Wednesday, April 11, 2007

Innovation-Driven Health Care, the Patient as the Centeor of the Universe, Copernicus, Patient-Centered Care, and Me

A Devastatingly Brief Tale about the Discovery of the Patient-Centered Universe, i.e., That The Health Care System Rotates around the Patient, Rather Than the Patient around the Health Care System

Finally we shall place the Sun himself at the Center of the Universe. All this is suggested by the systematic procession of events and the harmony of the whole Universe, if only we face the facts, as they say, “with both eyes open.”

Nicholas Copernicus, 1473-1543
De Revolutionibus Orbium Coelestium, 1543


I was speaking recently to Allen Wenner, MD, a family physician in Columbia, South Carolina.

Allen had just received a copy of my book Innovation-Driven Health Care. In it is a case study based on his founding and his work with the Instant Medical History, Inc. The Instant Medical History allows patients to electronically create their own history over the Internet before seeing the doctor by going to PatientCenter.com or by completing the Instant Medical History algorithm in his reception room.

Allen says 70% of patients complete the history before seeing him in the exam room (another 10% never show up at the office. They do not need to be seen for minor problems, so instead they do an e-visit.)

Allen’s collaborator in developing, using, and promoting the Instant Medical History is Dr. John Bachman, professor of primary care at Mayo in Rochester, Minnesota. Out of Bachman’s work has come Bachman’s Patient-Centered Law: No patient leaves the office without an electronic record containing details of their visit – history, exam results, and treatment plan.

But I digress. After reviewing Innovation-Driven Care, Allen commented, “Before you know it, you’ll be another Copernicus.” Nicholas Corpernicus, for those of you not in the know, was a Polish clergyman and astronomer, who spent the last 30 years of his life convincing the world that the Earth rotated around the sun rather than the other way around. His book, De Revolutionibus Orbium Coelestium, documenting his belief, was printed just before his death in 1543. Rumor has it, Copernicus carried it with him to his deathbed.

Well, Allen, I’m flattered. But I’m no Copernicus. I'm not even close. In health care, the belief that the health system rotates around the patient rather than the other way, around belongs to a galaxy of people.

• The Developers of WebMD, who believed and still believe the Web is the lever that will make patients the center of health care. WebMD, whose history dates back to 1995, describes itself this way:

WebMD is the leading provider of health information services, serving consumers, physicians, other healthcare professionals, employers and health plans. The online healthcare information, decision-support applications and communications services that we provide:

- Help consumers take an active role in managing their health by providing objective healthcare information and lifestyle information.

- Make it easier for physicians and healthcare professionals to access clinical reference sources, stay abreast of the latest clinical information, learn about new treatment options, earn continuing medical education credits and communicate with peers.

- Enable employers and health plans to provide their employees and plan members with access to personalized heath and benefit information and decision support technology that helps them make informed benefit, provider and treatment choices.

• Regina Herzlinger, PhD, professor of business administration at Harvard, who has steadfastly maintained and convinced the health care world that patients are perfectly capable of making intelligence health care decisions (see Consumer-Driven Health Care: Implications for Providers, Payers, and Policy Makers, Jossey-Bass, 2004). Her message is:

Consumer-driven health care is fundamentally about empowering health care consumers—all of us –with control, choice, and information. Consumer control will reward innovative insurers and providers for creating the higher-quality, lower-cost services we want and deserve. In this consumer-driven system, government will protect us with financial assistance and oversight, not micromanagement.

• Daniel Berwick, MD, of Harvard Medical School, founder of the Institute of Healthcare Improvement in Boston, where he preaches this gospel:

You might not think our health care system needs to be reminded to center its efforts on the patient But as the system has grown more complex and fragmented, and as providers feel more pressure to see more patients in less time, care has become centered not on the needs of patients, but around the needs of the system itself.
Care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their loved ones an integral part of the care team who collaborate with health care professionals in making clinical decisions. Patient-centered puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the tools and support they need to carry out that responsibility. Patient-centered care ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient. When care is patient , unneeded and unwanted services can be reduced.


• Steve Case, founder of AOL, who has sunk $100 million of his own money, into the Revolution Health Group, one manifestation of which is the revolutionhealth.com, a health care portal, created to revolutionize health care by putting the consumer at the center of health care. Revolutionhealth.com characterizes itself as:

Revolution Health is a health related portal site and social network. Users are urged to ask questions and answer other users’ questions, rate their doctors, participate in online discussions and otherwise contribute content. The site also has a number of tools to help people become healthier, such as a calculator that shows how long you need to do a given activity to lose a pound of weight, and a tool for showing you how much money an individual will save if he quits smoking. Every user has a profile page where they can link up to other users, set personal goals and aggregate content they’ve contributed to the site.

