Historical Perspective on Health Reform – Part 1, Medical Effectiveness

November 16, 2009 / Michael D. Miller MD / Comparative Effectiveness, Delivery of Healthcare, Public Health / 1 Comment

Since the time-line for health reform legislation has continued to be stretched, I recently spent some time cleaning out old files. In my excavations I came across papers, articles, memos and briefing books which demonstrate that no matter how much things change, some aspects of health reform have stayed the same. For example, below are a couple of snippets from memos about a proposed Medical Effectiveness Initiative from circa 1989:

Establishing a Medical Effectiveness Initiative at the OASH [Office of the Assistant Secretary of Health] level. (FY90 request = $52 million) This initiative would assess which medical treatments are cost-effective, and identify inappropriate and unnecessary medical practices.

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Advancements in Understanding Head Trauma and Preventing Long-Term Problems

January 28, 2009 / Michael D. Miller MD / Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war. Over the past year I’ve been talking with friends and colleagues about another connection between war and football – how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation. While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.…

Health Reform – Achieving Universal Coverage

January 5, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform, Medicaid, Public Health / 5 Comments

During the holidays the Obama Health Transition Team urged people to organize discussions about health care in their homes and communities – and then to report back. Reading about these discussions – including the one that Secretary Designee Tom Daschle attended in Indiana – made me think about what things are going to be needed to make health reform actually work.

My end-of-year reflections and ruminations led me to conclude that one of the most challenging parts of health reform will be to actually get more people enrolled in whatever expanded coverage plans are developed and implemented. Enrollment barriers are not new, but they are frequently not highlighted because they may present great political and fiscal risks.…

Transparency in Non-Profit Organizations

December 22, 2008 / Michael D. Miller MD / Delivery of Healthcare, Public Health / 1 Comment

The ongoing series of financial failures and scandals have made me more interested in financial transparency for non-profit organizations – which economic theory states are really supported by everyone because their donations are tax deductible which reduces total tax revenues. My thinking about the finances of non-profits has also been piqued because of an accounting class I’ve been taking, as well as by my last post about transparency in health reform legislation.

One recent example of non-profit organizations increasing their transparency is colleges and universities issuing press releases and sending letters to alumni about how the economic downturn has effected their endowment, and what steps they are taking to be more fiscally conservative – such as freezing hiring or delaying construction projects.…

Health Reform – How Much Expansion?

December 12, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Public Health / 1 Comment

Morton Kondracke, a columnist for Roll Call newspaper, (sorry on-line subscription required to read the full article), had a very interesting and insightful piece yesterday where he outlines some of the reasons that health reform in 2009 will be more expansive than in might have been a few years ago.

He makes two very concrete and connected observations. First, that the economic downturn will increase the number of people without health insurance by 5-6 million, and probably add a similar number to the rolls for Medicaid and SCHIP – which will add to States’ budgetary problems. And second, that the costs of health reform are likely to be much greater than expected – assuming of course that there isn’t a dramatic economic rebound. …

Making Physicians Better, and Making Better Physicians

December 10, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety / 5 Comments

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions. The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

Ask permission to enter the room; wait for an answer
Introduce yourself; show your ID badge
Shake hands
Sit down.

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Napping to Increase Productivity

December 7, 2008 / Michael D. Miller MD / Innovation, Miscellaneous, Public Health, Quality of Care & Safety / 1 Comment

The New York Times had a great short report about a scientific study comparing a short nap to caffeine for improving a person’s memory. The study found what many people have suspected for years – a nap is better than caffeine.

The benefits of napping are something that proponents of “power napping” have known for years. (Disclaimer: I’ve used the 20 minute power nap for years to re-energize and turn an afternoon impaired by a severe case of “the weakies” into several very productive hours.)

The study specifically found that naps were better for improving recall of a word list after both 20 minutes and 7 hours. …

Engage With Grace

November 26, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

Many bloggers are posting information today about a initiative to encourage conversation about a very difficult topic: How we want to die. This collective effort to prompt discussions about this topic at the beginning of the holiday season is very timely, and it is a good complement to my post last week about empathy and compassion in healthcare.

What follows is essentially the same text that appears on many other blogs along with a picture of the “One Slide” listing the 5 conversation promoting questions that are at the core of the Project:

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Engage with Grace: The One Slide Project is an astonishingly simple idea that literally touches everyone.…

Value of Employer Provided Health Benefits

September 18, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Health System Reform, Politics, Private-Employer Based Health Insurance, Public Health / 4 Comments

I recently heard Michael Critelli, Executive Chairman of Pitney Bowes Inc., talk about what the company has learned about the value of providing quality health benefits and services to their employees.

Because they have a workforce that is divided between their offices and customers facilities, Pitney Bowes has been able to conduct a natural experiment and see how providing access to different health and wellness services can effect their employees and the company’s costs. What they found was that providing a good quality health benefits package in conjunction with healthy food and exercise options, etc., has reduced health care costs for their employees that work in their own offices compared to employees who work off-site.…

Incentives for Everything But Primary Care

September 10, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Innovation, Medicare, Politics, Public Health / No Comments

Two interesting and related items recently dropped into my inbox concerning the future availability of primary care clinicians. As most people are aware, primary care services are becoming increasingly scarce – and has been seen here in Massachusetts expanding insurance coverage may only increase this strain. In addition, there is some good evidence that a major reason for our higher health care spending is having too many specialists and not enough primary care clinicians. So increasing the number of primary care clinicians might be part of the solution to controlling health care spending.

Incentives to Become a Specialist
The first article in my inbox was a Washington Post story stating that only 2% of graduating medical students were contemplating going into primary care. …

Digesting Medical Progress

September 1, 2008 / Michael D. Miller MD / Health System Reform, Information & Communications, Innovation, Miscellaneous, Nutrition, Public Health, Therapeutic Substitution & Interchange / No Comments

One of the challenges for improving the healthcare system is creating a vision for what is achievable in a timeframe of months or years. The first step for creating such a realistic vision is to understand how progress has been made in the past.

A microcosm of such progress was described in a recent article in The Economist. This article describes advances in our understanding of stomach ailments – one of my favorite areas of biomedical progress because in the last several decades dramatic changes have occurred in our basic knowledge about this area, and so many people can relate to stomach problems.…

Colon Cancer Insights – Vitamin D and Cannabis – “Good and Good for You”

August 7, 2008 / Michael D. Miller MD / Delivery of Healthcare, Innovation, Nutrition, Public Health / No Comments

A couple of recent reports provide new insights into preventing and treating colon cancer. These studies remind me of the scene in Woody Allen’s movie Sleeper, where he wakes up in the future to find out that all the things he thought were bad for you are really healthy.

The first study was in the Journal of Clinical Oncology which found that people who had higher levels of circulating Vitamin D and later developed colon cancer had a better survival rate than people with lower Vitamin D levels. An accompanying editorial points out that this could be because people who exercise more are outside for longer periods of time – which gives them more sun exposure leading to higher Vitamin D levels – and that more exercise itself might provide a better survival rate. …

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