Tuesday, August 31, 2004
Stigma Abates?
In another Psychiatric News article, a poll of Houston citizens suggests that community understanding of the etiology of mental illness is improving. Over 60 percent of those polled saw mental illness as a brain disorder. Only 5 percent saw it as a character flaw.
Here is what amazed me most about the study: almost 40 percent of those polled admitted to having a relative diagnosed with mental illness.
I take that back. Here is what was really most amazing: over half said they would pay higher taxes to improve access to mental health services.
Legislators say that raising taxes is the kiss of death for a political career. Perhaps legislators sometimes underestimate the compassion of their constituents.
Here is what amazed me most about the study: almost 40 percent of those polled admitted to having a relative diagnosed with mental illness.
I take that back. Here is what was really most amazing: over half said they would pay higher taxes to improve access to mental health services.
Legislators say that raising taxes is the kiss of death for a political career. Perhaps legislators sometimes underestimate the compassion of their constituents.
Monday, August 30, 2004
Mental Illness At Juvenile Detention
In the mid-1800's, Dorothea Dix began a crusade for the rights of people with mental illness to be treated humanely, after finding that most were being housed in jails, often living in filth, chained or beaten.
One hundred and fifty years later, a study reported in Psychiatric News finds youth with mental illness suffering a somewhat similar fate. According to a US House of Representatives report, two-thirds of juvenile detention facilities hold youth who are waiting for community-based mental health care.
When I compare the histories and symptoms of youth I evaluate inside of juvenile detention facilities with those I evaluate in a community clinic, I find just one striking difference: when the disruptive behaviors occur at home, parents of clinic-treated youth call the psychiatrist, but parents of the jailed youth call the police. Parents who call the police are more likely to end up with a child in juvenile detention, regardless of the etiology for the behavior problems.
One hundred and fifty years later, a study reported in Psychiatric News finds youth with mental illness suffering a somewhat similar fate. According to a US House of Representatives report, two-thirds of juvenile detention facilities hold youth who are waiting for community-based mental health care.
When I compare the histories and symptoms of youth I evaluate inside of juvenile detention facilities with those I evaluate in a community clinic, I find just one striking difference: when the disruptive behaviors occur at home, parents of clinic-treated youth call the psychiatrist, but parents of the jailed youth call the police. Parents who call the police are more likely to end up with a child in juvenile detention, regardless of the etiology for the behavior problems.
Sunday, August 29, 2004
Is Hyperactivity Really Increasing Among Girls?
An article in the latest Journal of the American Academy of Child and Adolescent Psychiatry suggests that while the incidence of psychopathology is not increasing in children overall, it is increasing in girls. The study (out of Finland) looked at changes in prevalence in the ten years between 1989 and 1999. The overall prevalence was unchanged, but that's because boys had fewer psychiatric symptoms while the rate of hyperactivity symptoms jumped in girls.
The number of children seen for mental health services more than doubled in the time period, mainly because the number of girls treated for hyperactivity quadrupled.
Where were all these hyperactive girls ten years ago? In the same classrooms, I imagine, but with school systems and parents more tolerant of variations in normal behavior, less bombarded with advertising about the efficacy of Ritalin and the like, and so less likely to label those behaviors as symptoms of hyperactivity.
The number of children seen for mental health services more than doubled in the time period, mainly because the number of girls treated for hyperactivity quadrupled.
Where were all these hyperactive girls ten years ago? In the same classrooms, I imagine, but with school systems and parents more tolerant of variations in normal behavior, less bombarded with advertising about the efficacy of Ritalin and the like, and so less likely to label those behaviors as symptoms of hyperactivity.
Thursday, August 26, 2004
Does Poverty Cause Psychopathology?
Apparently Texas isn't the only place where it's hell to be poor nowadays. News reports today show the number of ininusured increasing everywhere -- but it is worse in the South than elsewhere, and worst in Texas.
And poverty is at its highest level in six years.
There was a study awhile back that showed a relationship between poverty and serious behavior problems in children and adolescents. When families moved out of poverty, behavior problems decreased. The authors suggested that it might be that parents who made more money had to work less, and so could spend more time with their children.
