Hope On A Global Scale

At a time when the global economy is sagging and headlines are filled with reports of conflict and death, it is critical to keep in mind programs working to improve the health of mankind.

Of all the issues we have dealt with at the Institute of Federal Health Care, few seem more globally significant than immunization. Vaccines provide a nucleus around which public health efforts orbit in symbiosis. Vaccines have tremendous ROI in terms of avoided health care costs, and they can relieve or prevent suffering on a massive scale, as numerous studies have demonstrated.

If you want statistics, visit the Sabin Vacccine Institute’s website: www.sabin.org. The Sabin Institute works closely with the Bill and Melinda Gates Foundation to reduce the burden of vaccine-preventable diseases, both by increasing immunization rates and by developing new vaccines. The GAVI Alliance brings together developing countries, donor governments and organizations (including the Gates Foundation) and industry to bring immunization to the poorest parts of the world.

And now, a new organization reports happy news: the potential for a vaccine against dengue within two to three years. According to the Dengue Vaccine Initiative (of which the Sabin Institute is a member), several vaccine candidates are in various stages of advanced development, with clinical trials in progress on five of them.

A three-dose vaccine under development by Sanofi appears especially promising, with predictions that it could be available for widespread use by 2015. Dengue, also known as break-bone fever, kills about 20,000 individuals each year, many of them children.

So, things are happening that can relieve morbidity and mortality on a global scale. Let’s not forget that.

Birth Control A Complex Issue

By Harold M. Koenig, MD
Vice Admiral, US Navy (retired)

Recently a Georgetown University law student testified before a congressional committee about the high cost of contraceptive services.  She stated that contraceptives would cost her $3,000 during the three years she was in law school and so she supported the recent administration mandate that all health insurance programs provide contraception at no cost.  Georgetown is a Catholic university, so her testimony drew the immediate attention of the Church, the administration and the media.  She even received a phone call of support from the President after he saw her televised comments.  This delicate issue rapidly became more polarized and enflamed.

Birth control (BC) pills can cost nearly $1,000 per year or well under $100 per year, depending on the brand.  They all work pretty much the same and have similar ingredients, efficacy and safety.  The difference in cost is in the packaging and advertising and depends on whether the formulation is still on patent.  The most expensive ones are on patent and are advertised in slick, full-page color adds in magazines widely read by sexually active young women.  The women talk with each other about this, believe the advertising and demand the brand name prescription from their doctor — and most of them get it.  I checked with a large local health care group that provides birth control pills at no cost as part of their program, and they do provide the highest-cost pills to women who demand them.  They do this because they got so many complaints from patients when they tried to provide the less costly variety, it just became easier to give them what they demanded than to try and educate them.  The provider just spreads the costs between all of their program enrollees.

Individual providers in this program want to give these same young women the HPV Vaccine to prevent them from acquiring this ubiquitous virus that causes nearly all cervical cancer.  But some rules and regulations prevent them from giving it to an emancipated minor without parental consent.  Many of these underage girls have not told their parents they are sexually active and, for various reasons, don’t want them to know.  So, unless they are also using effective barrier or virucidal protection, they are at risk of acquiring HPV.

Another problem is the risk of acquiring STDs.  Many young people just becoming sexually active don’t understand that BC pills offer no protection from STDs, and perhaps give them a false sense of security about sex.  Most people have heard of gonorrhea, syphilis and HIV and know that the first two are curable and the third manageable if detected early enough.   The most common STD, though, is Chlamydia.  This less well-known infection can later on in life cause inability to conceive because of scarring in the fallopian tubes.  A young woman may not want to get pregnant now, but some day most of them will.  When they get to the time they feel their biologic clock is running out, they get desperate.  Unable to get pregnant the “natural” way, they resort to artificial methods that may work but are very expensive, tens of thousands of dollars per pregnancy.

Many doctors caring for young, sexually active women with multiple partners advise the use of condoms also to prevent getting an STD or acquiring HPV.  There is a lot more to the BC pill issue than just making them available to women at no cost.

