The leadership of HHS had a tele-conference on Monday to highlight the new Medicare incentives for physicians to adopt e-prescribing systems.  What the Washington Post and Kaiser Family Foundation reported about this press briefing that wasn’t in the HHS press release was that the Acting Administrator of CMS said that the per physician cost of e-prescribing systems is about $3,000 up front, and then $80-400/month for operation and maintenance.

These numbers caught my eye, because with the incentives in the Medicare bill, the break-even point for physicians is as follows:

First, let’s assume that the per month cost is $240 (the mid-point between $80 and $400), or $2,800 per year. Since the Medicare incentives for e-prescribing are a net 2% of Medicare reimbursements, that means to break-even the physician has to have $144,000/year in Medicare reimbursements – just for the operation and maintenance costs.  Additionally if the up front costs are spread over two years ($1,500/year), that raises the break-even point another $75,000, to $219,000/year.

For some clinicians, this amount of revenues from Medicare might be low, and therefore, it would make sense to get an e-prescribing system. However, if the doctor only sees a minority of Medicare patients, then the incentives could be a penalty.  Which is exactly what Congress expects the financial effects of the e-prescribing incentives to be. According to the Congressional Budget Office, “CBO estimates that the net budgetary effect of the electronic prescribing provision will be to reduce Medicare spending by $0.2 billion over the 2008-2013 period and $2.1 billion over the 2008-2018 period.”

Of course, if other insurers were to match (or exceed) Medicare’s incentive payments for having e-prescribing systems, then obviously the break-even point for physicians would come down, since the calculations wouldn’t balance solely on Medicare revenues.  However, I’m not aware that other insurers are rushing to provide financial incentives for physicians to use e-prescribing systems.

Additional Points
There are additional important points about e-prescribing that need to be made.  First, e-prescribing can have additional costs for physicians’ offices in the form of training time and lost productivity, and unlike electronic medical records, e-prescribing itself is unlikely to improve the office’s billing accuracy and revenues.  Second, e-prescribing can certainly provide clinical benefits by reducing medical errors with better communications about individual prescriptions.  I wrote about these issues a couple of weeks ago (see “Challenges to Making E-Prescribing Increase Efficiency and Improve Quality”), but want to reinforce one point here: Going from paper to computer communications can also introduce new opportunities for medical errors – particularly if people rely on the computer generated information while they might question the legibility or accuracy of a hand-written prescription. That is, technology is great, but its appropriate role needs to be understood by the users, who also have to use it correctly for it to provide real value.

I couldn’t resist witting something about this when I saw today’s press release from HHS which announced that Terry Cline, Ph.D., the administrator of HHS’ Substance Abuse and Mental Health Services Administration is leaving that post, and starting August 31st he will be the HHS Health Attaché and representative at the U.S. Embassy in Baghdad, Iraq.

On the serious side, I’m sure he will do good things to help improve the healthcare system in Iraq.  But on the less serious side, someone (maybe Jon Stewart?), needs to ask how did this happen?  How bad did he step on someone’s toes to get moved from Rockville, MD to Bagdad? Or was he just doing intensive and personal research into abusing substances, which led him to believe that Bagdad would be a nice place to be for a while?

While I certainly hope that Dr. Cline has a safe and productive time in Iraq…. but while he’s over there, given his expertise in substance abuse, maybe he can get over to Afghanistan too, since I understand they have a bit of an issue with poppies and heroin.

With two notable government actions in the last couple of weeks there has been significant movement towards increasing the use of e-prescribing.

DEA Proposed Rule
The Drug Enforcement Agency (DEA), proposed regulations on June 27th that would make it possible for controlled substances to be prescribed electronically. Interestingly, this was released right after a National Journal article on this topic.

