HEALTHPLANUSA.net QUARTERLY NEWSLETTER
Community For Affordable Health Care Vol IV, No 3, October, 2005
Utilizing the $1.4 Trillion Information Technology Industry
To Transform the $1.7 Trillion HealthCare Industry into Affordable HealthCare
In This Issue:
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1. Featured Article: Heed the New Health-Care Crisis by Robert Goldberg,
There will be
time enough — at the right time — to re-evaluate the nation's preparedness for
natural disasters. But today,
The public and private health system in
Many in Congress are using this public
health crisis to seek huge — and permanent — expansion of existing federal
health programs to oppose fundamental reforms of Medicaid. We must avoid the
nationalization of the health-care system that followed in
All survivors will be eligible for Medicaid or state-run children's health plans and can sign up in a matter of minutes through computerized or online registration. Federal and state governments have issued vouchers to patients to pay for prescription drugs and other survivors in the interim. The Public Health Service is using online technology and links to major health sites such as WebMD and Medscape to recruit and deploy thousands of physicians, surgeons, and psychologists at a per-diem basis who will be deployed as local need requires.
Many managed care plans have waived all sorts of restrictions: Wellpoint Health Care will cover any doctor or hospital — without restrictions — willing to provide care. Even as Congress considers trying to save Medicaid money by charging the poor a co-pay for their drugs, Wellpoint is eliminating them to insure that people actually get the medicines they need. . . .
Sustaining medical assistance in the wake of Katrina will require more money, but funds should not be used to simply expand existing entitlements. The goal should be to allow people to carry medical information and health insurance wherever they settle. The Department of Health and Human Services can accelerate the effort to establish wireless and Web-based communication systems in conjunction with electronic patient records. It should make its new EPR software available and create a public-private health information technology (IT) "strike force" to obtain, install and operate the systems. It should allocate demonstration grants for health IT to the Katrina relief effort. This would supplement the nearly 3000 Red Cross IT volunteers spread out throughout the South. . . .
Long after the headlines fade,
Robert Goldberg is director of the Manhattan Institute's Center for Medical Progress.
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How can health care professionals ensure that the quality of their service matches their knowledge and aspirations? As a number of hospitals and clinics have discovered, learning how to improve the work you do while you actually do it can deliver extraordinary savings in lives and dollars.
Steven J. Spear reports: Last year on Christmas day, a 32-year-old Belgian woman celebrated the birth of a healthy daughter. Nothing remarkable about that, you might say, except that seven years prior, this same woman had been diagnosed with Hodgkin’s lymphoma. Because doctors feared that chemotherapy would leave her infertile, they surgically removed, froze, and stored her ovaries. Once her treatment was concluded, with her cancer sufficiently in remission, they thawed the tissue and returned it to her abdomen, after which she was able to conceive and deliver.
miracles—improvements in fertility treatment, cancer cures, cardiac care, and
AIDS management among them—are becoming so commonplace that we take them for
granted. Yet, in the
How can this be
in the country that leads the world in medical science? It’s not that
caregivers don’t care. Quite the contrary: Health care professionals are
typically intelligent, well-trained people who have chosen careers expressly to
cure and comfort. For that reason, perhaps, many policy makers and management
scholars believe that the problems with American health care are rooted in
regulatory and market failures. They argue that institutions and processes
mandated by law and custom are preventing demand for health care from matching
efficiently to those most capable of providing it. In this view, the best
treatment for what ails the
I won’t dispute the benefits of these reforms. The efficiency of health care markets may indeed be gravely compromised by poor regulation, and economic incentives should reinforce health care providers’ commitment to their patients. But I fear that the exclusive pursuit of market-based solutions will cause professionals and policy makers to ignore huge opportunities for improving health care’s quality, increasing its availability, and reducing its cost. What I’m talking about here are opportunities that will not require any legislation or market reconfiguration, that will need little or no capital investment in most cases, and—perhaps most important—that can be started today and realized in the near term by the nurses, doctors, administrators, and technicians who are already at work.
