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where you stand . . . depends on where you sit

17 May

Living with Open Hands

“Where you stand . . . depends on where you sit . . .” The viewpoints you are most likely to advance (your stance politically, your opinions) are decisively determined by the place you occupy economically, in your career, in your community, in your organization, in society. We must not ever presume to speak for others; especially those outside of our scope, like the poor, the battered and bruised, the broken hearted, the “least of these.” We must ‘live’ there . . . and listen.

Three years ago, I sat in a very different place in life with very different viewpoints.
An entrepreneur, a social entrepreneur at that, making enough money to actually pay the bills.
Two income family.
Home owner.
Living in a middle class neighborhood.
Going to a middle class church in a poor neighborhood. (Made me feel better about church)
Wondering why those people in that poor…

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It’s not that simple

16 May

It’s not that simple.

The US health coverage system would be the most complex on planet earth according to the article referenced below [1].

Indeed the author of the article published in the rubric “perspective” of the new England Journal of Medicine wrote (quote):

“…the ACA was crafted to leave in place as much as possible of the preexisting system of health insurance. The problem was — and is — that this decision meant that reform had to be built on the most complex, kludgy, and costly system on planet Earth. Multiple layers of health coverage — as a fringe benefit of private employment, as compensation for military service, as public charity for the poor, as public coverage for the elderly and disabled, and as a private commodity purchased by individuals in a remarkably dysfunctional market — overlap and intersect to pay for care through a bewildering variety of agents in a system that even experts seldom fully comprehend.” (end of quote).

Until now I thought it was the French system that occupied the top place with numerous special schemes. If you want to have an idea of the French system you can consult the document issued by the French Agency for the Development and Coordination of International Relations (ADECRI) [2].
click to read the document

Anyway, be it in the US or in France, a nation wide health care coverage system unavoidably has to be complex if it intends to be comprehensive.

References:
1- Aaron HJ. Here to Stay — Beyond the Rough Launch of the ACA. N Engl J Med. 2014 May;Available from: http://dx.doi.org/10.1056/nejmp1404194 .

2- ADECRI The French Social Protection System, booklet downloadable from the Agency’s website: http://www.adecri.org. Copyright © ADECRI, 2008.

Health insurance: a matter of life and death

7 May

Health insurance would be a matter of life and death suggests the study referenced below:

Benjamin D. Sommers, Sharon K. Long, Katherine Baicker; Changes in Mortality After Massachusetts Health Care ReformA Quasi-experimental StudyChanges in Mortality After Massachusetts Health Care Reform. Annals of Internal Medicine. 2014 May;160(9):585-593.

The results are widely reported in the media and blogosphere.

Drs. Sommers and Baicker work in the Department of Health Policy and Management, Harvard School of Public Health, Kresge Building, Room 406, 677 Huntington Avenue, Boston, MA 02115 and Dr. Long works at the Health Policy Center, Urban Institute, 2100 M Street NW, Washington, DC 20037.

Since the design is purely observational, results must not serve to inference nor be generalized nevertheless they go in the same direction as common sense, and logic: health insurance therefore care accessibility therefore life prolongation. But until now that chain of events had still to be observed at a large-scale (state-scale) and this is the merit of this study.

 

Changes in Mortality After Massachusetts Health Care ReformA Quasi-experimental Study

Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
Ann Intern Med. 2014;160(9):585-593. doi:10.7326/M13-2275
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Geography is destiny in medicine

6 Apr

Heraclitus of Ephesus (Ἡράκλειτος, Herakleitos; c. 535 BC – 475 BC), a Greek philosopher, is known for having said: character is destiny (otherwise said A man’s character is his fate.)
The two main reasons why the derived adage “geography is destiny” applies to medicine are first that exposure to diseases risk factors varies from one region to another in a same country with the same health services and health insurance coverage :

http://earthsky.org/human-world/bill-davenhall-your-doctor-needs-to-know-your-place-history

and second that the pattern of care chosen by practitioners to treat the population for a given condition also greatly varies depending of the place of abode (still at a same health services and health insurance coverage level):

“A study of the geographic distribution in elementary school children discloses no correlation between Tonsillectomy and any other factor, such as overcrowding, poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications for operation.”

Quoted from:
http://proceedings.esri.com/library/userconf/health09/docs/plenary/goodman.pdf

There is tremendous unexplained variation in rates of surgical procedures from hospital catchment area to hospital catchment area, and region to region that cannot be explained by epidemiologic factors. For example, colleagues and I discovered in 1992 (see Spine, 1992) that the 15 fold difference in surgical procedures on the spine in Washington State was inexplicable by almost all population and diagnostic factors.

