Bernard Lown's legacy: from avoidable care to right care
Last week, the second conference on avoidable care was convened by the Lown Institute in Boston, MA, USA. Whereas its first conference held in April, 2012, focused specifically on overtreatment, the emphasis this time was on understanding the drivers and consequences of overuse, underuse, and misuse of health care. The ultimate goal is to achieve a just, effective, affordable, and above all humane health-care system that puts patients and people at its centre. Such a movement and campaign, led by US physicians, health-care workers, civil society, and religious leaders is inspiring and timely, especially because the USA has the world's most expensive health-care system with relatively poor outcomes. Where markets lead, care is often influenced by monetary considerations with unnecessary medical tests and ineffective treatments that might even cause harm to patients. Other countries, the UK included, should take note.
At the conference, Bernard Lown himself, who is Chairman Emeritus of the Lown Institute and won the Nobel Peace prize for International Physicians for the Prevention of Nuclear War in 1985, gave an impressive passionate and thoughtful speech. He argued strongly that we should restore humanism into medicine and regain the lost art of listening to, and having compassion with, patients. Currently, we have a hospital-centred sickness system driven by financial incentives—this is a broken system. The money saved by curbing overtreatment should be invested into preventive medicine and palliative care. Medicine should be a calling not a business—the selection and education of medical students needs to reflect this.
With finite resources, changing demographics, and an increasing burden of non-communicable diseases, a new patient-centred strategy with integration of prevention and care and with a stronger role of community-based care is universally critical. In a forthcoming Series, The Lancet, in partnership with the Lown Institute, will examine the extent and consequences of unnecessary care. In the meantime, those who agree should sign the Lown Institute's declarationof principles for right care to start nothing short of a health-care revolution.
The following Declaration came out of the"From Avoidable Care to Right Care" conference, held in Boston, MA December 3-5, 2013.
-SPC
The Declaration of Principles of the Right Care Alliance
Whereas:
- Modern medicine offers important benefits, yet it also has the capacity to cause harm;
- Those harms arise from three central failings of medical systems: the overuse, underuse, and misuse of medical services. Of these, overuse – including overdiagnosis, overtreatment, and the use of ineffective, unnecessary, and unwanted medical tests and treatments – has received the least attention;
- Overuse is common and tacitly accepted in modern health care;
- Overuse exposes patients to harm, including the risk of serious injury or death, suffering, and financial ruin, with little or no possibility of benefit;
- Overuse diverts resources from the provision of needed care, and crowds out investment in social services, education, nutrition, and other non-medical contributors to health;
- The health care industry puts money before people and allows personal and commercial interests to distort clinical decisions, thus betraying patients’ trust;
- Clinicians and health care leaders have an ethical obligation to protect patients from the harms of both underuse and overuse;
Therefore we, the signatories of this document, declare that performing unnecessary medical tests and treatments is unethical and unacceptable. We join the call for the medical profession to renew its sense of duty and commitment to patients. We call on health care leaders to recognize their ethical obligation to put patient care first. We call on civil society to advocate for a medical system that is affordable, effective, rational, personal, and just.
Our vision:
A more just and compassionate world where health and health care are basic rights. where patients are safe from unnecessary diagnosis, treatment, and harm. where patients’ wishes are respected by their caregivers. where clinicians serve as healers, and as advocates for those who are most vulnerable and in need of care. and where health care exists for the benefit of patients, communities and nations.
Our mission:
We, the signatories of this document, seek to foster a new social contract between civil society, the profession of medicine, and the business of health care. We will promote the creation, dissemination, and execution of this new covenant through community and professional organizing, convening, original research, public policy, public speaking, and writing.
We believe:
- the delivery of medical care is a moral enterprise that begins with the bond between clinician and patient.
- the profession of medicine is a calling, distinct from the business of health care.
- every person deserves access to effective, humane, and affordable health care.
- good medicine requires valid, unbiased science.
- medicine exists to ease human suffering and promote the health of individuals and communities. health care must be reorganized to fulfill this mission.