The scale of the
potential opportunities can be seen in the results of a number of projects I’ve
been following over the past five years at various hospitals and clinics in
Other hospitals have dramatically lowered the incidence of infections arising from surgery and of pneumonia associated with ventilators. Still others have improved primary care, nursing care, medication administration, and a host of other clinical and nonclinical processes. All of these improvements have a direct impact on the safety, quality, efficiency, reliability, and timeliness of health care. Were the methods these organizations employ used more broadly, the results would be extraordinary. In fact, you could read an entire issue of HBR, even several, and during that time the number of fatalities would be close to zero. (See the exhibit “The Health Care Opportunity.”)
Steven J. Spear (firstname.lastname@example.org)
is a senior fellow at the Institute for Healthcare Improvement in
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Policy Digest, Health Issues: Counterfeit Drugs Threaten
Due to insufficient
cross-border cooperation, counterfeit Viagra, antibiotics and other drugs in
Counterfeit medicines often are packaged like the genuine product and are hard to detect. Lifestyle drugs and essential medicines are particularly popular with counterfeiters, but there's an increase in the field of contact lenses and materials like surgical mesh.
Since there is
no recognized central reference point in
* Counterfeit medicines make up approximately 10 percent of the European pharmaceutical market -- up from zero 10 years ago -- and often are supplied by international criminal rings.
* Experts warn that purchasing health products over the Internet poses a major health risk since many of those drugs have not been approved by a competent health authority.
* A study by the U.S. General Accounting
Office in 2004 found that four out of 21 medicines ordered from Web sites
officers, doctors and pharmaceutical experts from
Associated Press, "Counterfeit Drugs Deemed Threat in
For text: www.foxnews.com/story/0,2933,170150,00.html.
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Panel studies retainer care, practice trends by Joel B
Finkelstein, AMNews staff,
What will it take to get physicians excited about practicing medicine again? That was the question Sen Robert F Bennett (R, Utah) asked a panel of physicians testifying recently before the Joint Economic Committee. Their answer: Opting out of the mainstream, health insurance-oriented system of reimbursement.
Like these physician panelists, a seemingly growing number of physicians are eschewing insurers and Medicare in favor of cash payments and retainer practices, also called boutique practices.
The American Medical Associations’ Council on Ethical and Judicial Affairs last year determined that the trend is not necessarily a bad thing.
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5. Lean HealthCare: Massachusetts General Looks to Lean
Massachusetts General Hospital (MGH) opened the
Proton Therapy Center (NPTC) emerged from pioneering work at the Harvard
“Proton therapy is a highly sophisticated component of radiation oncology,” describes Kathy Bruce, technical director for radiation oncology at MGH. “It uses a particle beam comprised of protons that are accelerated to a rapid pace, and once they hit tissue they have some special physical properties that are very beneficial in terms of radiation dosage to the area we want to treat vs. the area we want to protect. In many cases, tumors are adjacent to critical structures where the sensitivity of those structures limits the amount of dose we can give through conventional [radiation] means. But because of the physical property of the protons, we can do it differently and protect those structures.”
From the time NPTC opened its doors it sought to expand patient mix and volume, but while enhancements occurred, there continued to be pent-up demand for proton treatment. Last year 25 to 30 patients were treated per day, while the initial target for the center was 40 to 50 patients per day. “We had to look at the way were doing things to see how we could speed up the process without compromising the quality,” says Bruce.
While more patients with access to the proton beam can mean more opportunities to save lives, it’s not simply a matter of increasing throughput. Proton therapy is a complicated amalgam of medicine, physics, engineering, and compassion and involves treatment processes that few people will ever encounter and an incredible array of professions, processes, steps, and handoffs. Dr. Jean Elrick, MGH senior vice president of administration, says there are more people and disciplines involved in the proton center’s therapeutic identification, planning, and implementation processes than in any other facet of care at MGH. The process includes engineers, physicists, nurses, therapists, doctors, residents and fellows on teaching missions, anesthesiologists for children, and a machine shop — all in a new facility working with new technology. “And that’s just the clinical part, let alone all of the surrounding pieces of support that go into that clinical process, which makes it all the better place for lean because of how quickly on a relative basis that very complex, multiperson, multifactorial process could be so clearly laid out.”
