Saturday, March 10, 2012

Out of bed! Hospitals aim to keep elderly strong - Houston Chronicle

Bob Landorf walked miles during his hospital stay, dragging his IV pole along, too, on a mission to upend disturbing statistics for patients his age.

At least one-third of hospital patients older than 70 leave more frail than when they arrived, and many become too weak to go home. Nursing home care or rehabilitation often are needed, and even then, research suggests more than two-thirds remain weaker a year after being in the hospital.

Elder-care experts challenge the idea that this decline is an inevitable part of growing old. They say conventional hospital care focusing on treating disease rather than preventing frailty contributes to the problem.

"Non-medical people say, 'Grandma went to the hospital with pneumonia ... and she was never the same again," said Dr. Kenneth Covinsky, a geriatrics specialist at University of California at San Francisco. "Pneumonia is a serious illness, but it is treatable" and should not leave patients disabled.

He and other advocates say hospitals need to revamp old-fashioned models of patient care to address the nation's aging population — from getting patients out of bed to offering better food and homey surroundings.

"Life has 100 percent mortality. But if you can change the age at which people lose function," they may live longer, better lives, said Covinsky, who wrote about the issue recently in the Journal of the American Medical Association.

Some already are heeding the call, including the suburban Chicago hospital where Landorf was recently treated.

Intestinal discomfort sent Landorf to Northwest Community Hospital in Arlington Heights last month. Doctors put the 74-year-old part-time chemist on intravenous fluids and ran tests for a suspected blockage. But they didn't confine him to bed.

Two hospital units have volunteers who accompany patients on daily walking sessions of at least 15 minutes, their course marked by footprint decals on hallway walls. Landorf figures he did at least 20 laps daily during his stay.

His only complaint? "It would be nice if they had longer paths," he said.

Doctors found no intestinal blockage and sent him home after three days. Now he's back to working out three times a week, just like before his hospital stay.

Landorf thinks all that walking helped keep him in shape. The benefit is obvious, he said. "Any kind of exercise you can get when you're bedridden is good."

Days of bed rest raise chances for infection, can slow recovery from common conditions in the elderly including pneumonia, and contribute to surprisingly rapid loss of muscle strength in older patients. Dina Lipowich, Northwest's head of nursing and geriatrics, said the hospital is evaluating whether the walking program has reduced those risks.

"We want to preserve their independence," Lipowich said. "Gone are the days when we needed to stay in bed to get better."

Other hospitals, like Highlands Hospital in Birmingham, Ala., are changing standard mealtime practices to keep patients from losing weight. Busy staff may overlook whether patients eat, said Dr. Kellie Flood, medical director of a special elder-care unit at Highlands, operated by the University of Alabama at Birmingham.

One impediment is plastic wrapping the food, often a challenge for an older person's arthritic hands. Flood has enlisted college students to help remove the wrappers. Volunteers sometimes help feed patients, spending time with them during meals, making conversation that often helps lonely older people feel more like eating, Flood said.

The program is modeled after one at the University of Texas Medical Branch in Galveston, and Flood is evaluating whether the Alabama program has improved patients' function or shortened hospital stays.

She called it "one tiny piece" of maintaining baseline functioning.

The elder-care units where such efforts occur are one of the best-known models of geriatric hospital care, typically featuring specialists, nurses, physical therapists and other staffers who collaborate to keep older patients from becoming frail.

Often there is carpeting, special lighting or curtains to make older patients feel more at home. But the concept also involves challenging standard practices, from bed rest and feeding methods to routine use of things like urinary catheters that can increase risk of infection and which studies have shown are often needlessly used in older patients.

Developed more than a decade ago, the units have been slow to catch on. Fewer than 300 hospitals have them, or less than 10 percent of the nation's more than 4,000 hospitals.

Startup costs, typically at least $200,000, may be a key reason, but these units can save money in the long run, said Dr. Kyle Allen, an elder-care expert who worked for Summa Health System in Akron, Ohio.

A comparison showed that hospital stays for patients in these settings there were almost half a day shorter than for those in standard hospital units, Allen said. "That doesn't sound like a lot," but it translates to hundreds of thousands of dollars in annual savings, he said.

Now he is helping Riverside Health System develop an elder-care unit at its regional medical center in Newport News, Va.

America Is Stealing the World’s Doctors -

It was not an unusual death. Kunj Desai, a young doctor in training at University Teaching Hospital in Lusaka, Zambia, had seen many that were not so different and were equally needless. Still, this was the one that altered all his plans. "A guy came in, and he had a stab wound," Desai recalled, "and his intestines got injured." The operation was delayed, and the wound became infected. "Whatever he was eating would come out of his belly," Desai said. A carefully managed diet would have helped the man heal, but there were no dietitians at the hospital nor any IV drips of liquid nutrients with which to feed him. "He withered away to probably about 100 pounds when he died."