The DEA’s proposed rule is very important, because while it is appropriate to place stronger safeguards on medicines that are likely to be abused (which is the criteria for being a DEA scheduled medicine), having controlled medicines prescribed by pen and paper while all other medicines are e-prescribed would be a logistical problem and obviate many of the potential benefits of e-prescribing.  And technologically, if banks and others can provide secure login systems and other security measures, I would think that e-prescribing systems could be similarly secure to make sure that unauthorized people aren’t electronically writing themselves prescriptions for thousands of narcotics pills using a legitimate doctor’s DEA number.  (See more about this in the e-quackery section below.)

Medicare Bill Contains Carrots and Sticks for E-Prescribing
The Medicare bill which passed Congress yesterday included a provision to increase the incentives for physicians to use e-prescribing technologies.  These incentives are a small percentage add-on to allowed Medicare charges for physicians who are e-prescribing starting in 2009, and a cut to payments for allowed Medicare charges starting in 2011 for physicians who are not e-prescribing.

Movement in a Good Direction
Together these actions move the US healthcare system towards greater e-prescribing, something that if done right, should increase efficiency (with lower administrative costs), and improve quality of care and patient safety by creating a better system for detecting and preventing adverse drug reactions from known drug allergies and drug-drug interactions.  The use of computerized prescription order systems for patients in hospitals has been shown to accomplish both of these improvements, but how e-prescribing will work in the outpatient world remains to be seen.

Challenges to Making E-Prescribing Increase Efficiency and Improve Quality
There are many challenges for e-prescribing in clinicians’ offices.  Like electronic medical records, they have to buy and install the systems, learn how to use them, and then keep them updated – since new prescriptions keep getting approved etc.  Because of these challenges, it is estimated that only about 6-7% of physicians’ offices are currently using e-prescribing systems.

Optimally e-prescribing systems should be an integrated part of the office’s electronic medical records system so that it could identify potential problems with drug allergies, or the need to alter dosages for patients with impaired kidney or liver function.  And at a minimum, a free standing e-prescribing system should be able to keep track of each patient’s prescriptions to flag drug-drug interactions, otherwise it may become nothing more than a sophisticated fax machine – which some could argue (but I wouldn’t) is a rudimentary form of e-prescribing.

While, e-prescribing systems should provide alerts about drug-drug interactions,  potential allergic reactions, and the need for dosing adjustments, systems that constantly flash up reminders for such things when they’re not relevant, leads users to ignore them altogether. I take a lesson about this hazard from my brother who works on designing aircraft information systems. Clearly pilots need to know certain things at the right time, but I doubt any pilot would fly better or more safely if they kept getting an alert about it being unsafe to land the airplane because the wheels were up – even with the plane at 30,000 feet.  OK – that may be a bit of an extreme example, but if the e-prescribing system doesn’t know anything about the patient, it may send similarly useless alerts and lead those using it to ignore all alerts – which could be worse than having no alerts at all, since it having them pop-up and be ignored could provide a false sense of security.

This illustrates what most people involved with healthcare reform recognize - improving the quality and efficiency of healthcare in the US requires making the systems work better since our practitioners are generally already pretty good.  But giving these good people flawed systems won’t help them, their patients (i.e. us), or our overall healthcare system.

This brings me to one last point.  How many e-prescribing systems will each clinician’s office need?  I certainly hope that every pharmacy chain/group won’t require their own version of an e-prescribing system, nor will each payer, insurer or regulator require a different electronic or paper output of the prescription information for reimbursement or quality auditing purposes.  If that becomes the case, then e-prescribing will face even greater hurdles.

Since they do good work in this area, I also want to include the eHealth Initiative’s  summary of the challenges for e-prescribing systems:

• Financial burdens – Physician practices face varying financial burdens related to e-prescribing, including covering the implementation, training and maintenance costs.
• Workflow changes and change management – Although e-prescribing efficiencies and time savings are gained in the long run, introducing e-prescribing, and electronic health records (EHRs), can be difficult, time consuming, and requires adequate planning, training, and support, particularly in the beginning.
• Continued needs for greater connectivity – The infrastructure exists for connectivity among pharmacies, physician practices, payers and pharmacy benefit managers (PBMs), but some pharmacies, payers/PBMs and mail order pharmacies are not yet connected.
• Medication history – Although e-prescribing is an improvement over relying on paper medical records and patients’ memories, the information that is available may not always be comprehensive or accurate and therefore tools to adequately reconcile medication histories from multiple sources are needed.