Allen and his friend, John Bachman,are part of this patient-centered galaxy, but I am not. I am a mere messenger. What amazes me is that the Copernicus-like message that health care rotates around the patient is that it took us so long to figure out that the patient – not providers, insurers, or policy makers -- is the center of the solar health system.

6 comments:

Val said...

Excellent post, Dr. Reece. I like Annie's take on this:

"The sun will come out tomorrow... bet your bottom dollar that tomorrow, there'll be sun..."

I'm doing my part to let the sun shine in! :)

Richard L. Reece, MD said...

I would like Val and other bloggers out there to continue to comment. Blogging is nothing more than electronic conversation. I invite comments, even if they come from Little Ophan Annie, or whether they they arrive by blog, phone, or cyberspace.

Richard L. Reece, ND
860-395-1501
rreece1500@aol.com

Richard L. Reece, MD said...

In this blog of mine, I note a glaring error. Dr. Berwick's first name is Donald, not Daniel. My apologies.

Allen said...

To paraphrase Copernicus "Finally we shall place the patient at the Center of the health care system. All this is suggested by the systematic procession of events, and the wellness that could be possible, if only we face the facts, as they say, “with both eyes open.”

The patient is most interested in health care quality. Only the patient can do something about changing the lack of emphasis on quality in health care today. Look at the procession of events: high insurance premiums, poor outcomes, lack of access to care because of cost, unhappy doctors, and a system on the brink of collapse. The powerful insurance-medical-pharma complex controls health care with other priorities. They must be refocused back to quality not as a department, but as a mission.

The health insurer is not focused on quality. Insurers pay nothing for quality. Their customer is the employer. Insurers are interested in having more money at the end of the year from premiums than they paid out in claims. They concentrate on cutting their costs one CPT code at a time. The Evaluation and Management codes are how diagnoses are made accurately. By cutting those, you cut quality by definition. As a insurance VP told me once, "We pay you doctor to see the patients, if you want to practice quality medicine, do it on your own time."

Hospital administrators are not focused on quality. The hospital is interested in the bottom line. Their goal is competing for more paying patients than the next institution. They expand and become the largest employer in many communities. As long as they are not making any more mistakes than the hospital down the street, they are doing fine. Hospitals enable the healthcare mentality of covering up errors and mistakes because of physician fear of malpractice. They collude with insurers by making hospital bills unintelligible to prevent insurance transparency.

Pharmaceutical companies are not interested in quality. They are interested in shareholder reports and quality only as a department that controls liability. They provide lifesaving drugs at the highest price the market will bear to increase share price. Health care quality has no relationship to the price/earnings ratio. When pharmaceutical prices fall, they exit the market like they did vaccines in the last decade. Recently only two European drug makers supplied all our influenza vaccines. Pharma markets high dollar drugs to physicians with attractive young women as sales people bringing lunch with free pens. Do a Google search on “drug rep”. The recent move into high priced cancer therapies reasons cancer patients cannot sue and will pay any price. Why are there no drugs or even any drug trials for ALS?

Doctors are interested in quality, but have been totally dominated in the last 15 years by third party monopolies. While being protected from lawsuits by ERISA, insurers refuse to bargain with physicians about anything. When physicians complain about quality, insurers initiate anti-trust actions against them. Insurers tell physicians what quality of drugs to prescribe and what tests to do and what procedures to order. The 70% of physicians who say they will retire as soon as possible site the lack of ability to practice quality medicine as a reason. This contrasts doctors who formerly enjoyed practicing quality medicine into their 80s.

The present system simply does not work because quality of care is not a system property. A health care crisis like Avian flu could collapse the American health care system to the level of a third world country in weeks. The innovation in medicine in America should be equating health insurance to auto insurance. This would sundown laws allowing deductibility of health care costs for employers. Health insurance premiums should be deductible only to individuals who write out the check themselves. If the patient were at the center of health care costs and benefits, then insurers would be more interested in value for the health care dollar. In such a transparent system, patients could decide if their insurance company was worth the price. If insurers continue to buy mink-lined toilet seat covers for their CEOs’s yachts, then patients might decide that they would get better value for their health care dollar from a one-payer system.

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