The man was in his 30s, and his wife and children would have to fend for themselves. It was 2004, and Desai had worked at the chronically understaffed and underfinanced hospital for a year and a half. The hospital blood bank was often out of blood, and the lab was unreliable. The patients were often so poor that Desai would pay for private lab tests out of his own pocket. Desai came home in tears one day after being unable to save a premature baby boy. When the man with the stab wound died, the accumulation of preventable deaths — at what was, he kept reminding himself, the best public hospital in the country — finally became too heavy to bear.

"We were pretending to be doctors," Desai, who is 35, told me when we first met. This was in the cafeteria of University Hospital in Newark, and Desai was still in his surgical scrubs after a 30-hour shift. He talked about what he saw in Lusaka in the somewhat stream-of-consciousness way that war veterans sometimes speak about the battlefield. "What was I really doing?" he said. "Making myself feel happy? No."

As an idealistic, energetic young doctor, Desai imagined he would spend his career in Zambia, serving those in desperate need. But over the months at the hospital, he found himself fantasizing about another life — as a doctor in America. And in 2004, after he finished his internship, Desai quit his job at the hospital and began studying for the exams for a training position at an American hospital. Even while he did so, he told himself that after his stint in America, he would return to Zambia. His fellow Zambians, he knew, suffer from some of the gravest health crises in the world, not least of which is that Zambia's doctors tend to leave the country and never come back. "After completing residency training in the United States, I hope to return to Zambia and work where the need is the greatest, the rural areas," he wrote in a personal statement when applying for jobs in the United States in 2005. "I am Zambian, and I am committed to improving the quality of care that fellow Zambians receive."

Two years from now, Desai will be a fully qualified surgeon in America. He has a wife and a young daughter (he had neither when he moved to the United States), and once he's qualified, he can expect to make a very good living — the median salary of a surgeon in New Jersey is $216,000. In the main hospital in Lusaka, where Desai worked, a surgeon makes about $24,000 a year. The uncomfortable question that Desai put to the back of his mind when he arrived in the United States has begun to resurface and trouble him: Will he really fulfill his promise to himself and his country?

As we sat in the cafeteria, I suggested that if he did return to Zambia, he might be seen as something of a returning hero. Desai is a naturally polite and courteous man, but he is also disinclined to hold back from criticizing when he finds fault. In this case, his target was himself. He looked at the table and said: "The heroes are the guys that stayed. They didn't quit, and they didn't run away."

In a globalized economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America's best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the United States to work for American companies. And the United States, with its high salaries and technological innovation, is also the world's most powerful magnet for doctors, attracting more every year than Britain, Canada and Australia — the next most popular destinations for migrating doctors — combined.

The Council on Physician and Nurse Supply estimates that in 10 years, the United States could have a shortage of 200,000 doctors. Already, one in four doctors working in this country is trained in a medical school overseas (though this includes some American doctors who attended medical school outside the United States). American medical schools are producing more graduates, but many of them will become specialists who can command better pay. The demand for primary-care doctors is expected to stay high, perpetuating the demand for foreign medical graduates.

Even in the unlikely event that American medical schools produce more general practitioners, nothing but legislation would prevent American hospitals from cherry-picking the most promising young doctors the world has to offer, according to Laurie Garrett, a senior fellow at the Council on Foreign Relations. "If you can take from an applicant pool from the whole planet, why would you only take from Americans?" Garrett said. "For the foreseeable future, every health provider, from Harvard University's facilities all the way down to a rural clinic in the Ethiopian desert, is competing for medical talent, and the winners are those with money."

Some of the responsibility for the migration of health care workers lies with the immigration laws in the host countries. In 1994, Senator Kent Conrad, a Democrat from North Dakota, introduced legislation that empowered states to grant waivers to foreign doctors on J-1 student visas. They could stay in the United States after finishing residencies in American hospitals if they agreed to practice in communities where doctors were in short supply. The law, which has been continually renewed by Congress, has allowed more than 8,500 foreign doctors to gain jobs in rural communities, where patients often have to drive great distances to get medical care, and in underserved cities.

