Virginia Postrel, now a writer from The Atlantic Monthly, made a lasting impression in one of her articles from a prior publication. At a time when inflationary pressures in healthcare are running at 3 times the national inflation rate, and demand continues to grow, it is only too apparent that there are no easy fixes to any healthcare system. How we define health care is imperative to finding the solution.
Health care isn't a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries' supposedly universal systems only demonstrates how fraught the concept of "health care" is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care-if only from an emergency room-for some things, and that citizens (a critical word in this context) without money are covered by Medicaid. The real issue is how you define "health care." What gets included is a matter not only of medicine and economics but of culture and politics.
Tuesday, March 31, 2009
Monday, March 30, 2009
BC should embrace "Disruptive Innovation" in healthcare
In a healthcare system that is funded with public dollars, a status quo approach (meaning we continue to allocate resources at the same rate as we always have), is not sustainable. We simply have to look for better ways to do more for the people for whom our system is there to provide care.
In the last few years, BC has implemented some new ideas in healthcare, such the OASIS joint replacement program at UBC Hospital which has created a specialized care model including patient education, highly trained joint replacement nurses and support teams, and specialized post-operative care. The program has contributed to reducing province-wide wait lists for joint replacement, and more importantly, has helped patients get back to health quickly and efficiently.
It seems, however, that there is room for even more new ideas in healthcare in BC – ones that would put us at the forefront of quality patient care and appropriate return on the $13 billion invested annually by the government in keeping BC healthy.
The concept of innovative, and potentially disruptive, changes in how “healthcare is organized, paid for, and delivered”[1] was suggested by Jerome Grossman of the Harvard/Kennedy School Health Care Delivery Program just a month before he died last year. He based this upon the concept of disruptive innovation, first introduced by Clay Christensen in 1997, whereby it is believed that consumers will seek out suppliers/providers who offer a level of transparency, convenience of delivery, and costs that represent value. A novel concept in any healthcare system, to be sure.
In fact today’s healthcare model is based upon a fragmented care, fee-for-service model, whereby physicians and surgeons are paid for process, not outcomes. This removes the incentives for doctors to be proactive in managing wellness, not disease, and further provides an incentive to see as many patients as they possibly can. To be fair, this is not to say that doctors are doing unnecessary procedures; it is to say though, that there is no motivation to do things any more efficiently.
Christensen identified two requisite conditions for disruptive innovation: technology enablers and a disruptive business model that can profitably delivery these routine solutions to customers in affordable and convenient ways.[2] Grossman suggests that improved diagnostics and therapies, along with advances in information and communication technologies, have created the framework for disruptive innovation.[3] The BC healthcare system is committing millions of dollars to eHealth technologies in order to connect the disparate systems that exist today. This is step one in the process of disruptive innovation in BC.
With the technology in place, next there must be the development and implementation of ideas that contribute to doing things differently. We’ve dabbled in pay-for-performance to decongest the emergency room. We’ve put specialist doctors on salary in some hospitals to retain them and meet the demand for on-call services. We’ve opened diagnostic imaging facilities in their off-hours to expand capacity.
Perhaps these concepts from other markets have already been considered, but certainly they warrant another look:
- The wellness model of healthcare moves the burden of accountability to the patient; what about investing in wellness and disease prevention, and providing financial incentives to patients who meet certain targets.
- Providing incentives for physicians to support and use a wellness model – including diet and fitness assessments. Paying doctors to oversee wellness makes more sense than waiting for them to treat disease. Wellness management tools are already available, including web-based patient records which allow a patient to track their own progress (like they track their bank account), and communicate electronically with doctors. This model is already available in BC, however only to this extent in the private sector.
- With the shortage of family doctors, what about allowing people that meet certain criteria the opportunity to go directly to specialists? In other countries, this has worked, and has succeeded in shortening the time to specialist, as well as placing patients in control of their medical process. Within this model, Nurse Practitioners may provide a compliment to specialist care, and certain specialists may be given an expansion in scope of practice.
British Columbians should not fear disruptive innovation. It won’t choke the publicly funded system; in the short term, it may create changes that disrupt the normal routine of healthcare and in the long term, it will allow for a robust and self-sustaining system. As a strong and resilient population, BC needs to lead the way through disruptive change if it intends to continue its publicly funded healthcare delivery system into the future.
Monday, January 12, 2009
Screening Mammography: Let's talk about accountability
The Association of American Physicians and Surgeons recently issued a release stating that “Women get better care in the US than in Canada or England.” http://www.aapsonline.org/newsoftheday/00123. The statement came as part of the lobby of the new Obama-Biden transition team, which ran on a platform of improving access to and costs of care in the US.
The release used just one statistic to make its point, comparing mammography rates in the US, at 71.8% of women aged 50 to 64, with the 51.8% rate in Canada where, they say “everyone is insured.” While this is hardly indicative of the health status of an entire nation, it does point out a glaring shortcoming in Canadian healthcare: screening and accountability.