The Proton Therapy Process
NPTC’s 230 MeV proton beam originates at a cyclotron, a machine that accelerates particles to their multimillion electron-volt energy level. The beam is steered with huge magnets through concrete tunnels the length of a football field into one of three patient-treating areas — two gantries and one stationary treatment area. The beam peels off the main line and serves one treatment area at a time.
The gantries are massive 110-ton spherical structures that slowly rotate to any 360-degree angle within one millimeter of accuracy around a stationery patient. Patients, fitted with specially designed masks and molds, are positioned to within one-half centimeter of their calculated treatment position. The proton beam is targeted from any angle into three dimensions to match the shape of a patient’s tumor. Apertures and compensators are incorporated between the beam and patient, which direct and constrain the protons to the desired 3D areas; one patient may require multiple devices.
The beam-on time for a patient typically is between one minute and two minutes per field (the targeting of the beam from a given direction), and a patient may require from one to seven fields during their treatment session, says Susan Michaud, RTT, assistant chief radiation therapist of radiation oncology and supervisor at NPTC. Some complicated pediatric cases take more than one hour to set up and treat. . . .
The Lean Approach
Patient time under the proton beam is minutes, and offers no opportunity for time-savings. But the preparation time prior to patients receiving their therapy, the intake process to identify and schedule proton patients, and the treatment planning process were ripe for improvement and could lead to greater patient volumes.
NPTC’s need to increase capacity also coincided with a multipronged strategic plan at MGH, instituted under president Peter Slavin, which focused on process improvements and cost-savings hospitalwide. Dr. Elrick, the chair for the process-improvement strategic planning committee, had reviewed various improvement approaches, including lean, and attended a presentation by the Lean Enterprise Institute (LEI). She selected the proton center as a lean pilot project and “volunteered” Nancy Corbett, senior administrative director for the radiation oncology department to set lean in motion; Carey Palmquist, administrative director of practice operations, and Kathy Bruce supported Corbett.
Helen Zak, COO of LEI, and Guy Parsons, an LEI faculty member, reviewed the NPTC operations and its capacity challenges. They presented an approach of how lean principles could jumpstart improvements in the center via three days of workshops that involved a scoping session with leadership and value-stream mapping and action-plan sessions by a lean team. The leadership of the NPTC (Dr. Thomas DeLaney, medical director; Dr. Hanne Kooy, associate director and manager of radiation physics at the NPTC; and Dr. Jacob Flanz, technical director of the center) bought into the lean plan, says Corbett, once they were convinced that lean could “subtract” things that got in their way of providing the best possible care for patients.
Parsons was able to impress upon Dr. Elrick and NPTC staff the means to improve processes without touching and tampering with the caregiving component. He assured them that the initiative would “not talk about appropriateness of care. We don’t know about it. It’s everything else.” Everything else in lean terminology was the “waste” in the processes, the issues and obstacles that frustrated NPTC staff and prevented them from administering therapy in the most efficient and highest-quality manner.
The LEI approach, adds Dr. Elrick, also was dissimilar from the armies of well-dressed consultants who conduct interviews, distribute reports, offer copious recommendations, and link efforts to information technologies or long-term engagements. “I’ve been doing change management for 12 years; it has to come from within. This has to be us, not you. . . . ”
The lean initiative kicked off in September 2004 with the scoping session during which NPTC leadership identified what could and should be goals for the effort and who should be involved in the subsequent two days of value-stream mapping and action planning. “We didn’t pick people that would be immediately agreeable,” says Bruce. “We picked people who would be key to the success going forward, who we knew would be difficult to persuade, who really owned it. Every discipline was represented.”