For a diabetic or someone with heart disease in rural Nebraska, this is unquestionably a good thing. They may be unaware, however, that their gain is a poor country's loss. The migration of doctors and nurses from poor countries to rich ones elicits some highly emotional responses, not to mention a great deal of ethical debate. Writing in the British medical journal The Lancet in 2008, a group of doctors, several of them from Africa, titled their paper "Should Active Recruitment of Health Workers From Sub-Saharan Africa Be Viewed as a Crime?" (PDF) They concluded that it should. Other critics have used terms like "looting" and "theft."

Some of the anger is directed toward the doctors who leave. The managing director of University Teaching Hospital in Lusaka, Lackson Kasonka, suggested to me that doctors who received government financing for their educations and then left exhibited "a show of dishonesty and betrayal." (Desai is not in this group; his parents, who immigrated to Zambia, paid for his medical education in India, where they were born.) Peter Mwaba, the most senior civil servant in Zambia's ministry of health, said that doctors overseas should not "hold their country to ransom" by staying away until things, in their minds, sufficiently improve.

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Friday, March 9, 2012

Why the Web Lacks Authoritative Reviews of Doctors -

For all the debate about which Web sites have the best model for reliable reviews — paid or unpaid, anonymous or real name, Angie's List or Yelp or TripAdvisor — one thing is certain: a robust ecosystem exists online for restaurant and hotel reviews that has changed those industries for the better.

So it is puzzling that there is no such authoritative collection of reviews for physicians, the highest-stakes choice of service provider that most people make.

Sure, various Web sites like HealthGrades and RateMDs have taken their shots, and Yelp and Angie's List have made a go of it, too. But the listings are often sparse, with few contributors and little of substance.

What we have here is a demand and supply problem: many people want this information and more consumers would trust it if the sites had more robust offerings. But not enough people take the time to review their doctors. And fixing that problem means figuring out why.

Companies have tried to collect reviews of doctors since the early days of the Web, and has gathered more than most. The founder, John Swapceinski, was inspired to create it after his success with a site called, which is well known for the "hotness" rating that college students assign (or not) to their teachers.

"Anything that people spend time or money on ought to be rated," he said. RateMDs now has reviews of over 1,370,000 doctors in the United States and Canada.

But getting in the faces of the previously untouchable professional class has inevitably led to legal threats. He says he gets about one each week over negative reviews and receives subpoenas every month or two for information that can help identify reviewers, who believe they are posting anonymously.

Over at Angie's List, service providers have sued reviewers, whose names are known to the company, "a handful" of times, according to the company. Angie's List has paid their legal fees in the past, but the site's co-founder, Angie Hicks, said she could not commit to doing that in every case in the future.

None of the litigants at Angie's List have been doctors so far, but that doesn't mean they are thrilled with her health reviews. "They told me that 'Patients aren't smart enough to figure out whether I'm a good doctor,' " she said. "But I told them that these conversations have been happening all along." The only difference with the site, she points out, is that the doctors get to listen in.

Some doctors have silenced patients anyway. Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections.

This struck me as the height of audacity, and when I shared my feelings with the company, I was informed that the agreements had outlived their usefulness. What neither its vice president of marketing, Shane Stadler, or its founder and chief executive, Jeffrey Segal, told me, however, was that the company had retired the agreements in the wake of a lawsuit related to them and a complaint filed with the Federal Trade Commission.

Medical Justice has now turned 180 degrees and embraced the review sites. It helpfully supplies its client doctors with iPads that they can give to patients as they are leaving. Patients write a review, and Medical Justice makes sure that the comments are posted on a review site.

Sound coercive? Not to Mr. Segal, a lawyer and former neurosurgeon who says he has 150 to 200 active physician accounts for the service. "The reality is that every health care system is asking for feedback, even Medicare," he said.

Other doctors have taken matters into their own hands. Dr. Kent Sepkowitz, of the prestigious Memorial Sloan-Kettering Cancer Center in New York, gleefully recounted his creation of fake reviews on a couple of sites in the online magazine Slate in 2008.

These physicians are probably outliers, though. The American Medical Association speaks for them. Robert Mills, a spokesman, sent me a statement that he said was from the A.M.A.'s president, Dr. Peter W. Carmel, that read, in part: "Anonymous online opinions of physicians should be taken with grain of salt and should not be a patient's sole source of information when looking for a new physician."

This, however, is almost exactly the same statement it provided to its own publication, American Medical News, in 2008, when it was attributed to Dr. Nancy H. Nielsen, the president-elect of the A.M.A. at the time. Had they achieved some kind of mind meld?

When I pointed this out to Mr. Mills, he got Dr. Carmel to the phone rather quickly.

