Dr. Merrilee Fullerton on Healthcare

As of late last night, the next journal entry was going to be on President Obama's prescription for US health care which was discussed on ABC yesterday in a townhall setting with the President answering questions from fairly significant groups like the American Medical Association.

His comments were positive and included mentioning that primary care physicians need to have incomes more in keeping with specialists to make primary care more attractive. He also suggest that patients should have choice over which insurance plan works best for them....a marketplace for insurance products would be formed.

When questioned about a government insurance plan by former President Bush's health care staffperson who oversaw Medicare during the Bush era, he was asked about how the program would work if trillions of dollars were needed. If I recollect right, his response was something like "it won't be easy". That is the understatement of the decade.

In any case, it does appear he values primary care physicians and tens of thousands more will be needed in the US in the near future if plans for coverage of the uninsured is going to happen. We've talked about this before on this blog and numbers now seem to indicate that the US will need between 40,000 and 130,000 more primary care physicians. I hear a loud sucking sound.

This is occuring as our own College of Physicians and Surgeons of Ontario is bringing in more regulations of the medical profession here in Ontario that will likely lead to migration south of medical students and physicians, eager to throw off the shackles of a an apparently politically driven College that would appear to take its orders from the Toronto Star.

But enough about the changes in the US....it may not have the funding to create the changes required but I must say that Obama knows how to talk the talk.

In one of may last posts on the previous journal entry I provided a link for a case of a young woman stricken with neurofibromatosis and whose life is at risk yet OHIP is refusing to pay for an experimental treatment which is her only hope for survival. Now compare this to  the $2,700 per day fees that some consultants where charging for the eHealth work (and don't forget the tea and cookies) and to the billions that eHealth will spend on developing universal EMR/EHR which may never save any money at all.

One wonders if Ontario's health care system really exists for the right reasons. Is it a political tool used for some but not for others and for some diseases and not for others? It would certainly seem to be the case.

So along comes Kevin Falcon, British Columbia's new Health Minister who is reported to have said that he believes patients should be able to use their own money to buy expedited health care in the private sector as reported in today's National Post article, "Minister Backs Private Care".

Finally--a politician that is not tying himself to the mast of the listing good ship "Monopoly Public Health care" and who probably realizes that government cannot be the provider of all medical care and in fact, is not.

Some pertinent quotes from the article:

"I don't have any philosophical objection to it....What we have to do is improve the public delivery of services".

"I do not have any objections to people using their own money just as they do for dental care or sending their kids to private school."

"I think choice is a good thing and reducing it is not a good thing."

Well I'll be.......

Well, after 200 plus posts it just seemed reasonable to move the discussion to a clean slate. Please feel free to refer to previous posts on the last journal entry.

What can I say?

Entitlement, Feeding at the Trough, No Accounability, Nepotism, Hypocrisy.....and on an on.

Disappointment isn't really an adequate description for the degree of buddy buddy business going on here.

While I recognize that health care and eHealth are exceedingly complex, I would have hoped that the leaders at the top could have set an example.

Dr. Alan Hudson threatens to take funding from hospitals that cannot meet their ER Wait times numbers and yet apparently is involved in awarding hefty contracts to consultants with little or no accountability.

And Pricewaterhouse Coopers, the same firm that looked over the system within the last year is going to find something wrong with the mechanisms of awarding contracts at eHealth? I think not.

I encourage you not to let this drop. Our leaders must be held accountable in one way or another.

You want to spend $26 billion on eHealth like they did in the UK?

There is a spate of medical subjects to discuss and despite the mantra that health care has fallen off the radar of the public, I don't believe this to be true.

Whether it is reports on "female physicians less productive" (whatever productive means) or possible diagnostic errors from Saskatchewan (not all docs are the same and not many driving taxis despite the medical mythology that exists), or nurses taking the lead in private provision (now there's an irony--see the May 26, 2009 article in the National Post on home care-"Health-care's prescription), medical news is definitely in the public eye.

Unlike decades ago, when if you didn't read it in the newspaper or hear it on the radio (or from a talkative neighbor), news didn't really exist, we now have an age of information at our fingertips and a wealth of knowledge being spread amongst the masses (albeit not always accurate knowledge).

Despite Medicine's past paternalism, the delivery of medical care is changing in this New World where just about anybody can research a disease, understand the presenting symptoms and find the available treatments. Just don't ask a patient to be able to put this into  context necessarily or to safely choose the treatment. Because without the background of experience and the training that includes seeing thousands of patients, it is not always easy to put the pieces of the health care puzzle together.

People like Dr. Hudson willl state that other providers are needed to do more of the mundane tasks of a family physician and I quite agree  despite not believing that this will be a cheaper alternative. Nurses and PAs and dieticians could certainly monitor various chronic conditions and this could be quite helpful. Ultimately though, I think it should be the patient's choice as to who "pilots" their care (credit to Andris and eklimek for this concept).