One of the challenges with screening and prevention in Canada is that we don't provide unfettered access to screening tools such as PSA tests (men have to pay unless they have clinical indications or family history) and screening colonoscopies. In the US, government sponsored Medicare and Medicaid pay for screening colonoscopies every 5 years for EVERYONE on social assistance, after the age of 50. Some speculate that the higher screening rates in the US are as much to do with the insurance business as they are to do with good health literacy and patient accountability. Insurers often provide financial incentives for enrolled members to participate in screening programs because, they say, early intervention is less costly than a late diagnosis. OK, and it saves lives.
Every woman is entitled to a screening mammogram each year after the age of 40 under the BC Medical Services Plan. But while guaranteed access is one thing, patient accountability is another. There is demonstrable evidence that mammography, combined with physical exam, reduces the rate of mortality from breast cancer. Can it really be that 48% of Canadian females over the age of 50 can’t recognize this? Early detection will potentially save your life.
While we don’t provide access to all the screening tools that research suggests may be useful to early intervention, nor do we as Canadians, take responsibility for such screening and prevention tools. Booking a screening mammogram is as easy as calling 604 775-0022 to book your appointment in Vancouver, or visit http://www.bccancer.bc.ca/PPI/Screening/Breast/Screening+Mammography+Locations+and+Mobile+Services.htm#vancouver for other numbers and locations throughout BC.
If you are a woman over 40, and haven't taken advantage of access to mammograms, or over 50 (male or female) and haven't had your family doctor provide a fecal occult blood test as a colon cancer screening test (FOBT), you lack the responsibility and accountability for your own care. Good health requires your active participation, whether it is "free", or not.
The release used just one statistic to make its point, comparing mammography rates in the US, at 71.8% of women aged 50 to 64, with the 51.8% rate in Canada where, they say “everyone is insured.” While this is hardly indicative of the health status of an entire nation, it does point out a glaring shortcoming in Canadian healthcare: screening and accountability.
One of the challenges with screening and prevention in Canada is that we don't provide unfettered access to screening tools such as PSA tests (men have to pay unless they have clinical indications or family history) and screening colonoscopies. In the US, government sponsored Medicare and Medicaid pay for screening colonoscopies every 5 years for EVERYONE on social assistance, after the age of 50. Some speculate that the higher screening rates in the US are as much to do with the insurance business as they are to do with good health literacy and patient accountability. Insurers often provide financial incentives for enrolled members to participate in screening programs because, they say, early intervention is less costly than a late diagnosis. OK, and it saves lives.
Every woman is entitled to a screening mammogram each year after the age of 40 under the BC Medical Services Plan. But while guaranteed access is one thing, patient accountability is another. There is demonstrable evidence that mammography, combined with physical exam, reduces the rate of mortality from breast cancer. Can it really be that 48% of Canadian females over the age of 50 can’t recognize this? Early detection will potentially save your life.
While we don’t provide access to all the screening tools that research suggests may be useful to early intervention, nor do we as Canadians, take responsibility for such screening and prevention tools. Booking a screening mammogram is as easy as calling 604 775-0022 to book your appointment in Vancouver, or visit http://www.bccancer.bc.ca/PPI/Screening/Breast/Screening+Mammography+Locations+and+Mobile+Services.htm#vancouver for other numbers and locations throughout BC.
If you are a woman over 40, and haven't taken advantage of access to mammograms, or over 50 (male or female) and haven't had your family doctor provide a fecal occult blood test as a colon cancer screening test (FOBT), you lack the responsibility and accountability for your own care. Good health requires your active participation, whether it is "free", or not.
Saturday, January 10, 2009
Health Literacy
Research suggests that the single biggest indicator of health status of a society is its level of health literacy. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
There is no shortage of academic study in the area of health literacy, with much of it focussed on literacy rates and why health literacy is important. There is an underwhelming amount of programs designed to address issues to improve health literacy among target populations.
I'm starting a new non-profit to deliver health literacy programs to specific populations in the Lower Mainland of British Columbia. Our strategy is to develop a speakers' bureau of subject experts, develop consistent and appropriate presentations and materials, and delivery seminars and talks to established groups and organizations of seniors, low income women, and youth.
If you have subject expertise, literacy subjects, or an established group that would benefit from the delivery of a health literacy program, please let us know.
Astrid
There is no shortage of academic study in the area of health literacy, with much of it focussed on literacy rates and why health literacy is important. There is an underwhelming amount of programs designed to address issues to improve health literacy among target populations.
I'm starting a new non-profit to deliver health literacy programs to specific populations in the Lower Mainland of British Columbia. Our strategy is to develop a speakers' bureau of subject experts, develop consistent and appropriate presentations and materials, and delivery seminars and talks to established groups and organizations of seniors, low income women, and youth.
If you have subject expertise, literacy subjects, or an established group that would benefit from the delivery of a health literacy program, please let us know.
Astrid
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