"To advise people anonymously through an open site when this is an important decision for people's lives, I don't think it's proper," Dr. Carmel told me. "The evidence that's given on many of these consumer sites is undocumented, unverified and anonymous. It may well have nothing to do with actual patient treatment."

Given many physicians' wariness, it's understandable that patients may be reluctant to mix it up with them online. But patients may be steering clear for a far more ordinary reason: if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they don't want to create any awkwardness.

An Angie's List customer who read my column about the service last week raised a related concern. She said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn't want to end up blackballed by doctors at either. She wouldn't let me use her name in this article, given her fear of incurring their wrath.

Others idolize their doctors, which creates its own challenges. Dr. Sam Nussbaum, chief medical officer at the insurance giant WellPoint, which makes patient reviews of its network doctors available for all customers to see, explains it another way. The insurer has found that only roughly 20 percent of customers will switch to a generic drug or use a less expensive imaging center, even if there is no health risk. Why? Because their doctor told them so.

It is exactly this sort of unquestioning mind-set that may cause such low participation (or disproportionately positive reviews) at many review sites. At WellPoint, only about 10 percent of the 250,000 doctors in its network have at least one review. The company had planned on posting reviews only after it had at least 10 reviews for a doctor but had to change course. "We wanted statistical validity, but we really had too few doctors listed and wanted to increase that number," Dr. Nussbaum said.

Perhaps the biggest problem with the ratings is that they are incomplete. WellPoint tracks doctors' communication skills, availability, office environment and trust, but it doesn't yet provide information about medical outcomes. While it's nice to know how long different obstetricians make you wait, it would also be helpful to know how many babies they end up delivering by Caesarean section.

WellPoint knows a lot about a lot of this; in fact it pays many physicians more when they achieve better results. But it's not ready to share all of its outcome data. "Over time, we're going to make a lot of changes," Dr. Nussbaum said. "But the unintended consequences would be if certain surgical specialists would not take on the most challenging, needy and difficult patients."

Nevertheless, the big health care law requires Medicare to share all sorts of such data about doctors starting Jan. 1, 2013, assuming legal challenges don't get in the way. The A.M.A. has raised many concerns about "risk adjustments" for the factors Dr. Nussbaum mentioned as well as accuracy, among other things.

Until a single one-stop shop exists for both reviews and data that are fair and useful, we are left with one another. The problem with asking friends for a doctor recommendation is that even if they are a lot like you, they may not have any idea whether the doctor is a good clinician or not.

Careful readers can probably find some sites with listings for certain doctors that in number and detail add up to a useful measure of many of their skills. But you may not know anything about whether the reviewers are people similar to you.

The only solution then is to keep populating these sites en masse if you dare and your doctor doesn't seem to be the suing sort, taking care all the while to tell the truth and be fair. State as much about yourself and your condition as you feel comfortable sharing and be detailed in your comments and feedback.

No one of us is as smart as all of us, after all. But if most of us decline to contribute to the collected knowledge about the medical community, all of us lose out.

Thursday, March 8, 2012

Needed - Health Providers to Treat the Aging -

LAURA KAUFMAN no longer treats her patients in a suburban dental office. These days, she cleans teeth, does simple extractions and provides other basic care in the homes of inner-city elderly who are too frail to travel.

After a decade of private practice in the Boston area, Ms. Kaufman found that a growing number of her dental patients were older people and that she often had little idea of their complete medical picture. So she decided to become "geriatricized" — educated on how to recognize and handle aging patients, who typically have several chronic conditions, as well as multiple prescription medications.

"I saw these patients at my practice," she said. "And then my father-in-law was homebound, and I saw first-hand there were no at-home dental services available."

Eighteen months ago, she was accepted into a federally financed fellowship program in geriatric dentistry at Boston Medical Center that she will soon complete. The program for geriatric medicine, dentistry and mental health is one way that health care professionals can gain more specific knowledge and training to recognize and provide comprehensive care for the growing number of people 65 years old and up.

The federal government underwrites some fellowships and is asking for $54 million, up $11 million from last year, in the next budget for such training, especially for Geriatric Education Centers at dozens of medical schools and major medical centers. Private groups, notably the John A. Hartford Foundation, have also been financial pillars for elderly care training.

Even so, given the enormous number of retiring baby boomers, the problems are worrisome. Prestigious organizations like the Institute of Medicine have warned of a looming scarcity of medical professionals equipped to deliver coordinated treatment of elderly health problems.

There could be a shortage of as many as 90,000 doctors, about half in primary care, by the end of the decade, the Association of American Medical Colleges has warned. Doctors do not flock to practice geriatrics because Medicare reimbursement is comparatively low. The average geriatric specialist made $183,523 in 2010 — less than half that year's $392,885 median for dermatologists, according to the Physician Compensation and Production Survey. And, like all fledgling doctors, the geriatric specialist struggles with medical school debt.