E-Dispensing – Bad!!  And E-Quackery – Bad Too!!!
One of the other challenges for e-prescribing may be the practical and policy interactions between physicians’ e-prescribing and internet sites that sell medicines directly to a patient without a prescription.  While e-prescribing potentially can improve efficiency and quality, e-dispensing can lead to bad fiscal and clinical outcomes from patients getting fake, adulterated or dangerous pills and potions.

Information on the worst examples of e-dispensing is in a recent report from Columbia’s National Center on Addiction and Substance Abuse (CASA).  Their recent annual report found that the number of web-sites selling controlled medicines without a prescription has decreased from the start of 2007 to the start of 2008 - from 581 to 365.  The CASA report also found, “Of those sites not requiring prescriptions, 42 percent explicitly stated that no prescription was needed, 45 percent offered an “online consultation,” and 13 percent made no mention of a prescription.”

I’m not sure if anyone knows what the total number of patients using these sites is, or the number of prescriptions they are filling, so it’s unclear if this reduction represents a real decline in the “industry,” or just its consolidation and maturation.  What CASA also found - and that I find especially worrisome - is “an emerging practice of Internet sites selling prescriptions for controlled drugs that can be filled at local pharmacies. The report also found sites selling online “medical consultations” which enable Internet users to get controlled drugs online without a proper prescription.”  I call this e-quackery, because this is physicians acting inappropriately, or non-physicians acting in the role of a physician and practicing medicine without a license by writing prescriptions.

Other notable findings from the CASA report include:

• Of the few sites that require prescriptions, half permit the prescription to be faxed, allowing significant opportunity for fraud.
• Benzodiazepines (like Xanax and Valium) continue to be the most frequently offered drugs for sale with 90 percent of sites selling them; followed by opioids (like Vicodin and OxyContin) at 57 percent of sites, and stimulants (like Ritalin and Adderall) at 27 percent of sites.
• According to DEA estimates, in 2007 eleven percent of prescriptions filled by traditional pharmacies were for controlled substances compared to 80 percent of prescriptions filled by Internet pharmacies.
• There are no controls blocking access to these sites by children and teens.

Conclusions
Just to bring things full circle – clearly e-dispensing and e-quackery are bad, so perhaps the greater use of legitimate and appropriate e-prescribing will help to clamp down on these illegal and dangerous activities.  And from a personal perspective, I can also only hope that it will reduce the ongoing flow of spam emails for on-line medicines - and the similar onslaught of spam blog comments to this blog that you never see because I delete them, but which like spam emails, just chew up time from every day.

p.s. Sorry about the long post – but this is an important and complicated topic.

The Centers for Disease Control and Prevention released some interesting data yesterday.  They reported that in 2007 an estimated 23.6 million people (7.8% of the total US population) have diabetes.  Of these people, only 17.9 million know they have diabetes, while 5.7 million have not been diagnosed.  The good news is that the percentage of people with diabetes who don’t know it has decreased from 30 to 25% The bad news is that the number of Americans with diabetes is increasing.

Number  of People in the US (in Millions) with Diagnosed Diabetes: 1980- 2005

(from http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm)

How Bad Is a Little Sugar?
As the CDC’s Fact Sheet states, “Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age.” Diabetes causes high blood pressure, heart disease and stroke, and is the leading cause of blindness and kidney failure in adults.  Diabetes – because it affects the small blood vessels – also predisposed people to infections, and can lead to amputations from lack of adequate blood flow.  It also increases the risk of pregnancy complications, and leads to nervous system impairments.