Perhaps it would be less expensive to society to assure families had an adequate income so that parents could spend time with their children, rather than pay for psychiatrists, Ritalin, and (later) juvenile detention cells and probation officers.
And poverty is at its highest level in six years.
There was a study awhile back that showed a relationship between poverty and serious behavior problems in children and adolescents. When families moved out of poverty, behavior problems decreased. The authors suggested that it might be that parents who made more money had to work less, and so could spend more time with their children.
Perhaps it would be less expensive to society to assure families had an adequate income so that parents could spend time with their children, rather than pay for psychiatrists, Ritalin, and (later) juvenile detention cells and probation officers.
Wednesday, August 25, 2004
"Let the Little Children Come Unto Me..."
I loved this line that starts an editorial from the Austin American-Statesman this AM: "It's hell being poor anywhere in the United States, but in Texas, there's growing disdain for people who work every day but earn too little to afford more than the basics: food, shelter and clothing."
Amen. And that disdain, manifesting as society's refusal to help with the healthcare of the poor, indirectly affects the sense of mission, and even the livelihood, of those who seek to serve the poor.
Texas has a higher percentage of people without health insurance than any other state. And contrary to the stigma that says people without insurance are just too lazy to work, three out of four uninsured people in Texas have jobs or are the children of the working poor.
Children make up one-third of the people without health insurance in Texas. Which just goes to prove that when there is nothing but scraps left on the table, and when the pushing and shoving begins, there is little wonder that (at least in Texas) the only thing worse than being poor is being poor and little...
Amen. And that disdain, manifesting as society's refusal to help with the healthcare of the poor, indirectly affects the sense of mission, and even the livelihood, of those who seek to serve the poor.
Texas has a higher percentage of people without health insurance than any other state. And contrary to the stigma that says people without insurance are just too lazy to work, three out of four uninsured people in Texas have jobs or are the children of the working poor.
Children make up one-third of the people without health insurance in Texas. Which just goes to prove that when there is nothing but scraps left on the table, and when the pushing and shoving begins, there is little wonder that (at least in Texas) the only thing worse than being poor is being poor and little...
Monday, August 23, 2004
Standard-of-Care or Best-Value?
Psychiatric News has an article this week about the Texas Medication Algorithm project (TMAP). Although the article touts the clinical outcomes when using the algorithms, and although the algorithms are clearly the standard of care for public mental health medication treatment in Texas nowadays, there has been some controversy around how they were developed.
In that context, it was interesting that the article included a box that reminds readers of the "complexity" of doing clinical research in "today's research environment."
The issue in Texas is this: did pharmaceutical company funding of the project, or even of unrelated projects by its primary researchers, impact the project's outcome? Would newer, more expensive medications otherwise not have been the algorithm's first-line choice for treatment?
The problem in Texas is this: there is a declining number of dollars available for indigent psychiatric care. At the same time, medication costs are climbing. That leaves less dollars for doctors, counseling and rehabilitation.
Unfortunately, in the medical industry (unlike in other industries) care that is touted as "the standard" does not have to take best value into consideration. That's one reason medical costs are out of control.
In that context, it was interesting that the article included a box that reminds readers of the "complexity" of doing clinical research in "today's research environment."
The issue in Texas is this: did pharmaceutical company funding of the project, or even of unrelated projects by its primary researchers, impact the project's outcome? Would newer, more expensive medications otherwise not have been the algorithm's first-line choice for treatment?
The problem in Texas is this: there is a declining number of dollars available for indigent psychiatric care. At the same time, medication costs are climbing. That leaves less dollars for doctors, counseling and rehabilitation.
Unfortunately, in the medical industry (unlike in other industries) care that is touted as "the standard" does not have to take best value into consideration. That's one reason medical costs are out of control.
Sunday, August 22, 2004
Another Psychosomatic Disorder's Demise?
Historically, as long as the diagnosis of a disorder was symptom-based and rather nebulous, the disorder belonged to psychiatry. Once a syndrome could be narrowly defined, and especially if the pathogenesis could be determined, some other specialty would abscond with the disease.