Geriatrics is also seen as a plodding area of medicine, set apart from the glamour of life-saving heroics. That may be why the specialty has made little headway among nurses as well.

The Hartford Foundation and the Atlantic Philanthropies have supported a wide-ranging effort, at more than 300 hospitals, to provide nurses with geriatric training, in a program called Niche (Nurses Improving Care for Healthsystem Elders).

Medical schools and others have been exploring shorter and more specific ways to expose health care professionals to the complexities of aging care, especially because midcareer professionals have limited ability to leave their practices for a year or two of training.

The American Geriatric Society and other groups sponsor minifellowships, weekend workshops, Web seminars and online courses, and add material to the physician relicensing process that occurs every decade.

And the geriatric residency that must be completed before becoming a board-certified doctor has been reduced to one year from two, to make it less punishing financially for doctors.

After decades of practice in Maine where his caseload of aging patients was rising steadily, Dr. William Bogan Brooks, a psychiatrist, decided he needed to know more. He entered a one-year fellowship program in geriatric psychiatry at Brown University in Providence, R.I.

"Older people have more health problems, but they are also dealing with losses of loved ones and cognitive disorders," he said. Along with another doctor, he made home visits in the Boston area as part of a team to give patients health assessments. But it was not an easy year, Dr. Brooks recalled. Now in Alabama after completing the program last summer, he said: "I had to do some moonlighting at a local hospital. Taking the year was a financial hit, but I learned so much."

That is music to the ears of Sharon Levine, a geriatric physician who helps direct a Boston Medical Center program of weekend geriatric immersion workshops for doctors. "There will be at least 70 million Americans over age 65 by 2030, and we only have 7,100 board-certified geriatricians," she noted, adding that "there will never be enough."

Sharon A. Brangman, chief of geriatrics at SUNY Upstate Medical University in Syracuse, and a board member of the American Geriatrics Society, commented: "We have a huge disconnect in this country. Primary-care physicians — who were our feeder pipeline for geriatricians — are now seen as workhorses who are not doing dramatic medicine."

Joan Weiss, who heads the federal Health and Human Services program that finances Geriatric Education Centers and other health work force education efforts, predicted, "By 2030, we will need 36,000 geriatricians."

Wednesday, March 7, 2012

What Happened to the Girls in Le Roy -

Before the media vans took over Main Street, before the environmental testers came to dig at the soil, before the doctor came to take blood, before strangers started knocking on doors and asking question after question, Katie Krautwurst, a high-school cheerleader from Le Roy, N.Y., woke up from a nap. Instantly, she knew something was wrong. Her chin was jutting forward uncontrollably and her face was contracting into spasms. She was still twitching a few weeks later when her best friend, Thera Sanchez, captain of one of the school's cheerleading squads, awoke from a nap stuttering and then later started twitching, her arms flailing and head jerking. Two weeks after that, Lydia Parker, also a senior, erupted in tics and arm swings and hums. Then word got around that Chelsey Dumars, another cheerleader, who recently moved to town, was making the same strange noises, the same strange movements, leaving school early on the days she could make it to class at all. The numbers grew — 12, then 16, then 18, in a school of 600 — and as they swelled, the ranks of the sufferers came to include a wider swath of the Le Roy high-school hierarchy: girls who weren't cheerleaders, girls who kept to themselves and had studs in their lips. There was even one boy and an older woman, age 36. Parents wept as their daughters stuttered at the dinner table. Teachers shut their classroom doors when they heard a din of outbursts, one cry triggering another, sending the increasingly familiar sounds ricocheting through the halls. Within a few months, as the camera crews continued to descend, the community barely seemed to recognize itself. One expert after another arrived to pontificate about what was wrong in Le Roy, a town of 7,500 in Western New York that had long prided itself on the things it got right. The kids here were wholesome and happy, their parents insisted — "cheerleaders and honor students," as one father said — products of a place that, while not perfect, was made up more of what was good about small-town America than what was bad. Now, though, the girls' writhing and stuttering suggested something troubling, either arising from within the community or being perpetrated on it, a mystery that proved irresistible for onlookers, whose attention would soon become part of the story itself.

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France and U.S. Health Care: Twins Separated at Birth? - Megan McArdle - Business - The Atlantic

By way of introduction, I want to make clear that I have no particular expertise when it comes to healthcare policy. My knowledge is merely that of a layman who follows the news. I'm even well-aware that one of my esteemed co-guest bloggers is Avik Roy, who's one of the most talented health care wonks on the internet, whose work I avidly followed at his previous National Review digs. In fact, this post can be read as an invitation to Avik to enlighten me.

