Sean Khozin, MD, MPH

Despite the state’s move towards universal health insurance, visits to Massachusetts emergency rooms went up 7% between 2005 and 2007. This is consistent with a 2008 study in the Annals of Emergency Medicine showing that the primarily driver behind an increase in emergency room utilization from 1996 to 2004 was lack of access to convenient care, not lack of health insurance. In this study, uninsured individuals accounted for less than 16% of emergency room visits.

The moral of the story: health insurance coverage does not equal access to care, at least not as long as we have a shortage of primary care physicians. Ensuring access to care requires transforming our payment system, addressing the structural defects in healthcare delivery, and revitalizing primary care.

The arrival of digital medicine promises to shake the medical establishment to its roots, not least because it will hand so much more information over to patients themselves. But the biggest savings will not come through exotic pills or “patient empowerment”, but from the application of basic economics. Realign the incentives in health care so that innovation focuses on making patients better and health care cheaper…

Economist

I agree and our challenge remains reforming the payment system so that it can support the uptake of innovations that bring true value to the healthcare system.

Jay and I will be speaking to the medical students at Mount Sinai in NYC about Hello Health and the future of our beloved profession, replete with beer and snacks! We often speak in these settings and it’s always a pleasure to connect with the curious doctors and leaders of tomorrow.

Here’s the official invitation:

THE FUTURE OF MEDICINE!

HELLO HEALTH is revolutionizing health care using our familiar procrastination technology.

Frustrated with the bureaucracy of health care, a group of Brooklyn physicians created Hello Health: a system of affordable, efficient, user-friendly health care using facebook, video g-chat, and text messaging. Hear them speak about their vision…

WHERE: Annenberg Student Lounge
WHEN: Thursday April 16th at 6pm
BEER AND SNACKS WILL BE SERVED!

In the latest issue of the New England Journal of Medicine, Eric G. Campbell, Ph.D., writes about “The Future of Research Funding in Academic Medicine.”

The premise:

Medical schools and teaching hospitals in the United States are essential producers of basic scientific and clinical knowledge that drives our supply of new medicines, devices, and other health care innovations. Today, the funding for this work is dwindling, rendering the current structure of the biomedical research enterprise unsustainable. Given the economic crisis, the fiscal and operational models of this enterprise must be restructured if the stability of academic institutions is to be maintained and our growing health care needs are to be met.

Financial support for biomedical research in the United States comes from 3 main sources:

• Government (federal and state)
• Pharma/biotech industry
• Nonprofit foundations

The problem:

For the near future, the outlook for research funding from any of these sources is rather bleak. States are expected to reach a combined budget shortfall exceeding $200 billion…  Industry is spending more on research and development, but fewer drugs and medical devices are being approved for the market, and tightened regulation may be hurting profits… Evidence of a downturn in foundation support is already emerging. Since last October, unprecedented declines in the stock market have reduced foundations’ endowments by an average of 30%.

The solution (this one is a lot more difficult to predict and articulate):

If U.S. science is to continue playing a key role in global progress, some major belt tightening will be required. …major reform, with an eye toward long-term sustainability and management of research-enterprise growth, is essential. Although academic institutions face great challenges, our country’s unprecedented hardships may provide them with a long overdue stimulus to make needed changes. A failure to seize this opportunity could have dramatic consequences for the health of the research enterprise.

Ultimately, says Khozin, the goal is for Hello Health to go nationwide, and hopefully impact proposals for reform. “The heath-care system cannot be fixed the way it is,” Khozin says. “Top-down mandates won’t work. The best kind of reform is grass-roots.”

The above segment is an excerpt from a recent New York Post article where I talk about Hello Health and clearly show my affinity for grassroots-driven transformation in healthcare.