I see in JAMA that bacterial overgrowth is the proposed culprit for irritable bowel syndrome (IBS), one of the traditional psychosomatic disorders.
Mmm --- maybe...
A few posts back, I noted the high number of disorders -- psychiatric and otherwise -- that could be described as "nervous system disorders," specifically, "autonomic nervous system disorders. " The JAMA article suggests such a component to IBS.
I'd bet a cookie that some day all so-called psychosomatic disorders will be shown to be autonomic nervous system disorders.
I see in JAMA that bacterial overgrowth is the proposed culprit for irritable bowel syndrome (IBS), one of the traditional psychosomatic disorders.
Mmm --- maybe...
A few posts back, I noted the high number of disorders -- psychiatric and otherwise -- that could be described as "nervous system disorders," specifically, "autonomic nervous system disorders. " The JAMA article suggests such a component to IBS.
I'd bet a cookie that some day all so-called psychosomatic disorders will be shown to be autonomic nervous system disorders.
Tuesday, August 17, 2004
Why Antidepressants Don't Work
Too low of a dose and too short of a treatment time are the two biggest reasons for failure of anti-depressant medications.
But that assumes that the diagnosis is really major depression.
Yes, sometimes medications just don't work. But when that happens, improper diagnosis is the most likely reason. A pill can't fix a bad marriage or a miserable job, and it can't take away the pain when a loved one is lost - even though all of these may leave you with many of the symptoms of major depression.
One of the biggest problems with the decreasing reimbursement for physician services is that family docs and psychiatrists don't have enough time with a patient to do a thorough assessment. It takes more than seven minutes to sort out worries from symptoms of a major psychiatric disorder, and then come up with a thorough plan of treatment.
But that assumes that the diagnosis is really major depression.
Yes, sometimes medications just don't work. But when that happens, improper diagnosis is the most likely reason. A pill can't fix a bad marriage or a miserable job, and it can't take away the pain when a loved one is lost - even though all of these may leave you with many of the symptoms of major depression.
One of the biggest problems with the decreasing reimbursement for physician services is that family docs and psychiatrists don't have enough time with a patient to do a thorough assessment. It takes more than seven minutes to sort out worries from symptoms of a major psychiatric disorder, and then come up with a thorough plan of treatment.
Monday, August 16, 2004
Economic Recovery and Denial as a Defense
I'll never forget my days back in MBA school, listening to all the denial and rationalization for why the stock market bubble wasn't a bubble at all. Somehow this time it was "different."
In the Dallas Morning News today, Danielle Demartino reminds us that we are experiencing the same denial about the current "economic recovery." Even though there are no jobs, spending is too high, and oil prices are too high, folks are saying that those classic indicators don't matter.
This recovery is "different."
Denial is bliss, I always say...
In the Dallas Morning News today, Danielle Demartino reminds us that we are experiencing the same denial about the current "economic recovery." Even though there are no jobs, spending is too high, and oil prices are too high, folks are saying that those classic indicators don't matter.
This recovery is "different."
Denial is bliss, I always say...
Saturday, August 14, 2004
Nervous System Disorders
A friend recently called about her husband who won't take the medication for depression that his doctor prescribed. Even though he's felt miserable for months, he still believes that he needs to fight off the depression on his own.
In all my years in practice, I can't recall a single patient who refused to take his blood pressure medication because he thought he should be able to fight off high blood pressure. But I wish I had a cookie for every time someone declined my recommendation about starting anti-depressant medication!
I guess that's the old stigma about getting mental health care, right?
Yet, concretely, the same part of the body is troubled in both high blood pressure and depression -- the nervous system. And besides the fact that both might be described as "nervous system disorders," serious depression and serious blood pressure problems are similar in other ways. For example, they're both affected by stress. They both run in families. And, they both are potentially fatal if not treated.
There is no stronger advocate than me for psychotherapy as an alternative to medication to treat less severe depressions. And, each of us certainly needs to look for stresses that affect a major depression and consider changes to improve those situations -- but I feel the same way about stress and high blood pressure!
In all my years in practice, I can't recall a single patient who refused to take his blood pressure medication because he thought he should be able to fight off high blood pressure. But I wish I had a cookie for every time someone declined my recommendation about starting anti-depressant medication!