All that being said, from my outlook there's something that I haven't seen discussed and yet seems striking to me: how similar the French and U.S. healthcare systems are.

On its face, this seems like a preposterous notion: whenever the two are mentioned together, it's to say that they're polar opposites.

France has been called the best healthcare system in the world by the World Health Organization. And if there's something everyone in the US seems to agree on, it's that US healthcare, well, horribly sucks, although they strongly disagree about why and what to do about it.

And yet, to me, the similarities are glaring:

First of all, the French healthcare system is built on a large, highly-regulated private sector.Unlike Britain's NHS, the government doesn't own everything. Some hospitals are public, but many are private and for-profit. Indeed, there are publicly-traded hospital chains, just like in the US. Most doctors and nurses work in private practice. Even most of the ambulances are private. The sector is highly regulated and subsidized to be sure, but that's also true in the US.

Secondly, there's a crucial feature at the heart of the French healthcare system that is also at the heart of the US healthcare system--and that all US wonks hate: employer-provided insurance.

France has had a US-style employer-based healthcare system since the end of World War II, but theCouverture Maladie Universelle (literally: universal healthcare coverage), the government program that covers people who can't get insurance, was only enacted in the late 90s (ah, global macro booms). Given how tantalizingly close Bill Clinton was to passing universal healthcare in the early 90s, it's easy to imagine a parallel universe where Americans had universal healthcare before the French, again something you wouldn't guess from reading stories on French healthcare.

The way healthcare works in France, basically, as I understand it from living here (and I may be wrong about this because it gives me migraines), is that you get insurance through your employer which they deduct from their taxes. You can also buy it on the market (and don't deduct it from your taxes). If you can't get insurance, the government will pay for your treatment in a system similar to (I think?) Medicaid, ie you go to the doctor or the hospital you want, and the government will pay for it in a stingy way that incentivizes you to not want to rely on the government too much but still ensures no one is left to die on the streets. French doctors frequently grumble about CMU reimbursement rates as American ones do Medicaid/Medicare rates. Conversely, if you have a job with coverage, you can buy additional coverage and/or services out of pocket.

Some jobs have better healthcare than others: my wife works for a big management consulting firm and has very generous healthcare coverage; as her husband, I get coverage through her policy, since as a freelancer my options are mediocre.

When we had our baby, my wife and I sprung for a private clinic. We chose this clinic because it is a religious institution that provided religious services on top of medical ones, which was important to us, and only later discovered that it's one of the best clinics in Paris and therefore the world. And indeed we were stunned by the quality and level of service and the awesomeness of everything.

The way we paid for it, or rather, didn't, is that the government paid a sizable minority of the bill, and my wife's insurer paid the rest. We sprung for extras like a private room. If we had no or stingier insurance, we would have been free to pay the difference out of pocket. Or we could have gone with a less pricy private option, or with the public hospital which would have been free beyond a token deduction but much less nice.

From my understanding, this is different from how it works in the US, but not that much: it's still your employer-provided insurance that will pay for the hospital stay; you may have to pay a deductible and the government won't pay anything, but the idea of a third-party, employment-based insurer who pays--this idea that everyone agrees makes US healthcare so horrible--is also at the heart of the French system--which most people think is so awesome.

Again, I don't really understand how most of this works, but as a France-based follower of US politics, these parallels struck me as existing and underdiscussed.

Which begs the question: with such striking similarities, how come the outcomes are so different? Most importantly, how come the US healthcare system is so expensive and the French healthcare system so manageable?

One thing that's different, you might argue, is lifestyle factors: French people generally eat better than Americans, shoot each other less, etc. and so it costs less to fix them up. Prevention also plays a bigger role in France: when someone in my family was unemployed and uninsured, that person received vouchers for medical and dental checkups at the local public hospital (which I got to see and seemed gleaming and state-of-the-art, though that's not the state of most French hospitals). The idea that prevention is super important and cost-effective is a big theme in healthcare wonkery. Still, that explanation doesn't satisfy me. While there's probably some of that at play, I'm pretty sure it can't explain such a wide disparity.

Another thing you might argue, and again it's probably true to some extent, is that the French healthcare system is really a house of cards: it may not be horrible, but it will be soon. A striking number of people inside the system I've spoken to seem to believe this: many people are convinced that French healthcare will no longer exist as we know it within 10 to 20 years because of (like everywhere else) budgetary pressure, exploding debt and Boomers retiring. This should probably cool the enthusiasm of so many France-loving US healthcare wonks.