How Many People Have Diabetes Where I live?
The CDC doesn’t have county level data for 2007 yet, but the map below shows the percentage of people with diabetes in counties across the country.  [Note – People in Colorado do have diabetes, but in Colorado the country with the highest incidence of diabetes falls just below the threshold for the second color in the map.]

(from http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx)

What to Do About Diabetes?*
There are lots of good resources of information for patients about diabetes (see below), but without getting into too many specifics, people should talk to their doctors about three different types of things:

1. Testing: Get tested – both for diabetes as well as pre-diabetes, a condition which indicates impaired metabolism of sugar and a higher risk of developing diabetes.
2. Treatment: Get treated if you have diabetes.  Get treated for the diabetes itself and for other conditions that increase the risk of developing the complications of diabetes, such as high blood pressure and high cholesterol.  And be sure to take your medicines as instructed by your physician, and test your blood sugar as they recommend.  If you don’t understand how to take your medicines or have any questions about them, just ask your doctor or pharmacist.  Quality healthcare professionals would rather answer your questions and prevent problems from developing, than have to help you resolve any problems you develop from taking medicines incorrectly.
3. Personal Choices - Eat Right and Exercise: Whether you have diabetes or are at risk for developing diabetes diet is crucial, and exercise and weight loss can help improve diabetes and lowers the risk of developing diabetes and its complications.

Resources About Diabetes
American Association of Diabetes Educators - www.diabeteseducator.org
American Diabetes Association - www.diabetes.org
Centers for Disease Control and Prevention - www.cdc.gov/diabetes
National Diabetes Information Clearinghous - http://diabetes.niddk.nih.gov/ and http://diabetes.niddk.nih.gov/dm/pubs/stroke/#connection

*DISCLAIMER – THIS INFORMATION IS NOT SPECIFIC MEDICAL GUIDANCE, IT IS NOT INTENDED TO DIRECT TREATMENT OR PREVENTION FOR INDIVIDUALS,  AND SHOULD NOT BE SUBSTITUTED FOR ADVICE FROM PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS INCLUDING NUTRITIONISTS, AND DIABETES EDUCATORS.

Most of what I’ve read and previously written about electronic health records has been about making them work better or getting more clinicians to use them. Security of patients’ on-line data hasn’t been a major topic of concern. I’ve assumed that this was because these concerns had mostly been addressed back in the late 1990s during the development of the Health Insurance Portability and Accountability Act (HIPAA), or because those creating systems to allow medical information to be internet accessible – like those coalitions building dedicated Health Information Exchanges and companies like Microsoft, Google, and BlueCross BlueShield insurance plans – have resolved the security concerns.

Global Cyber-Security
However, I just read the cover story in the May 31st National Journal (”China’s Cyber-Militia”), which made me question these assumptions. The article doesn’t mention healthcare or electronic medical records, but it makes me very concerned because it discusses how Chinese hackers (or hackers working through computers based in China) have been responsible for serious industrial/utility computer breeches, and how government and private sector officials at the highest level are very concerned about this and the trend towards even more cyber-infiltrations.

If I had heard this third-hand I’d be inclined to dismiss it as extremist or Luddite hysterics. But the National Journal is solidly in the mainstream of responsible journalism, and even when their article cites reports from other publications (such as the New Yorker) they reinforce the point with information from other sources and direct interviews with knowledgeable insiders.

Some of the specific points in the article that made me sit up and take notice were:

The February, 2008 blackout affecting 3 million people in South Florida was probably caused by “a Chinese PLA [People’s Liberation Army] hacker attempting to map Florida Power and Light’s computer infrastructure apparently made a mistake. “The hacker was probably supposed to be mapping the system for his bosses and just got carried away and had a ‘what happens if I pull on this’ moment.” The hacker triggered a cascade effect, shutting down large portions of the Florida power grid, the security expert said. “I suspect, as the system went down, the PLA hacker said something like, ‘Oops, my bad,’ in Chinese.”