I guess that's the old stigma about getting mental health care, right?
Yet, concretely, the same part of the body is troubled in both high blood pressure and depression -- the nervous system. And besides the fact that both might be described as "nervous system disorders," serious depression and serious blood pressure problems are similar in other ways. For example, they're both affected by stress. They both run in families. And, they both are potentially fatal if not treated.
There is no stronger advocate than me for psychotherapy as an alternative to medication to treat less severe depressions. And, each of us certainly needs to look for stresses that affect a major depression and consider changes to improve those situations -- but I feel the same way about stress and high blood pressure!
Wednesday, August 11, 2004
Psychiatry's Future?
Many years ago, while on-call for the psychiatric hospital where I practiced, I was called in one Saturday afternoon to do an intake on a man brought in on a commitment. Apparently he had returned from a business trip and announced to his wife that he wanted a divorce. She, in all earnestness, thought he must be psychotic to want a divorce from her, and so she had him committed.
Medpundit's citation of a recent discussion of Soviet psychiatry (brought to my attention by Trent McBride) brought this anecdote back to mind.
But it had also come to mind while watching the movie, The Manchurian Candidate, last weekend. I commented to my wife afterwards that I could not count the number of people I had evaluated over the years who thought a device in the head was controlling them. In retrospect, perhaps one or two of them may have been right, who knows?
So I think it is easy, in a society with rampant persecution, to rationalize the notion that a dissenter might be mentally ill.
That's because social pressures and economic pressures drive the role of psychiatry (and most other businesses). In contemporary America, there are limited dollars available for mental health care, and those dollars are decreasing all the time. The pharmaceutical companies have the best marketing prowess, they have done the best job of navigating what freedom there is in the medical marketplace, and thus they have driven limited dollars in their direction.
That's exacerbated by what Daniel Callahan has called the "research imperative," the view that biomedical research is all good, and by contrast, anything not readily amenable to research-based proof is bad. Lacking sold research in its corner, psychoanalysis has been relegated to the latter.
I'm not convinced that Americans "need not fear" an emerging darkness similar to Soviet society. The Manchurian Candidate reflected McCarthy-era social fears, which many compare to post-9/11 America. Part of the problem when such societies emerge is the denial among most that it is even happeneing.
Medpundit's citation of a recent discussion of Soviet psychiatry (brought to my attention by Trent McBride) brought this anecdote back to mind.
But it had also come to mind while watching the movie, The Manchurian Candidate, last weekend. I commented to my wife afterwards that I could not count the number of people I had evaluated over the years who thought a device in the head was controlling them. In retrospect, perhaps one or two of them may have been right, who knows?
So I think it is easy, in a society with rampant persecution, to rationalize the notion that a dissenter might be mentally ill.
That's because social pressures and economic pressures drive the role of psychiatry (and most other businesses). In contemporary America, there are limited dollars available for mental health care, and those dollars are decreasing all the time. The pharmaceutical companies have the best marketing prowess, they have done the best job of navigating what freedom there is in the medical marketplace, and thus they have driven limited dollars in their direction.
That's exacerbated by what Daniel Callahan has called the "research imperative," the view that biomedical research is all good, and by contrast, anything not readily amenable to research-based proof is bad. Lacking sold research in its corner, psychoanalysis has been relegated to the latter.
I'm not convinced that Americans "need not fear" an emerging darkness similar to Soviet society. The Manchurian Candidate reflected McCarthy-era social fears, which many compare to post-9/11 America. Part of the problem when such societies emerge is the denial among most that it is even happeneing.
Monday, August 09, 2004
Alcohol as Self-Medication for Depression
Alcohol is a "depressant drug," so folks who drink heavily can look as if they have a clinical depression. How can a doctor tell if the depression is "real" or caused by too much drinking?
Let's say you go several weeks eating only bacon for breakfast, french fries for lunch and spare ribs for dinner. Then you go to the doctor one afternoon to check your cholesterol. It's likely going to be high! Should your doctor put you on cholesterol medicine, or tell you to change your eating habits first?