But, precisely because the US has the same macro problems, it doesn't explain why France does so well, and the US so badly, now. The US demographic picture is actually slightly better than France, so if that was the explanation, you'd think the US would be doing slightly better.

After mulling this on and off for many months since I've been thinking about this, I think the defining thing is: costs. Costs are just much higher in the US.

You see this with doctors: American doctors just make way, way more money than French doctors, which drives up costs across the board. The reason why American doctors must make more money than French doctors is because medical school in France is free and medical school in the US is really, really expensive. I don't have any figures, but I wouldn't be surprised if what the median starting doctor pays in student debt in a year is more than what the median starting French doctor makes in a year.

And by the way, this is why doctor is such an unappealing profession in France. Since I've been thinking about this, I've gone through my memory and been struck by how, when I was in school, nobody asked if I wanted to be a doctor. As I understand it, the cliché is that a bright young middle-class kid will become "a lawyer or a doctor." In my upper-middle-class background, no one even brought up the idea that I might want to be a doctor. Lawyer? Sure. Bureaucrat? Of course. Business executive? Why not.

Medical interns in France make less than the minimum wage per month (and therefore much, much less per hour) so if you want to become a doctor you had better have parents who can afford to support you into your late twenties. In the fancy prep school I attended, the only pupils who were thinking about becoming a doctor had a doctor parent. This completely scientific survey of some people I vaguely knew over a decade ago leads me to speculate that becoming a doctor in France has become sort of like contemplating a military career in both countries: a profession you might choose because of prestige/family tradition/passion but that has stopped being a smart financial bet and so draws on an increasingly narrow pool of applicants. Which is quite worrisome from a societal perspective when you think about it.

By contrast, you can't swing a cat across a dorm room at an elite US university without hitting a pre-med. Not all those kids will end up becoming doctors but the idea that becoming a doctor is an enviable path for a bright kid who wants a prosperous upper-middle-class lifestyle is well-entrenched.

Doctors are just one example. As Ezra Klein was arguing recently, prices in US healthcare are very high across the board, and that seems to be the big, big difference.

All of this is a roundabout way of saying that my neophyte impression is that the French and US healthcare systems, rather than being these wildly different systems operating from wildly different premises, are actually pretty similar. It just so happens that one is much, much more expensive than the other, and that's what leads to these very different outcomes.

Now, why is that? The process is well-understood: France (and other countries) simply set prices low by political fiat. The US doesn't, and so has very high prices.

So should the US do the same? The argument against is that medical innovation requires a profit motive, a view with which I concur. Non-US countries can get away with setting low prices only because medical innovators make their profits in the US, and the US is thereby subsidizing the rest of the world's healthcare costs.

That makes sense, but there's still a problem: in every other sector, competition and innovation drives prices down, not up. I work in the information technology industry where this effect has been staggering, and yet I see so many people blithely saying about healthcare, essentially, "Well of course prices are going to go up because the technology keeps improving", which makes intuitive sense until you realize that the opposite is true everywhere else.

The left-reformist response is that healthcare decisions are unlike other kinds of market decisions: there are information asymmetries (if your doctor says "Buy this pill" or "Take this procedure" even if it's unnecessary, you'll still do it because you don't know better), people aren't price sensitive (you're not going to risk killing grandma by buying the cheaper option). Therefore, the buyer-driven competitive market process that usually pushes prices down doesn't work for healthcare, which legitimizes the idea of government intervention to control prices.

That also makes some sense (then again: there are also information asymmetries in things like computers and cars--most consumers aren't computer or mechanical engineers--and yet relentlessly prices go down and quality goes up), but my instinctive response from my pro-market perspective is: I'd be more convinced by that argument if we'd at least tried to have a competitive market in healthcare products and services and found it wanting. Which we really, really haven't. A common example here is laser eye surgery, which isn't caught up in the regulatory-subsidizing web because it's considered a surgery, and where prices really have gone down as quality went up.

So, where does all that leave us? Well, I don't know. As I said, I'm a layman when it comes to healthcare policy. My pro-market instincts tell me that deregulation and consumer choice are the answer. It might look like Brad De Long's healthcare utopia, or it might look like Will Wilkinson's. I lean toward the latter (you should really read Will's post), but I also think DeLong's plan would be an improvement over the status quo, in either France or the US. And my thinking on the issue was also deeply influenced by the Atlantic story"How American Healthcare Killed My Father."