Caring for Those Who Decline Vaccines

Vice Admiral Harold M. Koenig, MD
Former Surgeon General
US Navy

Some physicians are starting to decline caring for children whose parents refuse to allow their children to be immunized.  I would never refuse to continue to care for a child because a parent made what I thought was an unwise decision regarding their child's health care.  

I would document that the parent had been informed about the need for immunizations and refused.  I would continue to care for the child and try to help the parents deal with this and other difficult decisions. People do change their minds as they gather more facts.  By continuing to provide care and establishing trust and confidence some will change their minds.

When a physician refuses to continue to care for a child because their parents object to a recommended course of care, the parents will be forced to find care somewhere else.  Unless they can find a physician with the above attributes, they will default to physicians who focus on episodic illness care and not preventive care and education.

We know the latter provides far better outcomes than the former.

The Promise in Big Data

The next big thing in health care appears to be “Big Data” — the voluminous amounts of information spewed from new technologies and electronic health records. Big Data can tell us which treatments work and which don’t, how best to deliver care and how to make care more accessible. A report last year by McKinsey and Company estimated that the U.S. health care sector could add more than $300 billion in value a year by plumbing secrets amassed in Big Data.

Big Data also is seen as advancing personalized care, with the cloud and supercomputers such as IBM’s Watson able to store and process huge amounts of information to reveal which treatments work best for the genomic makeup of a particular individual.

“If Watson can already observe tons and tons of data — and it sits there day after day, it doesn’t take breaks, it doesn’t take lunches — these computers when given enough data can actually find patterns that might lead to real cures or better treatments,” Shahid Shah, CEO of the IT consulting firm Netspective Communications, said in an article in Health Care IT News.

A challenge will be to pair mined data with information captured in the electronic health record, the article notes.

A November article in Forbes observes that new sources of information are proliferating:

“New types and sources of health care data have become available – or soon will – and in overwhelming quantity.  The federal government is investing $20 billion in Electronic Health Records; industry is developing new electronic transaction standards; and innovators like PatientsLikeMe, 23andMe, Fitbit and Zeo are helping people generate and share their own data.  The era of Big Data in healthcare has arrived.”

Can all these efforts dovetail for maximum benefit?

“We must start producing better evidence faster and on a large scale,” the Forbes article asserts.  “Before we can reduce costs and deliver meaningful improvements in outcomes, we must have meaningful evidence.  Without it, we can never know what works, and for whom.”

The promise of Big Data can be seen in the Veterans Health Administration, where mined data from its VistA electronic record — generally agreed to be the most successful such EHR in the nation — has produced such advances in care as the National Surgical Quality Improvement Program (since adopted as a national program of the American College of Surgeons).

The future of Big  in health care is enticing. Advances in computing allow us to view massive amounts of information, and to use it in new ways. The trick will be to make sure we do it wisely, and well.

Health Care and the Mayan Prophecy

I have a neighbor — a really lovely person — who believes we already have entered the early stages of the Mayan prophecy that the world will transition from one “world age” to another by December of 2012. It won’t end, it just will end as we know it today, and it is our choice whether this transition brings a better, more peaceful future or a cataclysmic one.

While the Mayan prophecy deals with a global view, and is time-specific, this general expectation really applies to all parts of everyday life, including health care. We can all work together to find ways of making care more cost-effective and of higher quality, or we can continue to worry about protecting our own turf, whatever the price tag. Of course, how to bring about a transition in health care is a matter of heated debate as 2011 ends. Health care now occupies more than 17 percent of our Gross Domestic Product. We certainly can’t afford to ignore it, as that percentage will continue to rise with an aging population.

What will 2012 bring? As the health care debate continues, it is our choice as to how productive — or cataclysmic — its outcome will be.

Happy Holidays.

Nancy Tomich

Why is Health Care Reform so Hard?