Now let's say you go several weeks drinking only beer and whiskey. Then you go to the doctor one afternoon because you feel depressed. Should your doctor put you on depression medicine, or tell you to change your drinking habits first?
I believe you should address the habits first. When making a diagnosis of high cholesterol, docs have you go a few hours without food before measuring your blood level. Likewise, before a doctor can diagnose clinical depression you have to be free of drugs and alcohol for awhile. In fact, research suggests you must go several weeks without drinking before you can make an accurate diagnosis of a mental disorder.
I'm also wary of the rationalization used by some substance abusers that they are "self-medicating" a depression. When they self-medicate, most folks pick a substance that makes the symptoms worse, not better...
Let's say you go several weeks eating only bacon for breakfast, french fries for lunch and spare ribs for dinner. Then you go to the doctor one afternoon to check your cholesterol. It's likely going to be high! Should your doctor put you on cholesterol medicine, or tell you to change your eating habits first?
Now let's say you go several weeks drinking only beer and whiskey. Then you go to the doctor one afternoon because you feel depressed. Should your doctor put you on depression medicine, or tell you to change your drinking habits first?
I believe you should address the habits first. When making a diagnosis of high cholesterol, docs have you go a few hours without food before measuring your blood level. Likewise, before a doctor can diagnose clinical depression you have to be free of drugs and alcohol for awhile. In fact, research suggests you must go several weeks without drinking before you can make an accurate diagnosis of a mental disorder.
I'm also wary of the rationalization used by some substance abusers that they are "self-medicating" a depression. When they self-medicate, most folks pick a substance that makes the symptoms worse, not better...
Sunday, August 08, 2004
Use of Psychotropic Medication by Region
Folks back East are less medicated for psychiatric disorders than elsewhere in the country.
That's just a sidebar to an article about the use of medication before and after 9/11. Most studies like this suggest no more than a modest increase in use after the attacks.
But this study shows that folks in the Northeast use one-third less antidepressants, anxiolytics, antipsychotics and sleeping meds than the national average.
And women use twice as many as men...
That's just a sidebar to an article about the use of medication before and after 9/11. Most studies like this suggest no more than a modest increase in use after the attacks.
But this study shows that folks in the Northeast use one-third less antidepressants, anxiolytics, antipsychotics and sleeping meds than the national average.
And women use twice as many as men...
Saturday, August 07, 2004
Placebo
An article in this months' American Journal of Psychiatry notes that the placebo effect is much greater in a study of patient with panic disorder or social phobia than in patients with obsessive-compulsive disorder. Why would that be? Does it suggest a greater biological substrate in OCD? Or does it reflect (as the authors suggest) that OCD is less likely to spontaneously remit? The mind-brain barrier problem again...
Friday, August 06, 2004
Hyperactivity in Adults
Now comes an article in JAMA reaffirming the diagnosis of hyperactivity in adults.
It was not too long ago that a young adult coming to my office seeking Ritalin or Adderall would most likely leave with a substance-use spectrum diagnosis – and without a script. In my experience, the symptoms of poor concentration, fidgetiness and impulsiveness in an adult who comes in asking for amphetamines is more likely to be amphetamine abuse than attention deficit disorder.
But nowadays it feels politically incorrect not to give the fashionable diagnosis and the amphetamines. Of course, research does suggest a high rate of multiple diagnoses in this group – including substance use disorders. Poor concentration and restlessness are listed under “anxiety disorder” in the diagnostic manual, as well.
I used to offer Wellbutrin to adults presenting with this set of symptoms who asked for treatment for hyperactivity, as Wellbutrin is a good second-line medication for hyperactivity. But usually my suggestion of this approach was declined by these patients. It was not what they had in mind…
It was not too long ago that a young adult coming to my office seeking Ritalin or Adderall would most likely leave with a substance-use spectrum diagnosis – and without a script. In my experience, the symptoms of poor concentration, fidgetiness and impulsiveness in an adult who comes in asking for amphetamines is more likely to be amphetamine abuse than attention deficit disorder.
But nowadays it feels politically incorrect not to give the fashionable diagnosis and the amphetamines. Of course, research does suggest a high rate of multiple diagnoses in this group – including substance use disorders. Poor concentration and restlessness are listed under “anxiety disorder” in the diagnostic manual, as well.