But I felt it was important to note what I see as big similarities between France and the US, when most of the commentary seems to regard them as polar opposites.

Tuesday, March 6, 2012

The 5 Things You Must Know Before Leaving the Hospital - Richard Senelick - Health - The Atlantic

There are days in our lives that bring great joy to our hearts and a smile to our faces. Like the first day of school, with all of the anticipation of the new year, or the last day of school, with the summer months just waiting for us to relax. Our wedding day and the birth of our children. Then there is the day we get to go home from the hospital after a surgery or sickness. We view this day as a major step from illness to recovery, but it is also a potential disaster for the ill-prepared.

Hospitalizations have become an accelerated process and are described by Edmund Pellegrino in his essay on human dignity as "today's mechanized experience of illness." Hospital stays are getting shorter every year and discharge doesn't occur when you are healed, but instead at a point where you can go to a less expensive location to recover. Most commonly, that place is your home. The only guaranteed aspect of your transition home is that it will not go as planned. You will be bombarded with more information than you can keep straight. My wife and I just went through this process, and even though I am a physician, there have been multiple times when we have looked at each other and asked, "What do you think he/she/they meant?"

Many hospitals, including the one where I am the medical director, have worked hard to improve the discharge process. But despite our efforts, our patients and families consistently rate it as one of the least satisfactory aspects of their hospital experience. In an attempt to reduce the number of patients who are readmitted to the hospital less than 30 days after they leave, Medicare and other insurers have focused on this process, and next year will begin penalizing hospitals if a patient returns.


Medicare has created "Your Discharge Planning Checklist" (PDF). This six-page document lists 22 different areas to cover with your doctor and health care team. In an ideal world, medical professionals would help you go over all of these points. But, in the excitement of getting to go home, few of us are likely to make it through the whole list. Here's my top five.

MEDICATIONS: It seems obvious, but this is the greatest source of confusion. You have the medicines at home that you were taking before you came to the hospital. When you checked into the hospital, these same medicines may have been changed to a generic or another equivalent medication that was substituted for the one you took at home. You may not be aware that the new prescription that the doctor gives you at discharge is really the same medicine you've been taking before. This may put you at risk to take a harmful double dose. You need to have your nurse or doctor carefully go over your old and new list to make sure everyone is on the same page. Another tip: Only use one pharmacy, so that the pharmacist will have a record of all your medicines and can identify any potential problems. Have the hospital or pharmacy fax your final list of medications to your primary doctor. So often the doctor who takes care of you in the hospital is not the doctor who will follow you once you go home.

RED FLAGS: When you are in the hospital, help is only a call buzzer away. Spike a fever and a nurse will draw your blood. Cough up something green and you will get a chest x-ray. But, once you are home, it is hard to know what warrants a call to the doctor. Don't settle for the computer-generated form that the hospital hands out to patients. Ask your doctor for your specific condition's red flags. How much pain is too much pain? How long will it continue to hurt when you urinate? How much longer will I be coughing? Is there anything special that should make me run to the hospital, rather than call my doctor?

WHO TO CALL: Get the specific phone numbers of who to call if there is a problem. My wife had surgery on a Friday, so I asked the doctor for the name of who would be on call that weekend, and if he would let them know that we were out there. Make sure that someone at the hospital you are leaving lets your primary care doctor know that you are loose on the street. I always give patients a copy of their entire lab and x-ray reports to carry back to their main doctor. If they get into trouble before a scheduled appointment, then they have the critical information with them.

FOLLOW-UP: One of the main causes of readmission to the hospital is that the patient has not had appropriate follow-up after they leave the hospital. You may be told to see your regular doctor in 10 days, but when you call, they cannot see you for six weeks. Have the nurse or case manager at the hospital you are leaving call and make the appointment. Insist on it.

START A NOTEBOOK: At our hospital we give each patient a spiral WITH (Wellness Information & Tools for Health) notebook. It has sections for all of the things we covered and more. As a rule, when you come home from the hospital you have bundles of papers, some important and others destined for the recycling bin. Stick the important ones in a notebook or folder. The CMS website also has some good forms (PDF) to put in your own notebook. Take your notebook with you to each doctor's visit so you have a list of your medicines, doctor's names, laboratory results, and instructions all in one place.

If you cannot get all of these questions answered yourself, then assign one family member to be in charge of the process. It is our -- your healthcare providers' -- responsibility to make sure you get the information, but ultimately, it is going to be your responsibility to remember everything, and make sure you have all of your facts straight. Whether you believe it is fair or not, no one is going to organize all this for you -- it is your responsibility, and in your best interests, to get it together.