,"
said Mary Webb, senior economist at Scotia Capital.

Brian Golden, a professor at University of Toronto's Rotman School of
Business, said provinces are weighing new sources of funding,
including "means-testing" and moving toward evidence-based and pay-
for-performance models.

"Why are we paying more or the same for cataract surgery when it
costs substantially less today than it did 10 years ago? There's
going to be a finer look at what we're paying for and, more
importantly, what we're getting for it," he said.

Other problems include trying to control independently set salaries
for top hospital executives and doctors and rein in spiraling costs
for new medical technologies and drugs.

Ontario says healthcare could eat up 70 percent of its budget in 12
years, if all these costs are left unchecked.

"Our objective is to preserve the quality healthcare system we have
and indeed to enhance it. But there are difficult decisions ahead and
we will continue to make them," Ontario Finance Minister Dwight
Duncan told Reuters.

The province has introduced legislation that ties hospital chief
executive pay with the quality of patient care and says it wants to
put more physicians on salary to save money.

In a report released last week, TD Bank said Ontario should consider
other proposals to help cut costs, including scaling back drug
coverage for affluent seniors and paying doctors according to quality
and efficiency of care.

WINNERS AND LOSERS

The losers could be drug companies and pharmacies, both of which are
getting increasingly nervous.

"Many of the advances in healthcare and life expectancy are due to
the pharmaceutical industry so we should never demonize them," said U
of T's Golden. "We need to ensure that they maintain a profitable
business but our ability to make it very very profitable is
constrained right now."

Scotia Capital's Webb said one cost-saving idea may be to make
patients aware of how much it costs each time they visit a healthcare
professional. "(The public) will use the services more wisely if they
know how much it's costing," she said.

"If it's absolutely free with no information on the cost and the
information of an alternative that would be have been more practical,
then how can we expect the public to wisely use the service?"

But change may come slowly. Universal healthcare is central to
Canada's national identity, and decisions are made as much on
politics as economics.

"It's an area that Canadians don't want to see touched," said TD's
Burleton. "Essentially it boils down the wishes of the population.
But I think, from an economist's standpoint, we point to the fact
that sometimes Canadians in the short term may not realize the cost."

http://news.yahoo.com/s/nm/20100531/hl_nm/us_health_3

Monday, May 31, 2010

Healing by 2-Way Video - The Rise of Telemedicine - NYTimes.com

ONE day last summer, Charlie Martin felt a sharp pain in his lower back. But he couldn't jump into his car and rush to the doctor's office or the emergency room: Mr. Martin, a crane operator, was working on an oil rig in the South China Sea off Malaysia.

He could, though, get in touch with a doctor thousands of miles away, via two-way video. Using an electronic stethoscope that a paramedic on the rig held in place, Dr. Oscar W. Boultinghouse, an emergency medicine physician in Houston, listened to Mr. Martin's heart.

"The extreme pain strongly suggested a kidney stone," Dr. Boultinghouse said later. A urinalysis on the rig confirmed the diagnosis, and Mr. Martin flew to his home in Mississippi for treatment.

Mr. Martin, 32, is now back at work on the same rig, the Courageous, leased by Shell Oil. He says he is grateful he could discuss his pain by video with the doctor. "It's a lot better than trying to describe it on a phone," Mr. Martin says.

Dr. Boultinghouse and two colleagues — Michael J. Davis and Glenn G. Hammack— run NuPhysicia, a start-up company they spun out from the University of Texas in 2007 that specializes in face-to-face telemedicine, connecting doctors and patients by two-way video.

Spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry. A fifth of Americans live in places where primary care physicians are scarce, according to government statistics. That need is converging with advances that include lower costs for video-conferencing equipment, more high-speed communications links by satellite, and greater ability to work securely and dependably over the Internet.

"The technology has improved to the point where the experience of both the doctor and patient are close to the same as in-person visits, and in some cases better," says Dr. Kaveh Safavi, head of global health care for Cisco Systems, which is supporting trials of its own high-definition video version of telemedicine in California, Colorado and New Mexico.

The interactive telemedicine business has been growing by almost 10 percent annually, to more than $500 million in revenue in North America this year, according to Datamonitor, the market research firm. It is part of the $3.9 billion telemedicine category that includes monitoring devices in homes and hundreds of health care applications for smartphones.