“It was not optional to come for part of the day if you were on the proton center team,” adds Corbett. “It was two days, beepers off, no answering pages. Participants, including physicians, had to have someone cover them for the full two-day commitment.”
For two days, a 15-member team of physicians and clinical and non-clinical staff drew a current-state map of the process, developed future-state maps, and set action steps and responsibilities that would move NPTC from the current state into the future.
Lean in Healthcare: To learn more about lean work promoted throughout the healthcare industry by the Lean Enterprise Institute, contact The Lean Enterprise Institute (LEI) Chief Operating Officer Helen Zak at 617-713-2900 or emailing email@example.com. The Lean Enterprise Institute, Brookline, MA, is a nonprofit research, training, and publishing company organization founded in 1997 to promote the principles of “lean thinking” in every aspect of business and across a wide range of manufacturing and service industries.
www.lean.org - Lean Enterprise Institute,
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has brought to the fore the strengths and weaknesses of
Why the discrepancy? Entrepreneurs and private charities often respond much faster than government because they are more agile and flexible. Just as important, they avoid wasting valuable resources, allowing help to go where it's needed the most.
considerable advantages emerge from the fact that government must follow
cumbersome rules, and that individuals are more careful with their own
resources than with other people's. There is a lesson here for
In many sectors of the economy, market competition consistently improves quality while reducing costs. Health care is an exception, but not because competition cannot work. In fact, the recent rise in cash-paying patients traveling abroad for medical care shows that market competition makes even urgent, high-cost acute care more affordable.
Rather, health care is an exception because market competition is not allowed to work. Market competition requires three key elements: (1) a large pool of actual and potential producers with new ideas; (2) consumers who are free to choose different products; and (3) consumers who weigh the costs and benefits of those products. At every turn, government tax, spending, and regulatory policies thwart these necessary conditions of a free market.
To mention just
one example, heavy government subsidies (through programs such as Medicare and
Medicaid) and tax penalties (for workers who do not let an employer purchase
their health care) discourage patients from weighing costs against benefits. As
a result, Americans pay for more of their medical care through third parties
(86 percent) than patients in 17 other advanced countries, including
Time and again, free markets have proven an effective framework for making products of ever-increasing quality available to an ever-increasing number of consumers. To make high-quality care available to more Americans, we need reform that will allow markets to work in health care. That should include:
* More flexible health savings accounts.
Though promising, this new health insurance option is too restrictive. Congress should create large HSAs that are more flexible and give workers ownership of all their health care dollars and decisions.
* Injecting choice, competition, and ownership into Medicare.
This federal program for the elderly engenders enormous waste and will soon impose a crushing tax burden unless we act soon. Congress should give seniors greater choice of health plans, and allow workers to save their Medicare taxes in personal accounts for their health care needs in retirement.
* Reforming Medicaid as Congress reformed welfare.
This federal-state program for the poor creates the same harmful incentives as the welfare system Congress reformed in 1996. Those reforms should be applied to Medicaid.
* Health insurance deregulation.
Costly state regulations make health insurance too expensive for many, and each state prohibits the purchase of coverage licensed in other states. Congress should tear down those barriers.
* Provider deregulation.
Regulation of medical professionals (e.g., licensing, scope-of-practice, and telemedicine laws) and facilities (e.g., certificate-of-need laws) restrict the availability of medical care, particularly for the poor. Those laws should be relaxed. . . . To read the original article, please go to www.cato.org/pub_display.php?pub_id=5070.
Michael F. Cannon is director of health policy studies at the Cato Institute, and co-author of Healthy Competition: What's Holding Back Health Care and How to Free It from which this article is adapted.