The article also discusses how the massive August 2003 blackout in the Northeastern US is believed to have been due to Chinese hackers – despite the public explanation that it was caused by overgrown trees in Ohio hitting high voltage lines.

The article even delves into how Chinese hackers are infiltrating corporate computer systems to steal company technology and business secrets, plans and strategies. For example, it includes a security expert’s story about one company’s experience of entering into face-to-face business discussions in China where “the Chinese based their starting points for negotiations on the Americans’ end points.” As Joel Brenner, the US government’s chief counterintelligence officer is quoted in the article, “If you travel abroad and are the director of research or the chief executive of a large company, you’re a target.”

Security of Online Health Records
Two potential weaknesses of utility and corporate computer systems may be because their systems are from third party vendors or were built with older architecture designed before on-line security was a concern. Because the computer systems for electronic health records and information exchanges are being built by the companies who are using them or have ongoing contracts for maintaining them – and are probably being built with newer software architectures – perhaps they are better protected.

The other reason why online health records may be more secure than utility or corporate systems is that hackers probably don’t have the financial or geopolitical incentives to break into medical record depositories. However, I can imagine situations or incentives for groups (aside from pure nihilism) that could change that – butI don’t want to speculate here and give anybody any ideas.

But if one of the great potential values of electronic medical records is having them joined together into Health Information Exchanges, and hackers are apparently able to infiltrate and wreak havoc in sophisticated computer networks, then I hope those developing EMR and HIE systems are really paying attention to security issues. If patients have concerns that their personal information is hackable, this could lead to a tremendous backlash against the use of a technology that should be very valuable for improving the quality of care and reducing the long-term growth in healthcare costs.

The Medicare Payment Advisory Commission released its annual report to Congress on Friday. In chapter 2 of its report, MedPAC makes two significant proposals for improving the financial incentives for primary care providers.

Great Incentives for Primary Care Practitioners Not Just Primary Care Services
First, it recommends changing Medicare’s reimbursement system for “evaluation and management” (E&M) services. While last year Medicare increased payments for E&M services, they couldn’t differentiate between types of physicians providing these E&M services, i.e. the Medicare system doesn’t distinguish between a family physician and a cardiologist if they are providing the same type and level of intensity of service.

Therefore, MedPAC recommends that a subset of primary care related E&M services, (e.g. office visits, home visits, long-term care patient visits), provided by clinicians who meet a minimum percentage threshold of a clinician’s total Medicare billing, (and thus would be identified as being “primary-care-focused practitioners”), should receive higher Medicare payments. (MedPAC choose to identify primary care clinicians based upon a percentage of primary care services - rather than specialty designation - because it would be administratively simpler and ensure that the incentives would be directed towards clinicians actually providing primary care services.)

The specific recommendation from the MedPAC report is:

The Congress should establish a budget-neutral payment adjustment for primary care services billed under the physician fee schedule and furnished by primary-care-focused practitioners. Primary-care-focused practitioners are those whose specialty designation is defined as primary care and/or those whose pattern of claims meets a minimum threshold of furnishing primary care services. The Secretary would use rulemaking to establish criteria for determining a primary-care-focused practitioner.

This is a sea-changing proposal in that it seeks to differentiate how Medicare Part B reimburses primary care providers versus subspecialists – and thus makes Medicare Part B payments more granular than was done when the RBRVS system was first installed in the early 1990s. (Back then, the fight was between so-called cognitive and procedural services.) This refinement will enable Medicare in the future to use its payment system as a more managerial tool for shaping the healthcare delivery system to increase the supply and access of primary care practitioners. The need for such changes is evident by the shrinking number of medical school graduates going into primary care:

However, because the proposal is intended to be budget-neutral it explicitly pits the financial interests of primary care practitioners against subspecialists, which means that the subspecialists will not eagerly welcome these changes to Medicare since they would be getting a smaller piece of a same-sized pie. (Note – MedPAC’s analysis shows that using the a cut-off of 65% of primary care services for clinicians to receive a 10% increase in payments for these services, would increase reimbursements for these services by a total of 6.2%, and would require a reduction for all other services of 0.9% to achieve budget neutrality.)