Christine Chang, a health care technology analyst at Datamonitor's Ovum unit, says telemedicine will allow doctors to take better care of larger numbers of patients. "Some patients will be seen by teleconferencing, some will send questions by e-mail, others will be monitored" using digitized data on symptoms or indicators like glucose levels, she says.

Eventually, she predicts, "one patient a day might come into a doctor's office, in person."

Although telemedicine has been around for years, it is gaining traction as never before. MedicareMedicaid and other government health programs have been reimbursing doctors and hospitalsthat provide care remotely to rural and underserved areas. Now a growing number of big insurance companies, like the UnitedHealth Group and several Blue Cross plans, are starting to market interactive video to large employers. The new federal health care law provides $1 billion a year to study telemedicine and other innovations.

With the expansion of reimbursement, Americans are on the brink of "a gold rush of new investment in telemedicine," says Dr. Bernard A. Harris Jr., managing partner at Vesalius Ventures, aventure capital firm based in Houston. He has worked on telemedicine projects since he helped build medical systems for NASA during his days as an astronaut in the 1990s.

Face-to-face telemedicine technology can be as elaborate as a high-definition video system, like Cisco's, that can cost up to hundreds of thousands of dollars. Or it can be as simple as the Webcams available on many laptops.

NuPhysicia uses equipment in the middle of that range — standard videoconferencing hookups made by Polycom, a video conferencing company based in Pleasanton, Calif. Analysts say the setup may cost $30,000 to $45,000 at the patient's end — with a suitcase or cart containing scopes and other special equipment — plus a setup for the doctor that costs far less.

Telemedicine has its skeptics. State regulators at the Texas Medical Board have raised concerns that doctors might miss an opportunity to pick up subtle medical indicators when they cannot touch a patient. And while it does not oppose telemedicine, the American Academy of Family Physicians says patients should keep in contact with a primary physician who can keep tabs on their health needs, whether in the virtual or the real world.

"Telemedicine can improve access to care in remote sites and rural areas," says Dr. Lori J. Heim, the academy's president. "But not all visits will take place between a patient and their primary-care doctor."

Dr. Boultinghouse dismisses such concerns. "In today's world, the physical exam plays less and less of a role," he says. "We live in the age of imaging."

ON the rig Courageous, Mr. Martin is part of a crew of 100. Travis G. Fitts Jr., vice president for human resources, health, safety and environment at Scorpion Offshore, which owns the rig, says that examining a worker via two-way video can be far cheaper in a remote location than flying him to a hospital by helicopter at $10,000 a trip.

Some rigs have saved $500,000 or more a year, according to NuPhysicia, which has contracts with 19 oil rigs around the world, including one off Iraq. Dr. Boultinghouse says the Deepwater Horizon drilling disaster in the Gulf of Mexico may slow or block new drilling in United States waters, driving the rigs to more remote locations and adding to demand for telemedicine.

NuPhysicia also offers video medical services to land-based employers with 500 or more workers at a site. The camera connection is an alternative to an employer's on-site clinics, typically staffed by a nurse or a physician assistant.

More ...

http://www.nytimes.com/2010/05/30/business/30telemed.html?th&emc=th

When Patients Meet Online, Are There Side Effects? - NYTimes.com

COULD we cure diseases faster, or at least better control them, through crowd-sourcing?

That is the premise behind social networking sites like CureTogether.com andPatientsLikeMe.com, which offer online communities for patients and collect members' health data for research purposes.

PatientsLikeMe provides forums where more than 65,000 members with epilepsymultiple sclerosis and more than a dozen other disorders are encouraged to share details about their conditions and the success or pitfalls of specific drug treatments.

"When patients share real-world data, collaboration on a global scale becomes possible," the site says. "New treatments become possible."

Moreover, in a world where serious side effects often emerge only years after a new medication enters the market, such real-time information from real-world patients may also provide an early warning signal for drug safety problems.

PatientsLikeMe has an innovative for-profit business model, too. It sells health data, gathered from member profiles but with certain identifying information removed, to drug makers and others for scientific and marketing research.

Jamie Heywood, the company's chairman, says both patients and drug makers delve into that data to meet their own needs.