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Last month, David
Prentice, PhD, Sr Fellow in Life Sciences, Family Research Council, at
"There is a lot of misinformation out there," he began. "There is something fascinating about science. One gets such wholesale returns of conjecture by people thinking embryonic stem cells can be directed into any type of tissue or organ. Many think it would be about like going to a parts department and asking for a new femur for a 57-year-old patient with aseptic necrosis of the femoral head. True, ESCs are totipotent– they can grow into any type of tissue including tumors and cancers. But they are difficult to direct. The number of volunteer donors may be enormous. For instance, to treat 17 million diabetics with ESC would require 170 million human eggs."
Dr Prentice cited a number of examples of adult stem cells, from the umbilical core or nasal stem cells, that are already being used to treat spinal cord injuries, Parkinson's, myocardial damage from infarction and pulmonary injuries. He went on to explain how adult stem cells circulate between various organs for repair and maintenance of tissues. Adult Stem Cells, like Embryonic Stem Cells, progress to Progenitor Cells that differentiate into cells that heal injured tissue.
Adult Stem Cells are the most promising source for treatment, according to Dr Prentice. "They are able to generate virtually all adult tissues. They can multiply almost indefinitely, providing numbers sufficient for clinical treatments. They have proven success in laboratory tissue culture. They have proven success in animal models of disease. They have proven success in current clinical treatments. They are able to “home in” on damaged tissue. They avoid problems with tumor formation. They avoid problems with transplant rejections. They also avoid the current ethical quandary."
As to the question of why we are hearing all this emphasis on Embryonic Stem Cells, Dr Prentice replied: Since there is not much in the way of better treatment, and the risks are greater, the big push for ESC research is primarily money, not human good. There may eventually be benefits, but the ground work can be done with Adult Stem Cells, and the few ESC lines already authorized with the human risks which should be more than adequate for all the basic work required for many years.
He concluded that it really appeared that the proponents of embryonic stem cell research and funding really want a class of human cloned embryos without rights that they can use for whatever experiments they want without human rights disclosure.
After our visit
to Capitol Hill in
For more information: DO NO HARM, The coalition of American Research Ethics can be found at www.stemcellresearch.org.
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Dr Thomas commenting on his visit to
Dr Richard: But poor quality in health care is government induced. American doctors have always had the highest standards of excellence with physicians logging more continuing medical educational credits on a yearly basis than any place else in the world. The federal government promoted managed care where bureaucrats, who are basically medical illiterates, tell physicians how to practice medicine by telling them they are spending too much time with patients. They allege that we should be able to see, examine, evaluate, and treat a patient in 10 or at most 15 minutes. Artificially limiting the exchange of health information between doctor and patient would obviously lead to missing many important details that would increase the errors in making the diagnosis.
Dr Harriet: By making doctors look bad, they are de-professionalizing the medical profession and making them look like school children that need remedial work, rather than focusing on the bureaucratic etiology. Quality will automatically increase as the government steps aside. After all, quality has always been our middle name. In an open Medical MarketPlace, patients will always choose the best doctors, nurses and hospitals and the worse doctors would have to improve their quality or they might be looking for other employment. In government or bureaucratic medicine, the worst doctors get paid the same as the best doctors and obviously the quality of care will gradually deteriorate to that given by the incompetent.
Dr Thomas: After my experience in
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Most would agree that people are less careful about what they purchase or how much it costs when spending someone else’s money.
For example, a decade-long health insurance experiment found that people given “free” medical care consumed 43 percent more care, yet saw little or no benefit in terms of health. In contrast, those who had money set aside for the first few thousand dollars of their medical expenses, bore the full consequences of their decisions. They demanded value in return for their money.
* Government encourages and even requires Americans to turn their health care dollars over to their employer or the government itself.
* That’s why roughly 86 percent of all
medical bills in
* As a result, patients quite reasonably act as though they are purchasing health care with someone else’s money.
In 2004, Congress took a first step toward establishing an ownership society by creating Health Savings Accounts, or HSAs. HSAs remove many of the incentives that encourage Americans to turn their health care dollars over to an employer. Here’s how they work:
HSAs promote an ownership society by fostering:
* Personal Responsibility: Because they own the money that purchases their routine medical care, HSA holders take the time to become more savvy consumers and take greater care of their own health.