I used to offer Wellbutrin to adults presenting with this set of symptoms who asked for treatment for hyperactivity, as Wellbutrin is a good second-line medication for hyperactivity. But usually my suggestion of this approach was declined by these patients. It was not what they had in mind…
Wednesday, August 04, 2004
Dizziness
It occurs to me that just about every medical specialist treats some disease that causes dizziness. When a patient presents with dizziness, the neurologist worries about high blood pressure, the cardiologist worries about heart disease, and the ENT considers an inner ear disorder.
When psychiatrists see someone with dizziness, we worry about panic disorder. It's a pretty common problem, but it's one that often goes months and months without being diagnosed -- if it ever is! Most folks have had a panic attack some time or another -- dizziness, faint feelings, flushes, chest pain, fear of dying. But if you never have, remember the time you had your worst case of "stage fright" and multiply it tens times in intensity. Now, imagine having that severe of a panic attack several times a week, or even daily. That's panic disorder.
Fortunately, there are very good treatments available for panic disorder. Medication can slowly resolve the attacks, and help folks return to their normal routines. And often the medications can be stopped after the problem has resolved.
When psychiatrists see someone with dizziness, we worry about panic disorder. It's a pretty common problem, but it's one that often goes months and months without being diagnosed -- if it ever is! Most folks have had a panic attack some time or another -- dizziness, faint feelings, flushes, chest pain, fear of dying. But if you never have, remember the time you had your worst case of "stage fright" and multiply it tens times in intensity. Now, imagine having that severe of a panic attack several times a week, or even daily. That's panic disorder.
Fortunately, there are very good treatments available for panic disorder. Medication can slowly resolve the attacks, and help folks return to their normal routines. And often the medications can be stopped after the problem has resolved.
Tuesday, August 03, 2004
Biz-Speaking, The Patient is the Product
In the arguments on how to finance health care, there is no question that movement toward a competitive marketplace enhances quality of care, and increases access to care for the uninsured and underinsured. Here's a link to an analysis of a program in Texas that switched from a single-provider for mental health services to a competitive environment, with marked increases in patients-served and no indicators to suggest reduced quality.
But no medical care in this country is provided in a free market.
The biggest roadblock to this is the current payment structure, which puts too much distance between the patient and the dollars. As I said yesterday, this means that the patient is not the customer. From a business perspective, the patient (or at least patient care) is the product, and it is being purchased by a company (or by the government).
And actually, the purchaser delegates an insurance company to buy on its behalf. The purchaser also delegates much of the product selection (medication, procedures) to the supplier-doc -- without regard to cost.
So at best, the provider (that is, the doc) is incentivized to provide the product that the intermediary wants, not what the patient wants. At worst, no one pays attention to cost or quality -- and certainly no provider is incentived to do so.
Finally, the purchasers have no way to discriminate product quality, and so they end up paying the same price for a medical-Chevy as they do for a medical-Cadillac. (Just ask most docs if they know the relative cost of equally-effective medications for the same disorder.)
The best way to reduce costs, increase access, and improve quality is to return purchasing power to the patients, and then arm them with outcomes data. Give employees each a fixed benefit for health care costs (and buy each a personal stop-loss policy), tell them they can keep what they dont spend -- and watch costs plummet with no reduction in outcomes. That frees of medical-care dollars system-wide to increase access for the underinsured.
But no medical care in this country is provided in a free market.
The biggest roadblock to this is the current payment structure, which puts too much distance between the patient and the dollars. As I said yesterday, this means that the patient is not the customer. From a business perspective, the patient (or at least patient care) is the product, and it is being purchased by a company (or by the government).
And actually, the purchaser delegates an insurance company to buy on its behalf. The purchaser also delegates much of the product selection (medication, procedures) to the supplier-doc -- without regard to cost.
So at best, the provider (that is, the doc) is incentivized to provide the product that the intermediary wants, not what the patient wants. At worst, no one pays attention to cost or quality -- and certainly no provider is incentived to do so.