Members can seek out patients of the same age, sex, and disease progression, whose profiles are displayed on the site, to see which drugs or doses worked for them. Drug makers can pinpoint subgroups — say, severely depressed middle-aged men — who reported the greatest improvement on a particular medication.

"What we have done is made a system that allows you to think about personalized medicine," says Mr. Heywood. He co-founded the site in 2004 with his brother Ben and a friend after another brother, Stephen Heywood, developed amyotrophic lateral sclerosis, or A.L.S., commonly known as Lou Gehrig's disease. (Stephen died in 2006.)

But pharmaceutical crowd-sourcing also raises important questions about the trade-off between the benefits of information sharing and the risk of patient exploitation.

More ...
http://www.nytimes.com/2010/05/30/business/30stream.html?th&emc=th

Sunday, May 30, 2010

Healing by 2-Way Video - The Rise of Telemedicine - NYTimes.com

ONE day last summer, Charlie Martin felt a sharp pain in his lower back. But he couldn't jump into his car and rush to the doctor's office or the emergency room: Mr. Martin, a crane operator, was working on an oil rig in the South China Sea off Malaysia.

He could, though, get in touch with a doctor thousands of miles away, via two-way video. Using an electronic stethoscope that a paramedic on the rig held in place, Dr. Oscar W. Boultinghouse, an emergency medicine physician in Houston, listened to Mr. Martin's heart.

"The extreme pain strongly suggested a kidney stone," Dr. Boultinghouse said later. A urinalysis on the rig confirmed the diagnosis, and Mr. Martin flew to his home in Mississippi for treatment.

Mr. Martin, 32, is now back at work on the same rig, the Courageous, leased by Shell Oil. He says he is grateful he could discuss his pain by video with the doctor. "It's a lot better than trying to describe it on a phone," Mr. Martin says.

Dr. Boultinghouse and two colleagues — Michael J. Davis and Glenn G. Hammack— run NuPhysicia, a start-up company they spun out from the University of Texas in 2007 that specializes in face-to-face telemedicine, connecting doctors and patients by two-way video.

Spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry. A fifth of Americans live in places where primary care physicians are scarce, according to government statistics. That need is converging with advances that include lower costs for video-conferencing equipment, more high-speed communications links by satellite, and greater ability to work securely and dependably over the Internet.

"The technology has improved to the point where the experience of both the doctor and patient are close to the same as in-person visits, and in some cases better," says Dr. Kaveh Safavi, head of global health care for Cisco Systems, which is supporting trials of its own high-definition video version of telemedicine in California, Colorado and New Mexico.

The interactive telemedicine business has been growing by almost 10 percent annually, to more than $500 million in revenue in North America this year, according to Datamonitor, the market research firm. It is part of the $3.9 billion telemedicine category that includes monitoring devices in homes and hundreds of health care applications for smartphones.

Christine Chang, a health care technology analyst at Datamonitor's Ovum unit, says telemedicine will allow doctors to take better care of larger numbers of patients. "Some patients will be seen by teleconferencing, some will send questions by e-mail, others will be monitored" using digitized data on symptoms or indicators like glucose levels, she says.

Eventually, she predicts, "one patient a day might come into a doctor's office, in person."

Although telemedicine has been around for years, it is gaining traction as never before. MedicareMedicaid and other government health programs have been reimbursing doctors and hospitalsthat provide care remotely to rural and underserved areas. Now a growing number of big insurance companies, like the UnitedHealth Group and several Blue Cross plans, are starting to market interactive video to large employers. The new federal health care law provides $1 billion a year to study telemedicine and other innovations.

With the expansion of reimbursement, Americans are on the brink of "a gold rush of new investment in telemedicine," says Dr. Bernard A. Harris Jr., managing partner at Vesalius Ventures, aventure capital firm based in Houston. He has worked on telemedicine projects since he helped build medical systems for NASA during his days as an astronaut in the 1990s.

Face-to-face telemedicine technology can be as elaborate as a high-definition video system, like Cisco's, that can cost up to hundreds of thousands of dollars. Or it can be as simple as the Webcams available on many laptops.