Harold M. Koenig, MD

Vice Admiral, Medical Corps, United States Navy, Retired

America has been struggling with how to reform its health care system for several decades now.  The principal arguments made for why we need reform are:

·       Costs, we spend more on health care per capita than any other nation

·       The uninsured, 15% of our population historically has had no health insurance coverage

·       Shorter life expectancy than many other highly developed nations that spend much less per capita on health care than we do

Since the end of WW II health care inflation has exceeded the general cost of inflation and in recent decades has exceeded it by 2.5 - 3 times.  Soon it will consume 20% of our Gross Domestic Product.  Many believe this is not sustainable. 

Before WWII and during the Great Depression people paid cash, or bartered, for their health care.  If they couldn’t pay or barter for it, they usually went without.  During WW II there was a wage/price freeze. Employers could provide better benefits to attract and retain workers, so health care and pension benefits were offered. 

After the war employers continued to provide health care benefits.  Soon nearly two-thirds of Americans had employer provided health insurance.

Those who weren’t in the work force either paid for health care out-of-pocket, they got “charity” care or they just didn’t get it.  Amongst this latter group were many of the nation’s elderly. As part of the Great Society program of the Kennedy-Johnson administration, a program to pay for hospital care for those over 65, Medicare, was started in 1965.  Since then Medicare has been expanded with a cost-shared program to help pay for doctor bills (Medicare B), a managed care option (Medicare C) and most recently, a prescription drug benefit (Medicare D).  Today there are 40 million people over 65 enrolled in Medicare and another 8 million enrolled in another addition to the program for the disabled.  Between 1946 and 1964, 76 million Americans were born, known as the baby-boomers,  and they are beginning to retire.  Medicare costs will soon increase dramatically and with it the nation’s total health care bill.

Medicare coverage, employer provided coverage and those who pay for their own health insurance still leaves the nation with many without coverage.  Medicaid is a federal-state program for low-income individuals that meet certain criteria.  The State Children's Health Insurance Program (SCHIP) – more commonly known as the Children's Health Insurance Program (CHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

Even with all these programs we still have ~ 15% of people without coverage.  How to cover them is another major part of the financing problem.

That Americans have a shorter life expectancy than people living in over 40 other nations and that we pay more per capita for health care is often used as a reason why we need health care reform.  But a better understanding of these statistics is necessary before relying on them.  According to the US Census Bureau there are 308 million of us living in America now.  That’s over 100 million more than were here when the Great Society program got underway less than fifty years ago – meaning we’ve been adding about two million people a year.  Much of that population growth has not been from our indigenous birth rate; it is from people immigrating here.  Our fertility rate has been barely, and is probably now, insufficient to maintain our population numbers.  Today one of every eight of us living in this country was not born here – that’s forty million people.  Most of those people came here for the same reasons our ancestors did, they are looking for a better life for themselves and their families, and most of them hopefully will find it.  They carry with them the burden of disease brought from their homeland, and that takes a toll.  Most of them don’t live as long as we who were fortunate enough to be born here do.  They count in our life-expectancy statistics.  Over a million of them come here every year, and most stay.  No other nation has immigration like this, in fact, many have the opposite, emigration and a lot of their emigrates are heading here.

We also have regional differences in life expectancy, which we have a fair degree of understanding about, as we do gender and ethnicity differences.  Most of the explanation for these differences is because of cultural and educational differences rather than health care availability.  Better access to health care is not going to increase life expectancy near as much as are improvements in education.

One short comment about physicians.  When I graduated from medical school I did so along without about 8,000 others.  When the Great Society program was being built one of the elements in it was to double the output of physicians because the designers knew that it was going to take a lot more doctors to take care of all the elderly – older people need a lot more medical care.  So, over the next decade the number of medical school graduates doubled – to 16,000 a year.  Today we graduate about 17,000, not near enough.  We need another massive increase in physician output to take care of the 40 million people who don’t have health care insurance today and all the others heading our way.