In a transformed health system, patients can expect to:
- have access to the care they need
- be able to advocate for care that better meets their needs
- be safe from unnecessary treatment and needless harm
- feel cared for as whole persons
- be protected from commercial interests
- be informed and involved in choices about their treatment
In a transformed system, clinicians can expect to:
- have the time they need to care for their patients
- make clinical judgments in the best interests of their patients
- be free from undue worry about litigation
- feel supported in their efforts to improve care
- feel confident in the science that supports their decisions
- feel proud of their profession and privileged to serve patients
Our pledge:
We, the clinicians, patients, and others who sign this document, commit to support the best care possible. We clinicians accept the ethical obligation always to put patients’ needs first. We acknowledge that there are limits to our collective knowledge and power to cure. We agree to spread our sense of this obligation. We recognize the power we have gained through our training and status as clinicians, and accept our responsibility to engage our patients, learn their preferences, and share treatment decisions. As patients, we recognize our power to spur change with our collective voices.
Together, we choose to take action because we know the current system is neither morally nor economically sustainable. To this declaration and its principles, we pledge our energy, our skills, and our voices.
With Affordable Care Act, Canceled Policies for New York Professionals
By ANEMONA HARTOCOLLIS
Many in New York’s professional and cultural elite have long supported President Obama’s health care plan. But now, to their surprise, thousands of writers, opera singers, music teachers, photographers, doctors, lawyers and others are learning that their health insurance plans are being canceled and they may have to pay more to get comparable coverage, if they can find it.
They are part of an unusual, informal health insurance system that has developed in New York, in which independent practitioners were able to get lower insurance rates through group plans, typically set up by their professional associations or chambers of commerce. That allowed them to avoid the sky-high rates in New York’s individual insurance market, historically among the most expensive in the country.
But under the Affordable Care Act, they will be treated as individuals, responsible for their own insurance policies. For many of them, that is likely to mean they will no longer have access to a wide network of doctors and a range of plans tailored to their needs. And many of them are finding that if they want to keep their premiums from rising, they will have to accept higher deductible and co-pay costs or inferior coverage.
“I couldn’t sleep because of it,” said Barbara Meinwald, a solo practitioner lawyer in Manhattan.
Ms. Meinwald, 61, has been paying $10,000 a year for her insurance through the New York City Bar. A broker told her that a new temporary plan with fewer doctors would cost $5,000 more, after factoring in the cost of her medications.
Ms. Meinwald also looked on the state’s health insurance exchange. But she said she found that those plans did not have a good choice of doctors, and that it was hard to even find out who the doctors were, and which hospitals were covered. “It’s like you’re blindfolded and you’re told that you have to buy something,” she said.
The people affected include not just writers, artists, doctors and the like, but also independent tradespeople, like home builders or carpenters, who work on their own.
Some have received notices already; others, whose plans have not yet expired, will soon receive letters in the mail. It is unclear exactly how many New Yorkers are affected; according to state health officials, as many as 400,000 independent practitioners get health insurance through job-related group plans, but that number also includes people who receive coverage through their spouses’ employers.
The predicament is similar to that of millions of Americans who discovered this fall that their existing policies were being canceled because of the Affordable Care Act. Thecrescendo of outrage led to Mr. Obama’s offer to restore their policies, though some states that have their own exchanges, like California and New York, have said they will not do so.
Looking at Vermont - Is Single-Payer Health Care an Option for Maine?
"A wicked complicated task" -Vermont is moving toward one standardized system of payment for health care and it's using the federal Affordable Care Act (ACA) to accomplish the task.
"A wicked complicated task" -Vermont is moving toward one standardized system of payment for health care and it's using the federal Affordable Care Act (ACA) to accomplish the task.
by Andy OíBrien
The Free Press - Midcoast Maine
At a recent health care forum hosted by the University of Maine's Muskie School of Public Service titled "Global Budgets, Payment Reform and Single Payer: Understanding Vermont's Health Reform," former State Senator Peter Mills recalled meeting a 90-year-old woman named Shirley who was the 12th person hired by Blue Cross Blue Shield of Maine.
