Housecalls, baby!

29 12 2011

Direct Primary Care is the future of medicine.  With insurance premiums spiraling out of control, more and more people are looking for the least expensive alternative to traditional insurance.  It’s the classic problem of insurance.  How much insurance do you need if you are in reasonably good health?  Actuaries will tell you, for example, that a traditional health insurance plan with high premiums, low co-pays for doctor visits and prescriptions doesn’t really make financial sense for say, a 25 year old male in good health (it makes more sense for a woman of the same age, who should be getting annual exams and has the possibility of getting pregnant).  He’s unlikely to see a doctor unless he’s seriously ill, doesn’t want to spend a lot of time in a heavy consult with his doctor and certainly doesn’t want to hassle with the average wait time to see his doctor. His doctor, similarly, is not likely to be stumped by the average ailment for this person and if she suspects its a common illness going around (like the flu), she’s likely to prescribe bed rest and plenty of fluids, and probably only do a diagnostic test out of obligation instead of necessity.  Hardly a case of House, M.D.  Compare this with the same guy with a bad case of the sniffles stopping off at the Minuteclinic (or, the Wal-Mart), waiting 15 minutes to see a nurse practitioner with automated tools at his disposal.  In about 15 minutes, the nurse has checked our guy’s blood pressure (it’s fine, he’ll want to check it more often after his 30th birthday), determined our 25 year old has a sinus infection and prescribed an antibiotic our patient can pick up in 15 minutes by walking across the store (and maybe picking up a bottle of Gatorade and a Snickers as an anodyne to his misery).  The whole affair is addressed in less than an hour.

Oh, and he paid $35 for the visit by swiping his card at the nurse’s terminal.  And $25 for the prescription.  And the whole visit including diagnosis and prescription can be captured electronically and saved in our patients’ personal health record like MS HealthVault or similar, so should this be part of a chronic problem, it can be shared with all the medical providers he may visit in the future.

The time involved with a traditional doctor’s office visit almost certainly took longer, then the patient has to travel to another location to pick up the prescription that maybe the doctor sent ahead, or maybe it’s on a little piece of paper that the pharmacist has to put in the queue. Then, there’s the small army of staff in a doctor’s office.  Their main purpose: to wrangle the myriad of paperwork for a whole variety of health insurance plans, engaging in the back and forth with the payer to get reimbursed and pass bills on to those patients who either don’t have insurance or have enough insurance. It’s all about the administrative overhead.  Is this for everyone?  Definitely not, but not only will this approach make sense for those in reasonable health (paired with some form of catastrophic insurance), but also those with chronic diseases that require close management.

Or, maybe the doc comes to you.  Why isn’t this happening, then?  It will and it’s probably closer than you think.  As more and more people are becoming active consumers of healthcare services, we will see more uninsured (and insured) people trying out MinuteClinics, (maybe) Wal-Mart, MedLion or a handful of similar concepts.  I’m waiting for a single entrepreneurial medical professional to figure out how to safely care for people from a roving van, armed with a few key medical instruments, a cell phone and a laptop.


Dispatches from the Field – January 2, 2008

2 01 2008

Hospitals Slow in Heart Cases, Research Finds

In nearly a third of cases of sudden cardiac arrest in the hospital, the staff takes too long to respond, increasing the risk of brain damage and death, a new study finds.

Researchers estimate that the delays contribute to thousands of deaths a year in the United States.

Fewer Small Firms Offer Health Insurance

Fewer small employers offered health insurance this year, despite the widespread availability of new, lower-cost high-deductible insurance plans, a survey released today by benefit firm Mercer shows.

Advocates of the high-deductible plans touted them as one solution to the growing number of uninsured, expecting the plans to appeal to small employers, who would continue to offer health insurance as a result.

“That’s not happening,” says Blaine Bos, a Mercer partner and one of the study authors. “In fact, the reverse is happening.”


Students Face Health Issues Without Insurance After College

Patrick Rastelli ’08 had hoped to take a year off after graduating from Brown this spring. But after some thought, Rastelli decided to travel last summer instead, and when he graduates, he wants to get a job as quickly as possible. He’s not seeking prestige or money, but rather something most college students take for granted: health insurance.

Report Links Higher Rates of Uninsured and Suicide

The higher the percentage of residents in a state who say they can’t afford health care, the greater the prevalence of serious depression and the higher the suicide rate in that state, suggests a report released to USA TODAY.

Dispatches from the Field – November 21, 2007

21 11 2007

Interest in Wellness Programs Grows: Survey

More employers are providing financial incentives designed to drive employee participation in wellness efforts, a survey shows.

Employers Shift Focus to Prevent Obesity

The seven most common chronic diseases — six of which can be caused or worsened by obesity — are costing employers $1.1 trillion in lost productivity, a recent study says.

Program Quantifies Costs of Chronic Conditions

It’s no secret that chronic medical problems, such as high blood pressure and low back pain, can mean time off the job. What’s hard to quantify, is how much that absenteeism can cost a company. Until now.^1544416

Consultant: Prepare for PHRs

Patients will demand personal health records, so health care organizations should be preparing technology and privacy models now, a consultant specializing in emerging technologies says.