Build a Medical Home
MedPAC’s second proposal to promote more primary care is to increase the number of Medicare beneficiaries with medical homes.

Medical homes are the latest name for initiatives to give patients a single clinical practice or practitioner to ensure that their care is coordinated with the goal of improving the quality of care, and controlling costs by avoiding unnecessary complications and unnecessary testing. Medical homes are particularly important for people with chronic conditions for ensuring appropriate compliance with recommended treatments, disease monitoring and preventive testing. As the MedPAC report states, “Unlike the current fee-for-service (FFS) payment system, which emphasizes treatment for acute conditions and face-to-face care, medical home programs encourage practitioners to coordinate their patients’ care between visits and among providers. In improving care continuity and coordination, medical homes can enhance the role of primary care practice … [and] … increase our health system’s quality and efficiency.”

Medical homes are not new concept, as care coordination has been discussed since the original concept for HMOs several decades ago. Recently they have been promoted by primary care associations, and Medicare will start a medical home demonstration project in January 2009. MedPAC’s proposal builds off of the planned pilot, and would provide additional monthly payments to medical home practices providing the care coordination services. (Signing up with a medical home would be voluntary for Medicare beneficiaries and they would not have to pay any additional co-payments or premiums.)

MedPAC’s specific medical home proposal, which goes beyond the planned pilot project, is:

The Congress should initiate a medical home pilot project in Medicare. Eligible medical homes must meet stringent criteria, including at least the following capabilities:

• furnish primary care (including coordinating appropriate preventive, maintenance, and acute health services) [and medication management]
• conduct care management
• use health information technology for active clinical decision support
• have a formal quality improvement program
• maintain 24-hour patient communication and rapid access
• keep up-to-date records of beneficiaries’ advance directives, and
• ‘maintain a written understanding with each beneficiary designating the provider as a medical home.

Medicare should provide medical homes with timely data on patient utilization. The pilot should require a physician pay-for-performance program. The pilot must have clear and explicit thresholds for determining whether it can be expanded into the full Medicare program or should be discontinued.

MedPAC recommends an enhanced pilot project - rather than a national initiative -because there are administrative and technical factors that still need to be worked out, including, how to structure monthly payments to medical homes, and how to provide medical homes information about services provided to their patients by other providers so they can do care coordinating. The good news proposals for specialist physicians in MedPAC’s is that the pilot is not being proposed as budget neutral, but would cost between $250-750 million over 5 years.

Conclusions
Most experts think these proposals will be effective in improving the healthcare delivery system in the US, and I agree – provided that they are structured and implemented so they actually change the actions of physicians and patients. To be successful they need to change physicians’ practice patterns to focus more on primary care and care coordination, and to change patients’ behaviors so they use their primary care clinicians for more of this care management. In addition, as is reflected in the charts above, these proposals face the logistical challenge of finding enough primary care clinicians to provide these services. These changes will take time - it takes years to alter patient-physician relationships, shift how physicians practice or increase the supply of primary care clinicians – but this is not a reason for further procrastination.

p.s. I’m writing this from the road, so my editing and grammar may be somewhat deficient – my apologies.

A long-standing debate in the life sciences has been the role of nature versus nurture in determining individual characteristics. For example, how much of an individual’s height is determined by their genes and how much by their nutrition – both in childhood and prenatally?

In the last few decades advances in our understanding of genetics has shifted this dichotomy to describe it in terms of genetics versus environmental factors, and expanded our appreciation for the role nature/genetics play in causing all manner of human diseases. For example, it was discovered that genetically determined slow serotonin transporters in the brain can predispose individuals to developing depression. However, the more we learn about genetics, similarly exciting discoveries are being made into how environmental factors influence the activity of genes, and thus affect an individual’s health.