"When she started work at Blue Cross, hospital coverage could be bought for 85 cents a week for an individual, $1.50 for a couple, and $2 for a family," said Mills. "When she retired 42 years later, Blue Cross Blue Shield employed over 1,000 people."
Health care payment and delivery has changed a lot since Shirley was hired back in 1942. It now costs nearly $3 trillion a year, exceeding 16 percent of Gross National Product (GNP). Despite the high cost, studies have shown that the American health care system is not making us any healthier than other industrialized countries.
Speaking at the forum, Maine's former commissioner of Health and Human Services Trish Riley cited a 2009 study by the Institute of Medicine that found $750 billion in annual waste in America's health care system. Inappropriate care and inefficient delivery of care made up the biggest part of that waste, at about $340 billion, while excessive administrative costs totalled $190 billion, overpricing accounted for $105 billion, fraud cost about $75 billion and missed prevention was $55 billion.
According to Mills, while the federal government has so far unsuccessfully tried to get a handle on skyrocketing health care costs, it is in the "50 laboratories of democracy" where he sees the greatest potential for progress.
"The virtue of our 50 United States is their capacity to solve problems in different modes and its smaller scale to gather evidence about what works and to foster sound solutions," said Mills. "And who should be better at that than small and nimble states like Maine and Vermont?"
"When she started work at Blue Cross, hospital coverage could be bought for 85 cents a week for an individual, $1.50 for a couple, and $2 for a family," said Mills. "When she retired 42 years later, Blue Cross Blue Shield employed over 1,000 people."
Health care payment and delivery has changed a lot since Shirley was hired back in 1942. It now costs nearly $3 trillion a year, exceeding 16 percent of Gross National Product (GNP). Despite the high cost, studies have shown that the American health care system is not making us any healthier than other industrialized countries.
Speaking at the forum, Maine's former commissioner of Health and Human Services Trish Riley cited a 2009 study by the Institute of Medicine that found $750 billion in annual waste in America's health care system. Inappropriate care and inefficient delivery of care made up the biggest part of that waste, at about $340 billion, while excessive administrative costs totalled $190 billion, overpricing accounted for $105 billion, fraud cost about $75 billion and missed prevention was $55 billion.
According to Mills, while the federal government has so far unsuccessfully tried to get a handle on skyrocketing health care costs, it is in the "50 laboratories of democracy" where he sees the greatest potential for progress.
"The virtue of our 50 United States is their capacity to solve problems in different modes and its smaller scale to gather evidence about what works and to foster sound solutions," said Mills. "And who should be better at that than small and nimble states like Maine and Vermont?"
Cancer patient’s insurance still on hold
Posted on 12 December 2013
By Katie Kerwin McCrimmon
Cancer patient Donna Smith is stuck in limbo again.
Smith has been trying to buy health insurance through Colorado’s exchange since opening day on Oct. 1.
She worries now that she might not have her new health insurance on Jan. 1 as she had hoped. Smith, 58, is a two-time cancer survivor now facing a relapse.
“It’s frightening. It’s maddening,” said Smith. “I can’t go without insurance.”
Back in October, Smith struggled to create an account because Colorado’s exchange,Connect for Health Colorado, had some IT glitches when it launched. A few days later, Smith filled out an extremely long Medicaid application, then had to wait 37 days to get a denial from Medicaid. She went ahead and picked a plan in November. Then Colorado’s floods forced Smith and her husband to move from Castle Rock to Denver. And now, the Connect for Health agents told her that changing her address is not a simple matter and that she may no longer qualify for the Kaiser plan she picked, even though her new home is less than a mile from one of Kaiser’s Denver medical offices.
Smith is stuck waiting for a written confirmation before she can confirm her Kaiser coverage, mail a check and start to make appointments with doctors for care in January.
The uncertainty and the challenges of the sign-up process have been infuriating.