I firmly believe that bottom-up innovation can be the most viable way of addressing many of the deficits of our healthcare system such as limited access to care and inefficiencies in care delivery.  I should point out, however, that there is certainly a need for top-down reform, which has the potential to spark innovation and lay the groundwork for more efficient practices. For example, tort reform to discourage predatory lawsuits against physicians is of crucial importance in reducing healthcare costs. The constant and ubiquitous fear of lawsuits drive physicians to order unnecessary tests and procedures that may trigger a trail of more expensive tests and procedures, all to meet the legal needs of documenting the physician’s thought process. Complications do sometimes arise as a result of these rather paranoid acts of self-defense. This practice is appropriately called defensive medicine and has made the act of doing too many unnecessary things an absolute legal necessity for physicians. Meaningful tort reform is the only solution and that comes from the top.

There are other examples of top-down initiatives that can have a positive and meaningful impact such as payment reform to reward physicians for the use of technology (e.g. email communication with patients) and delivering preventive care.

Another good article coauthored by Jerome Groopman, New Yorker staff writer and Harvard physician, on the dangers of promoting protocol-based medicine:

…rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.

David Sackett, a guru in the world of evidence-based medicine, is cited in the article as famously saying that “half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half — so the most important thing to learn is how to learn on your own.”

Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms.

We can never replace the individual judgement of good physicians with strict protocols, not in the foreseeable future. Medicine remains more of an art than science and science is driven more by creativity than vise versa. Strict rules on how to practice medicine can force physicians down the wrong path and end up hurting patients.

The PSFK folks aptly dubbed the panel discussion that Jay and I were on last week “simplify my healthcare.” It’s a great description and speaks directly to what we do at HelloHealth: we enable the delivery of top quality care in a convenient, efficient, and pleasant manner. We use smartly designed technology to simplify the healthcare experience and restore the patient-doctor bond.

Colin Nagy (moderator), Richard Fine (Help Remedies), me and Jay (HelloHealth)

Here’s a more detailed summary of our panel discussion as noted on the PSFK website:

Panel discussion on the state healthcare from both product and services points of view. Both Help and HelloHealth have identified the shortcomings of a medical system that has placed the continued success of the medical business machine ahead of the care of patients. Medications are developed to satisfy marketing departments and product schedules and don’t have any connection to actually making you feel better.

Medicine cabinet is the saddest place in your house

- Richard Fine

Help strives to strip away all the marketing bullshit that surrounds over the counter medication that creates confusion in the remedy aisle a the drugstore. Simple packaging, no additives or special formulas. They are striving for the essentials and simplicity in delivery of medical care product.

Healthcare Industrial Complex

“I get paid to $10000 to treat asthma & $300 to prevent it. The system is broken.”

“Doctor gets 6%-7% of each dollar spent on healthcare. The rest goes into supporting the insurance billing system”

“We spend 1 hour with a doctor, 8,764 hours without a doctor”

Hello Health seeks to position itself outside of the standardized healthcare system that has been constructed as a billing system for insurance companies rather that a care system for patients. By removing the middle man from the health care equation they propose that health insurance be used for the catastrophic needs, not for everyday sniffles or routine care.

You don’t use car insurance for an oil change. Why use health insurance for routine care?

Hello Health is a platform that creates a social network, between patients and doctors, allowing one to find a doctor that a a good fit, rather than one that happens to be in their insurance network. Doctors sign up, create a profile and are available via email, IM, video chat. Your health records are all online and your care is portable.

This was a combination presentation and panel which, format wise, was the best as it allowed the audience to see work as the presenters wanted it to be seen and then discussed within the panel. Colin Nagy also did a great job of being a moderator, which in these situations is usually best done by staying out of the way and gently guiding the conversation.

Low reimbursement rates and too much paperwork is forcing doctors to opt out of Medicare. “Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare.”

This is bad news for our elderly and aging population and highlights why health coverage does not equal access to care. It also points to the administrative hassles that are weighing down primary care.

I’ll be on a panel at the PSFK conferene tomorrow with my business partner taking about HelloHealth. Stop by if you’re in the area.