NuPhysicia uses equipment in the middle of that range — standard videoconferencing hookups made by Polycom, a video conferencing company based in Pleasanton, Calif. Analysts say the setup may cost $30,000 to $45,000 at the patient's end — with a suitcase or cart containing scopes and other special equipment — plus a setup for the doctor that costs far less.

Telemedicine has its skeptics. State regulators at the Texas Medical Board have raised concerns that doctors might miss an opportunity to pick up subtle medical indicators when they cannot touch a patient. And while it does not oppose telemedicine, the American Academy of Family Physicians says patients should keep in contact with a primary physician who can keep tabs on their health needs, whether in the virtual or the real world.

"Telemedicine can improve access to care in remote sites and rural areas," says Dr. Lori J. Heim, the academy's president. "But not all visits will take place between a patient and their primary-care doctor."

Dr. Boultinghouse dismisses such concerns. "In today's world, the physical exam plays less and less of a role," he says. "We live in the age of imaging."

ON the rig Courageous, Mr. Martin is part of a crew of 100. Travis G. Fitts Jr., vice president for human resources, health, safety and environment at Scorpion Offshore, which owns the rig, says that examining a worker via two-way video can be far cheaper in a remote location than flying him to a hospital by helicopter at $10,000 a trip.

Some rigs have saved $500,000 or more a year, according to NuPhysicia, which has contracts with 19 oil rigs around the world, including one off Iraq. Dr. Boultinghouse says the Deepwater Horizon drilling disaster in the Gulf of Mexico may slow or block new drilling in United States waters, driving the rigs to more remote locations and adding to demand for telemedicine.

NuPhysicia also offers video medical services to land-based employers with 500 or more workers at a site. The camera connection is an alternative to an employer's on-site clinics, typically staffed by a nurse or a physician assistant.

Mustang Cat, a Houston-based distributor that sells and services Caterpillar tractors and other earth-moving equipment, signed on with NuPhysicia last year. "We've seen the benefit, " says Kurt Hanson, general counsel at Mustang, a family-owned company. Instead of taking a half-day or more off to consult a doctor, workers can get medical advice on the company's premises.

NuPhysicia's business grew out of work that its founders did for the state of Texas. Mr. Hammack, NuPhysicia's president, is a former assistant vice president of the University of Texas Medical Branch at Galveston, where he led development of the state's pioneering telemedicine program in state prisons from the mid-1990s to 2007. Dr. Davis is a cardiologist.

Working with Dr. Boultinghouse, Dr. Davis and other university doctors conducted more than 600,000 video visits with inmates. Significant improvement was seen in inmates' health, including measures of blood pressure and cholesterol, according to a 2004 report on the system in the Journal of the American Medical Association.

In March, California officials released a report they had ordered from NuPhysicia with a plan for making over their state's prison health care. The makeover would build on the Texas example by expanding existing telemedicine and electronic medical record systems and putting the University of California in charge.

California spends more than $40 a day per inmate for health care, including expenses for guards who accompany them on visits to outside doctors. NuPhysicia says that this cost is more than four times the rate in Texas and Georgia, and almost triple that of New Jersey, where telemedicine is used for mental health care and some medical specialties.

"Telemedicine makes total sense in prisons," says Christopher Kosseff, a senior vice president and head of correctional health care at the University of Medicine and Dentistry of New Jersey. "It's a wonderful way of providing ready access to specialty health care while maintaining public safety."

Georgia state prisons save an average of $500 in transportation costs and officers' pay each time a prisoner can be treated by telemedicine, says Dr. Edward Bailey, medical director of Georgia correctional health care.

With data supplied by the California Department of Corrections and Rehabilitation, which commissioned the report, NuPhysicia says the recommendations could save the state $1.2 billion a year in prisoners' health care costs.

Gov. Arnold Schwarzenegger wants the university regents and the State Legislature to approve the prison health makeover. After lawsuits on behalf of inmates, federal courts appointed a receiver in 2006 to run prison medical services. (The state now runs dental and mental health services, with court monitoring.) Officials hope that by putting university doctors in charge of prison health, they can persuade the courts to return control to the state.

"We're going to use the best technology in the world to solve one of our worst problems — the key is telemedicine," the governor said.

More ...

http://www.nytimes.com/2010/05/30/business/30telemed.html?src=me&ref=homepage