“I’m now in a different level of limbo. It’s like Dante’s Inferno. You just keep going to a different level and thinking, ‘Is this it? Are we stuck here?’ ”
Solving the Shortage in Primary Care Doctors
By CATHERINE RAMPELL
Again and again, we hear that the country has too few doctors, particularly for primary care. And Obamacare is supposed to make the shortage much worse in the coming years as more Americans become insured and try to shoehorn themselves into already crowded medical offices.
But why, exactly, are doctors in such short supply?
I had always assumed the culprit was medical school enrollment. But when I looked into those numbers, I found that they are actually increasing noticeably. Thanks to the opening of new medical schools and expanded admissions at existing ones, enrollment is projected to rise by 30 percent between 2002 and 2017, according to theAssociation of American Medical Colleges. That’s in addition, mind you, to the swelling number of med students studying abroad, with the goal of eventually practicing in the United States.
It turns out that the real bottleneck is at the post-med-school step: residencies, those supervised, intensive, hazing-like, on-the-job training programs that doctors are required to go through before they can practice on their own.
There has been little growth in residency slots; they totaled 113,000 in 2011-12, from 96,000 a decade earlier. Exactly why residencies have not increased faster is a subject of great debate in the health care industry.
Hospitals, doctors and med students usually give the same explanation: Congress is too stingy.
After all Congress, through Medicare, subsidizes the vast majority of residency slots, at $10.1 billion annually, or an average of $112,642 per resident per year. Congress froze the number of subsidized positions in 1997, and hospitals argue that the best way to train more doctors is for Congress to open the spigot and fund more jobs.
Obviously Washington is not keen on doling out more money for anything right now, especially not for Medicare. But there’s a bigger problem with that argument: It’s not clear that hospitals actually need taxpayer money to pay for more residents, because those residents might actually be turning a profit for those hospitals right now. It’s hard to know, though, because hospital accounting is so opaque.
Enrollment Errors Cut, Officials Say; Fixes Are Overstated, Insurers Report
By ROBERT PEAR
WASHINGTON — The Obama administration said Saturday that it had reduced the error rate in enrollment data sent to insurance companies under the new health care law, even as insurers said that the government’s records were still riddled with mistakes.
The quality of the data is important; it could affect the ability of people to get medical care and prescription drugs when they go to doctors’ offices and pharmacies starting next month.
More than 137,000 people selected health plans in the federal insurance marketplace in October and November, and administration officials say more than 100,000 signed up in the first week of this month.
For each person who signs up, the government is supposed to send information electronically to an insurance company in a standard format known as an 834 enrollment transaction. In some cases, consumers selected a health plan at the federal website, HealthCare.gov, but the government did not notify the insurance company. In other cases, insurers received duplicate files for the same person, files for one person were sent to an insurer in another state, or the “relationship code” was wrong so that, for example, a man’s daughter was listed as his wife.
The White House said Saturday that the government was now informing insurance companies of nearly all new enrollments.
Julie Bataille, a spokeswoman at the federal Centers for Medicare and Medicaid Services, acknowledged that the government had failed to inform insurance companies about some people who had chosen health plans on HealthCare.gov, but she said the number of such cases from Oct. 1 to Dec. 5 was lower than 15,000.
“Since the beginning of December, missing 834s as a percentage of total enrollments has been close to zero” — down from 15 percent in the two weeks starting Oct. 13, she said.
Ms. Bataille said most of the problems occurred from Oct. 1 to mid-November, as enrollment reports on some consumers “were either not being generated, or had errors due to larger technical system issues.”
The Selling of Attention Deficit Disorder
By ALAN SCHWARZ
The Number of Diagnoses Soared Amid a 20-Year Drug Marketing Campaign
After more than 50 years leading the fight to legitimize attention deficit hyperactivity disorder, Keith Conners could be celebrating.
Severely hyperactive and impulsive children, once shunned as bad seeds, are now recognized as having a real neurological problem. Doctors and parents have largely accepted drugs like Adderall and Concerta to temper the traits of classic A.D.H.D., helping youngsters succeed in school and beyond.