* Freedom: HSAs re-establish the freedom to choose one’s doctor, to choose one’s health insurance, to own one’s health insurance policy, and to save for future medical needs. HSA funds follow workers from job to job and provide coverage in
between jobs. They can even empower workers to purchase health insurance policies that also stay with them through job changes.
* Competition: Individual ownership will make health care markets more competitive. Providers must work harder to win the dollars of consumers who face trade-offs between medical care and other items.
Click here to learn how Congress can further promote the Ownership Society through HSAs.
Most people would also agree that assets are safer when they are under the direct control of the person they are meant to benefit. Yet elderly Americans don’t have the protection of ownership when it comes to their health care. . . .
The tax burden of the Medicare program is growing. It may soon reach the point where workers refuse to pay the high taxes necessary to provide promised benefits.
Rising health care costs and a shrinking ratio of workers to beneficiaries are increasing the tax burden that Medicare places on every worker.
* According to Cato Institute economist Jagadeesh Gokhale, Congress would have to increase the Medicare payroll tax by 500 percent to finance future benefits. By 2008, an increase of 700 percent would be necessary.
* Before long, workers will resist such dramatic tax increases, which will jeopardize seniors’ access to medical care.
It doesn’t have to be that way.
Congress can increase the security of seniors’ access to medical care by giving seniors ownership of their Medicare benefits. Congress should permit workers to save a portion of their Medicare taxes in a Retirement Health Savings Account that will grow over their working lives and provide for their health care in retirement.
To read the entire article, go to http://www.cato.org/special/ownership_society/boaz.html
John and Alieta Eck, MDs, for their first-century
solution to twenty-first century needs. With 46 million people in this country uninsured,
we need an innovative solution apart from the place of employment and apart
from the government. To read the rest of the story, go to www.zhcenter.org. Stay tuned for
their next innovative move in designing the healthcare system for the entire
Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, no Medicaid, no HIPAA, just patient care. Dr Harris is also nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at www.northernurology.com/articles/healthcarereform/administrativectomy.html.
PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist states: "Our point-of-care payment clinic makes acute and chronic primary medical care affordable to the uninsured of our community by refusing to accept any insurance (along with the hassles and crushing overhead that inevitably come with it). Read the rest of the story at www.emergiclinic.com.
Dr Vern Cherewatenko has success in restoring private-based medical practice that has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the “Cash-Based Revolution.” The patient pays in full before leaving. Because doctor charges are anywhere from 25 – 50 percent inflated due to administrative costs caused by the health insurance industry, you’ll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.
Dr. Nimish Gosrani has set up a blend between concierge medicine and a cash-only practice. “Patients can pay $600 a year, plus $10 per visit, to see him as many times in a year as they want. He offers a financing plan through a financing company for those unable to plop down $600 all at once.” Patients may also see him on a simple fee-for-service basis, with fees ranging from $70 for a simple office visit to $300 for a comprehensive physical. Dr. Gosrani reports that he saves two hours per day that he used to spend dealing with insurance company paperwork. To read more, go to http://cgi.photobooks.com/scripts/troll.cgi?dbase=moses&page=2&setsize=10&practice=Nimish+C.+Gosrani%2C+MD&pict_id=2001670.
Dr. Elizabeth Vaughan is another
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Stay Tuned to the MedicalTuesday.Network and the HealthPlanUSA.Network and have your friends do the same.
Del Meyer, MD, CEO & Founder
Words of Wisdom
Government is the great fiction, through which everybody endeavors to live at the expense of everybody else. – Frederic Bastiat, French political economist, (1801-1850) Essays on Political Economy, 1846.
This Month in History
October is the
month to commemorate the founding of
October is also
the month in which we celebrate the anniversary of the discovery of
So this October,
let’s set out to discover