As chronic diseases lend themselves to monitoring by various providers, we still need specialists and family physicians to put medical science into perspective for the patient and the team. It is not sufficient to know that all diabetics should have an annual eye exam, foot assessment, and monitoring of various health parameters. One needs to know how one aspect of treatment will affect another and when a symptom or sign should be a red flag instead of just another line on a patient's list. And don't forget the human need for emotional support, human touch and trust.

With this in mind I read with great interest, The Economist, April 18th edition, "Medicine goes Digital" and if you can go back in the Economist Archives it is well worth the read.

The space on this journal entry can't do it justice but it provides the scope of the changes that are coming. I for one, cannot see how government is going to afford even a small percentage of these changes. I'll list the  the links in the comments section.

Titles of interest from the April 18th edition of The Economist:

HIT or miss: Health reformers have long wanted to digitise medical records. They are getting closer. Page 4.

Flying blind: Digital medicine will improve medical care-and it may possibly revive drug discovery too. Page 6

Getting Personal: The promise of quick and cheap genome sequencing. Page 9

A doctor in your pocket: Developing countries are using mobile phones as a way of leapfrogging to personalised medicine. Page 11

Fantastic Journey: Medical technology is making medicine more portable, precise and personal. Page 15

Health 2.0: The arrival of digital medicine is already empowering patients-but will it also lead to better health? Page 17 (of course, you could probably tell that this one interested me the most..."the shift towards patient empowerment is 'unstoppable'"......and with this must come increased responsibility)

Coupled with these changes is the advent of more private involvement in the health care world. There is simply no way for government to fund every last bit of technology. It doesn't even do it now.

Where will technology take us? To more access for patients and likely more choice along with more patient responsibility and individual funding of personal health care segments.

I've mentioned American Well before and its Hawaiian endeavor to bring online visits to appropriately replace office visits. One study examined the potential for online care.  The areas focused on were non-emergent care replacement, acute physician office care replacement; and maintenance physician office care replacement. The study was followed by the extension of "Milliman's Care Guidelines for Online Care"TM which are evidence-based clinical guidelines spanning the continuum of care including chronic care and behavioral health.

Most recently, a collaborative of physicians created "Decision Guides for Online Care" which supports providers when a patient presents online with a common complaint such as abdominal pain, headache or earache. More details on this can be found at American Well's Online Care Community in an article by Roy Schoenberg called "Developing Guidelines for Online Care".

So...health care is about to make a huge leap......take a big breath but don't close your eyes.

Happy reading and I'll post as many links as I can. Enjoy the day!

Okay, okay. I see that some of us want to discuss this topic which I was trying to avoid because there is so much press on this already it almost appears to be hype of some form. Just my spidey senses tingling.

Now don't call me reckless....I do understand the severity of the situation in general but there are lots more likely things to kill you right now than H1N1. I do agree with limiting the spread initially and I can see why Mexico has imposed the restrictions it has. Very sensible.

I suggested a few years ago when I sat on a Trans Atlantic flight with a traveller behind me who sounded like they were about to cough up their bowels, that passengers who were coughing be given masks. The air hostess seemed to think it would be insulting to the passenger involved but really, to think that people travelling sick like this should be ignored by responsible parties is an attitude that belongs packaged away in some musty dusty old place.

I do recollect that the plan here in Ottawa was sadly lacking in common sense when it first rolled out. There was no plan to close schools or stop public gatherings and in fact, the concept was to have people who thought they might have the pandemic illness to come to community areas to be assessed...so if they didn't have it before, they would probably have it after being around many who did! Not very sensible to me.

So here you go, H1N1....talk all you want. Next topic is The Economist, April 18th edition...a must read!

While everyone seems focused on the Swine Flu, people seem to forget that patients are dying from many other things. Cancer Care Ontario reports that chemotherapy wait times in Ontario are rising. Last year, they were stagnant despite large increases in funding...and that was before the economy went South.

One of the comments on this topic was eluded to in the last journal entry Comments section and it is a poignant reminder that the better we get at treating disease, the more government will need to spend in health care.

Last May, chemo wait times were stagnant despite large increases in funding. This May, they are rising and increased funding given Ontario's financial circumstances is questionable.

"We are victims of our own success", was the comment. Patients are living longer with their cancer because of new treatments and new medications and thus are chemo-treatment repeaters. I'm grateful that this is an option for patients but I cringe a little when I think of the repercussions of a goverment monopoly health care system in which patient responsibility is  largely ignored as part of the solution but in which rationing is rationalized by the use of "evidence-based" medicine and "best-practices" which are really buzz words for limiting patient's options in a constrained system. And anyhow, it looks like the UK's NICE system of evidence based medicine actually ends up costing more. Don't ask me how.

Let's be honest about this. If government cannot afford to provide care and treatment in a timely way or to the satisfaction of the patient, then it would be fair not to promise this in the first place and to allow patients to plan ahead. But that would take more responsibility and it seems nobody expects this from patients.

That is a big problem  no politician seems to have the courage to address.