Finally, the purchasers have no way to discriminate product quality, and so they end up paying the same price for a medical-Chevy as they do for a medical-Cadillac. (Just ask most docs if they know the relative cost of equally-effective medications for the same disorder.)
The best way to reduce costs, increase access, and improve quality is to return purchasing power to the patients, and then arm them with outcomes data. Give employees each a fixed benefit for health care costs (and buy each a personal stop-loss policy), tell them they can keep what they dont spend -- and watch costs plummet with no reduction in outcomes. That frees of medical-care dollars system-wide to increase access for the underinsured.
Monday, August 02, 2004
Alternative to Socialized Medicine
In an essay in the June edition of Harvard Business Review, Michael Porter argues for redefining health care competition at the level of outcomes, rather than at the level of insurance plans. Right now, price is really determined in negotiations between the human resource departments of major companies and insurance companies, as the latter compete to provide coverage to those businesses.
That's a long ways away from the poor patient who is at everyone's mercy.
Porter argues that in most businesses, process improvements drive down prices and costs while quality rises. But in health care, costs are forever climbing, many patients receive poor quality care, and there are wide discrepancies in quality among providers who all get paid the same.
That's because the people in the healthcare business -- health plans, payers, providers and doctors -- engage in what Porter calls "zero-sum competition." We divide the current value rather than creating any new value. He says we seek to transfer costs onto one another, limit access to care, hoard information and stifle innovation, all to the detriment of patients.
Porter calls for making outcome data widely available, so that "product" quality becomes a major factor in patient choice of physicians and hospitals. That is, there needs to be a Consumer Reports annual "Doctors and Hospitals" issue, just like the one for cars.
I think this would work, but with one proviso: Insurance plans would have to allow patients to go to any doctor of their choosing. And ideally, the price would be determined by the patient. Because one of the major problems of the current sytem is that the doctor's "customer" is not the patient, at all -- it's the insurance company.
That's a long ways away from the poor patient who is at everyone's mercy.
Porter argues that in most businesses, process improvements drive down prices and costs while quality rises. But in health care, costs are forever climbing, many patients receive poor quality care, and there are wide discrepancies in quality among providers who all get paid the same.
That's because the people in the healthcare business -- health plans, payers, providers and doctors -- engage in what Porter calls "zero-sum competition." We divide the current value rather than creating any new value. He says we seek to transfer costs onto one another, limit access to care, hoard information and stifle innovation, all to the detriment of patients.
Porter calls for making outcome data widely available, so that "product" quality becomes a major factor in patient choice of physicians and hospitals. That is, there needs to be a Consumer Reports annual "Doctors and Hospitals" issue, just like the one for cars.
I think this would work, but with one proviso: Insurance plans would have to allow patients to go to any doctor of their choosing. And ideally, the price would be determined by the patient. Because one of the major problems of the current sytem is that the doctor's "customer" is not the patient, at all -- it's the insurance company.
Sunday, August 01, 2004
Cost-effective Medical Care
In my July 25th post on the new "disease management" initiative for poor people with mental illness in Texas, I mentioned that its goal is to treat fewer, sicker people better.
What happens to those deemed not sick enough? One worry is that they deteriorate until they require a stay at a psychiatric hospital. It's sort of like saying that finances disallow you to treat diabetes until the blood sugar is high enough that symptoms warrant hospitalization.
Now comes evidence that perhaps the crisis for those left untreated has already started, even before the disease management program gets up and running.
I'm reminded of the dilemma when a cash-strapped public health system enforces a co-pay on every outpatient clinic visit, only to see outpatient visits go down and more-expensive ER visits go up. Some interesting medical economic problems could be analyzed there.
What happens to those deemed not sick enough? One worry is that they deteriorate until they require a stay at a psychiatric hospital. It's sort of like saying that finances disallow you to treat diabetes until the blood sugar is high enough that symptoms warrant hospitalization.
Now comes evidence that perhaps the crisis for those left untreated has already started, even before the disease management program gets up and running.
I'm reminded of the dilemma when a cash-strapped public health system enforces a co-pay on every outpatient clinic visit, only to see outpatient visits go down and more-expensive ER visits go up. Some interesting medical economic problems could be analyzed there.