So, this is why it’s so hard to do health care reform.  It is going to cost a whole lot of money, and we haven’t figured out how to convince the population of this great nation that we have to do this.  We need to educate people about why this is important and what it is going to take to do it.  That is the task before us.

Reducing Hospital Costs

By Harold M. Koenig, MD

Vice Admiral (Ret.) Harold M. Koenig is former Navy surgeon general and currently serves as chief medical officer of AwarePoint, which develops RTLS systems.

For several decades America has been alarmed about rapidly rising health care costs that have been increasing at triple the overall rate of inflation.  Hospital care is the biggest single component of health care costs.  This rate of health care inflation is unsustainable and hospitals must do something about it.  Some suggestions are made at the end of this post, but first a quick review of how we got here.

Approaching the second decade of the new century economic headwinds brought a financial slow down, recession, rising unemployment, financial institution failure and even threats of sovereign default.  Retrospectively the reasons for much of this are clear.  For decades we bought too much on credit, then sold the credit as bundled derivatives to other nations.  Interest is now due, payable and growing on this debt.

America’s housing bubble deservedly receives much of the blame for these economic problems, but there is plenty to spread around.  Traditional lending standards had been relaxed so much that just about anyone could get credit.   The diligence was not done to determine if borrowers would realistically ever be able to pay back their loans.

Warnings were sounded by traditionalists, but the cacophony from those enjoying new homes, autos, electronic gadgets and nice vacations drowned them out.  Many people believed we were in a new economy that would continue to only grow and never contract.  Recessions were thought to be a historical relic.

At the same time demographics were as always, destiny.  The baby-boom generation was rapidly approaching retirement, and promises for pensions and healthcare benefits exceeded the investments to finance them.  Government at all levels and private enterprises were faced with the reality that keeping these promises was a conundrum.

The 2010 census showed that of the 310 million people in the USA 15% lacked financed health care.  That is equivalent to the population of Spain.  This was an issue of national shame and international embarrassment.

In January of 2009 the new administration and congress put getting financed health care for all in this country at the top of their legislative agenda and passed the Patient Protection and Affordable Care Act (PPACA).  It is now going through the inevitable court challenges and its legality will ultimately be determined in the Supreme Court, probably in 2013, but implementation has already started.   Built into PPACA is a requirement that the government start collecting money to pay for benefits before they are provided.  PPACA isn't like buying something on credit; it's more like the long-gone consumer "lay-away" plans.  So, when benefits under PPACA become available there should be money to pay for them.

PPACA was made affordable so enabling legislation could be passed by identifying areas where costs could be reduced.  Medicare is a large part of healthcare costs, so $500 billion (that's a half-trillion) was removed from its budget over the next decade.  The biggest part of Medicare spending is for hospital care so huge reductions in hospital reimbursement are coming.  Medicare now provides over half of most private sector hospital's revenue.  Medicare is first payer for military retirees receiving care under Tricare for Life, so Medicare reimbursements to the Military Health System will also decrease.  Health care costs in Veterans Administration hospitals have been increasing, so though not receiving reimbursement from Medicare, they will also be under pressure to reduce costs.

Federal hospitals have only one way to cope with the coming decrease in financial resources, become more efficient.  The sooner they start the better off they will be.  Real Time Location Systems (RTLS) are a new technology that can help hospitals become more efficient, safer and reduce costs.

Here are some links explaining how RTLS can help:

Improving patient safety

Reducing Surgical Site Infections

Hand Washing Prevents Infections

RTLS Enabled Automatic Tracking

Improving Chances for Heart Attack Survival

Cost Containment and Efficiency Improvement

Hospital Infection Prevention

Improving Management of Heart Attack Patients

Improving Emergency Department Efficiency

Helping Nurses Become More Efficient

Tracking Assets in Real Time

Efficiently Moving Patients in Real Time

Improving Hospital Efficiency, Quality and Compliance

Efficient Hospital Transport Increases Revenue