Thus - like many things with multifactorial causes - the pendulum swings one way and then the other, i.e. between nature/genetics and nurture/environment.

But what has also become clear is that genetics and environmental influences are not  separable - they interact in important ways, and both can cause health problems and be routes to solutions too.

What recently caught my eye in the nature versus nurture debate were two studies about smoking cessation that came out in the last couple of weeks. The first, by Nicholas Christakis published in the New England Journal of Medicine (and reported in the May 22nd New York Times) describes the importance of social factors for people trying to quit smoking. This study demonstrates how an individual’s social environment plays a dramatic role in their ability to stop smoking, and how people can help each other stop smoking as a collective activity.

On the nature side of the equation, NIH researcher George Uhl led a study that shows how genetic markers can predict which of two smoking cessation treatments will be more likely to work for an individual. From these two studies it is also possible to postulate that individuals may have genetic predispositions that effect the ability of social networks to help them to stop smoking – or possibly to start smoking in the first place. (Didn’t we call this peer-pressure in junior high?)

I find both these studies very interesting because for years smoking has often been described in terms of individual choice (or weakness), and as such something that is completely separate from genetic or environmental factors. These studies refute that popular myth, and more generally illustrate the fundamental point that most illnesses and healthcare problems are complex, and that the solutions to these problems need to be similarly sophisticated. This also reminds me why I cringe a bit when someone says to fix a healthcare problem, “all we need to do is…….”

What are your favorite examples of interacting genetic and environmental factors, or where simple solutions have gone awry when used for complex problems?

Memorial Day weekend is the traditional start of summer. This weekend also brought me in touch with some other markers of time, including:

• A great celebration of life event for the passing of a friend’s father – a terrific gentle bear of a man who had faded away in recent years after more than four score years
• A double birthday party for the children of some friends – a 9 year old and a first birthday
• Senator Kennedy’s long tenure and track-record of accomplishments – which were chronicled in many news reports following his being diagnosed with a brain tumor

I was also reminded of the importance of planning over time by a recent op-ed that mentioned a national organization’s call for increasing medical school enrollment in order to avoid a future shortage of physicians. Since the time from the start of medical school to the end of clinical training is generally 7-10 years, this pipeline is similar to the process for developing drugs. Each require many years for the development process as well as for increasing output capacity – which are both limited by money and other resources (trained people, physical structures and equipment).

However, because increasing this output capacity takes time, it is important to invest in them before the need is there. Senator Kennedy has understood that for decades, as has been evident by his long support for biomedical research funding. We can only hope that it will provide substantial benefits to him in his latest fight. And if not, then the hope is that these investments will benefit the generation of the birthday celebrants from last weekend. I believe this will happen since decades ago cancer was seen as a dreaded diagnosis, but now for many patients, it is curable or manageable – just ask, John Lester, the Red Sox pitcher who went from cancer patient to pitching a no-hitter in less than 2 years. And the hope for the future is that if the family or friends of today’s nine year olds have to face cancer in several decades, they will be able to use one of their favorite words of today - “boring.” (“School is boring.” “The beach is boring.” “That’s boring.” “This is boring.”)

The promise of today’s research into cancer and other diseases is that over time, treatments will become boring. Boring is the best type of medical problem to have, because it indicates that it’s treatment is so routine, easy and palatable that both the physician and the patient have no anxiety about it.

Past research and development weren’t enough for my friend’s father – who had a terrific life and shared Senator Kennedy’s passion for sailing. Time will tell if the last few decades of research were enough to make Senator Kennedy’s treatment boring. As summertime comes and goes this year and next, here’s hoping that more and more of the medical problems we and our families see are boring. I think it is fitting that as Memorial Day 2008 passes, we recognize these events and promises of the future, and remember what has been, but also what can possibly be.