But Dr. Conners did not feel triumphant this fall as he addressed a group of fellow A.D.H.D. specialists in Washington. He noted that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”
“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”
The rise of A.D.H.D. diagnoses and prescriptions for stimulants over the years coincided with a remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors, educators and parents. With the children’s market booming, the industry is now employing similar marketing techniques as it focuses on adult A.D.H.D., which could become even more profitable.
Few dispute that classic A.D.H.D., historically estimated to affect 5 percent of children, is a legitimate disability that impedes success at school, work and personal life. Medication often assuages the severe impulsiveness and inability to concentrate, allowing a person’s underlying drive and intelligence to emerge.
But even some of the field’s longtime advocates say the zeal to find and treat every A.D.H.D. child has led to too many people with scant symptoms receiving the diagnosis and medication. The disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma, according to a New York Times analysis of C.D.C. data.
VIDEO FEATURE: How Pharmaceuticals Sell A.D.H.D.
http://www.nytimes.com/video/us/100000002574787/how-pharmaceuticals-sell-adhd.html?emc=edit_tnt_20131214&tntemail0=yPoh Si Teng and Alan Schwarz
What makes A.D.H.D. ads so effective? Harvard professor Dr. Aaron Kesselheim analyzes several ads and discusses how many of them play on parents’ common fears about their children.
Bill Nemitz: DHHS racked by a failure of leadership
The department, by far the largest in Maine’s state government, has become a cafeteria of crises.
It wasn’t exactly a ringing endorsement. Back in early 2011, while introducing Mary Mayhew as his new commissioner of the Maine Department of Health and Human Services, Gov. Paul LePage offered up an odd admission.
“We have interviewed an awful lot of people from all over the country,” LePage said during a news conference while Mayhew, smiling gamely, stood at his side. “I will tell you I’ve been rejected more by women in the last two weeks than in four years of high school and six years of college – and it’s all about money. We can’t pay enough.”
Almost three years later, one can’t help but wonder why Maine taxpayers are paying Mayhew at all.
Her department, by far the largest in Maine’s state government, has become a cafeteria of crises.
Her strategy, straight from the LePage playbook, is to deflect, delay and, when all else fails, blame DHHS’ many and varied blunders not on her own incompetence, but on “politics.”
Her legacy, if that’s what you want to call it, will be a social safety net that came apart at the seams – from a transportation program that leaves its needy clients stranded, to a million-dollar contract with a “consultant” who specializes in cutting services to the poor, to a proposed new regional office in South Portland that gives new meaning to the old Maine adage “you can’t get there from here.”
Many who enrolled in health plans still await confirmation
Anxiety grows as health plan delays could leave some customers without a policy by Jan. 1.
By Chad Terhune5:08 PM PST, December 12, 2013
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Thousands of Californians have overcome long waits and website glitches to sign up for Obamacare insurance, but now enrollment snags may prevent some of them from actually having coverage starting Jan. 1.
Some people who picked a health plan as far back as October through the Covered California exchange say insurers are telling them they still have no record of their enrollment. As a result, bills haven't gone out and consumers can't pay their initial premium to ensure coverage takes effect in less than three weeks.
Thomas Gallo of Glendora signed up his wife and son on the second day of enrollment in October. After hearing nothing for weeks, he said, he was told by the state in late November that his application and some others had been lost.
Gallo reapplied over the phone, but he said he still has no confirmation from Blue Shield of California about his family's Silver plan. Gallo, a retired accountant, has Medicare for himself.
"The back end is so backed up, and no one can give me an answer," said Gallo, a strong supporter of President Obama's healthcare law. "What happens if we don't get coverage by Jan. 1? There are real problems here."
Consumers' anxiety has grown as they endure long waits on the phone, computer errors and conflicting answers from the state and insurers about their coverage. The average wait time at the state's call centers climbed to 36 minutes last week, and California is still trying to clear a backlog of paper applications filed in October and November.
State officials say the huge demand for insurance is a positive sign for the rollout of the Affordable Care Act. They acknowledge there have been delays, but they say the vast majority of people are enrolling smoothly and getting their first insurance bills. The state said it didn't have exact figures on how many customers are still waiting for proof of insurance.
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