Drugstore Clinics Spread, and Scrutiny Grows

“We’ve got big problems in health care, and this is not the answer,” said Dr. Rick Kellerman, president of the American Academy of Family Physicians. “They are a response, they are a niche market and an economic opportunity, but we still have an underlying primary care crisis in this country.”

Patients, however, have flocked to the clinics, according to a new industry group, the Convenient Care Association.

Trials and Tribulations at the FDA

4 08 2007

The Food and Drug Administration has long been criticized for the extremely lengthy review period that new medical treatments and pharmaceuticals in particular have to endure before their release to the public. The complaint is that the delays in approval costs lives. The Libertarian economist Milton Friedman once proposed that the FDA be abolished in favor of a manufacturer driven drug review process. But the agency has has historically been one of the most important watchdogs for the American public. In 1960, an FDA reviewer named Frances Oldham Kelsey refused to cave in to heavy pressure by Richardson-Merrell pharmaceutical company of Cincinnati to approve its night time sleeping aid in time for a Christmas release. Kelsey’s recalcitrance ended up being fortunate. The drug, thalidomide, was eventually implicated in birth defects that impacted over 10,000 children in 46 countries. Only a handful of the defects occurred in the US, the result of samples distributed by Richardson-Merrel to physicians on a trial basis. The FDA itself was created in response to the horrific conditions in meat-packing facilities described in Upton Sinclair’s The Jungle as well as the proliferation of “patent medicines and nostrums” that were marked as cures for various conditions. Created by small time entrepreneurs as well as companies still in business today, many of these medicines were ineffectual in treating their advertised ailments and some caused serious injury and death to consumers.

The thalidomide tragedy that impacted the global community is the oft-cited example of why we need the FDA (in fact, Friedman references it the above citation). But the FDA continues to be criticized for the delays in the approval process. The process has been blamed for creating needless suffering and death when sick patients can’t get access to life-saving but unapproved products. Also, drugs that have been approved are later to have serious side-effects that were completely unanticipated, like Vioxx, which was withdrawn from the market after being linked to increased risk for heart attacks and strokes. At the time of the withdrawal in 2004, over 100 million prescriptions for Vioxx may have been written.

Clearly, the typically lengthy FDA approval process did not catch the problems with Vioxx. The Food FDA estimates that Vioxx may have contributed to over 27,000 heart attacks and sudden cardiac deaths before it was pulled from the market. One of the main problems with FDA oversight of drugs is that it has little authority and less budget to mandate post market surveillance of drugs once they are approved. Numerous studies have outlined the obvious: compared to employees of pharmaceutical companies, FDA researchers are overworked and underpaid, and as result, turnover is high at the agency, further undermining oversight. In its report on the drug safety system in the U.S, the Institute of Medicine identified the lack of regulatory authority, the dismal lack of resources and “lack of transparency” of both the FDA’s Center for Drug Evaluation and Research and the pharmaceutical companies as well as other problems “has compromised the credibility of FDA and of the pharmaceutical industry.”

The problems with FDA are serious and will require major political will to solve. One fact is of note: in the case of Vioxx, a number of private insurers with electronic patient records systems identified the problems before the FDA did. While the post market surveillance program needs to be retooled, electronic patient records could be an important part of the strategy. In essence, monitoring the health data for patients receiving a drug could be a key strategy in post market surveillance. Pharmaceutical companies would be well served by investing in the deployment of Electronic Medical Records in doctor’s offices and by supporting more rigorous post market trials, helping to restore consumer’s trust in themselves and the FDA.

P4P – Latest News

29 07 2007

Health Data Management: Study Finds Better Pay-for-Performance Methodology
A group of researchers has found that using lab data for pay-for-performance program methodology can be up to 67 times more important than other models that rely on billing information.

San Francisco Business Times: Increased use of IT helps medical groups improve clinical quality
The more that California medical groups use information technology, the better they score on a range of important clinical quality measures, according to the Integrated Healthcare Association, which released its Pay for Performance results for 2006 on Monday.

The Medical Home

28 06 2007

The Commonwealth Fund released this study that connects having a “Medical Home” with improved health outcomes for minorities. While creating a medical home for all consumers is an important goal, I have to ask myself if this is an area where we should be putting more thought into enabling technology. The obvious items like secure e-mail and access to personal health records are one piece, but is there a way to enable even more accessible forms of communication to remind consumers when it is time for tests, exams, etc.? Let’s talk about auto dialing systems for phones, proactive data mining so we know who is not coming in and generating bulk mailings and coming up with tools to empower case managers and clinicians to work with patients remotely. For example, I remember somewhere along the way hearing about behavioral health specialists doing therapy over the phone in order to reach rural patients. We need a medical home for patients to be sure, and we have to address physical access to facilities as well, but are we leveraging technology enough?