While watching the Red Sox-Milwaukee baseball game on TV last Saturday, the announcers were discussing Julio Lugo, the Red Sox shortstop who had missed 5 games with a concussion. One of them noted that the team had done baseline neuroimaging testing on all the players so if they had a concussion during the season they would have a baseline to compare to their post-concussion tests. I assume that they also did non-imaging neurological testing, such as reflexes and memory, etc., and this was an extension of all the other evaluations the players went through.

The reason I found this interesting is that it highlights the importance of having an understanding of both a patient’s baseline and their goals. For example, the ability of someone to play the piano after a hand injury is healed depends upon whether or not they could play the piano before the injury. (Sorry – that’s from a very old joke.)

Obviously after a professional baseball player has a concussion, the important factors include reflexes and visual focus since hitting a 90+mph fastball and catching a rocketed ground ball requires precise physical abilities. But for the rest of us - and overall healthcare quality - baseline functioning and goals are important because they are different for every patient, and should be a crucial component of the conversation between a patient and their clinical team. Only when the clinician understands what the patient’s abilities were before the illness or injury, can they work with the patient to develop a treatment plan that they hope will get the patient to their goals.

This may all sound silly or simplistic, but too often I have heard stories about patients who complain that their physician has given them the treatment plan without considering their desires or perspectives - as in “this is what where going to do.” Unfortunately, physicians sometimes only see one reasonable treatment course. But patients are as different as baseball parks – and I mean globally from sandlots to Yankee stadium – and their perspectives, concerns and treatment goals really are just as diverse.

I’m ready for blasts from physicians and others on this one, so let me know what you think.

At a policy related forum for medical residents at the Massachusetts General Hospital last week, one of the questions was about end of life care. The other panelists and I answered from a clinical perspective - and I also put a plug in for the Kenneth B. Schwartz Center which does educational programs for clinicians about strengthening patient-caregiver relationships and communications.

However, during the informal discussion after the panel, a number of the residents raised questions about how much of our healthcare spending goes for treating people at the end of life. In talking with them about this, I recalled three things having looked at this issue several years ago: First, there is a lot of public misunderstanding and misrepresentation of information about this topic. For example, percentages of Medicare spending turning into percentage of total healthcare dollars, or spending in the last year of life being reported as spending in the last month of life. Second, the percentage of healthcare spending in the last 6 months of life has not changed in decades. And third, people agree that if a patient’s life expectancy was clear, then it would be easy to reduce spending at the end of life. This last point was one of the reasons for hospice care, which attempts to both improve clinical care and reduce costs. Hospice has been a big clinical success since - unlike hospitals and general home care services - it is designed to fit the needs of the patient and their family.

So what about costs at the end of life? I did a quick (and admittedly non-comprehensive) search for more information, and found that:

• As of the late 1990s, care in the last year of life consumed about 27% of Medicare’s spending and this percentage hadn’t changed in 20 years. These costs represent 10-12% of total healthcare costs, and 30-40% of this spending occur in the last month of life.
• There is great variability of costs incurred during the last 6 months of life across the country – with up to a 250% difference. But this might also reflect the overall variability in healthcare costs by location.
• A 2007 study found that hospice use reduced Medicare’s costs in the last year of life by 23%, but a 2004 study found that savings from hospice were only with younger patients with cancer, and that overall, hospice enrollment cost Medicare more money.
• A great 2002 article reviews the literature and the issues about end of life care – including how Medicare financial incentives may contribute to more intensive care and higher costs.

So what are my conclusions? Any focus on reducing spending on end of life care as the solution for our rising health care costs is misplaced. These costs are significant, but they are only part of the problem since their growth reflects the overall rise in healthcare spending. And Buntin and Huskamp’s conclusion in their 2002 article, that we have “critical gaps in our knowledge about how to design a better end-of-life care system for Medicare beneficiaries,” is right on target.

What are your thoughts about end of life care, hospices, and educational organizations for clinicians like the Schwartz Center?