Quoted from:
https://depts.washington.edu/geog/2011/03/in-health-care-geography-is-destiny/

From the citations quoted above we could even go further in completing the adage by saying: in medicine geography is not only destiny it is also the caregiver.

Lessons from Medicare

17 Mar

Are disease management, patient education or value based payment cost efficient?

In the medicare experience results were mitigated and barely paid the program’s fees. You can read the brief that has been issued by the  Congressional Budget Office‘s health and Human Resources division:

http://www.cbo.gov/sites/default/files/cbofiles/attachments/01-18-12-MedicareDemoBrief.pdf

and the blog that discusses the report:

http://theincidentaleconomist.com/wordpress/can-the-better-care-lower-cost-act-live-up-to-its-name/

In France  a program of disease management and care coordination has been implemented. Its name is Sophia and it targets two chronic diseases, asthma and diabetes mellitus. More information here:

http://www.ameli-sophia.fr/le-service-sophia

But I can’t find any evaluation of the kind of the CBO report that searches if the health care cost savings, inherent to the program, balance the program’s fees. If you have found such a report let me know.

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How we pay our Doctors

2 Mar

Before the health insurances era Doctors were often payed in nature with eggs, chicken or other farm products. Needless to say that they were often poorly paid, furthermore people called them so lately that the care was unable to keep them alive and the doctors lost their patients in the same time. Once the Doctors and the people they cared got the health insurances to be created Doctors received currencies for their services and could see more than once their patients. The issue of payment was transferred to the insurer. In the beginning insurers reimbursed with a fee for service model like the patients did previously. But the increasing amount of money needed made them think of an alternative payment model. And here came the Pay for Performance model.

France has already put in place such a payment model here:
http://www.csmf.org/upload/File/Conv_med/conv_med_annexes_110726.pdf

USA will implement this mode of payment in 2019 here:
http://www.medpagetoday.com/PublicHealthPolicy/Medicare/40568

Developing countries have already experienced these kind of payment here:
http://www.esciencecentral.org/journals/impact-of-pay-for-performance-on-utilization-of-health-services-and-quality-of-care-in-low-and-middle-income-countries.hccr.1000116.pdf

Below are other links related to the way Doctors will be payed in the future:

http://theincidentaleconomist.com/wordpress/can-the-better-care-lower-cost-act-live-up-to-its-name/

http://advocacyblog.acponline.org/2013/07/house-sgr-bill-promotes-medical-homes.html?utm_source=twitterfeed&utm_medium=twitter&utm_campaign=Feed:+AcpAdvocateBlog

http://advocacyblog.acponline.org/2013/04/does-measurement-improve-performance.html

http://doctorscaucus.gingrey.house.gov/news/documentsingle.aspx?DocumentID=364922

http://energycommerce.house.gov/markup/markup-committee-print-amend-title-xviii-social-security-act-reform-sustainable-growth-rate

The effects of Expanding health coverage

8 Feb

The Affordable Care Act (aka Obamacare) is practically a laboratory experiment at the scale of a continent that allows health economists to observe the effects of expending the health coverage to a whole population (a thing that Europeans have done and that they call modestly Universal Disease Coverage, in French couverture maladie universelle or CMU). Starting from his reading of a
Congressional Budget Office (CBO) report the health economist Austin Frakt lists the incentives and disincentives to work that a mandatory health coverage creates. But in my view the point is: does the labor market need workers anymore, with or without health coverage? If it really needs workers then it would be better that they could afford care and rehabilitation, it is the interest of both the employer and the employee. If it doesn’t, the labor market will always consider that the costs are to high.
The blog the incidental economist is about health economics, below is the post with a link to the CBO report:
http://theincidentaleconomist.com/wordpress/cut-out-the-noise-and-read-the-cbo-report/

Mandatory health care insurance: arguments of the pros and cons

2 Dec

Here below is a link toward a blogger who listed 21 arguments attempting demonstrate why and how people could afford themselves to avoid to subscribe to a mandatory health care insurance.

http://www.analyticbridge.com/profiles/blogs/2004291:BlogPost:223149

In my point of view, this kind of discourse do not consider two corner stones of the issue of health care insurance: solidarity (or in other word compassion toward our less wealthy fellow citizens) and the disproportional cost of the modern cares compared with the financing capacity of a single person.

Nonetheless the blogger’s propositions related to the chronic diseases prevention should be implemented. But the are not sufficient in case of an accidental damage.

 

Health services research

21 Oct

Recently I found a definition of the field I am interested in:  ie the health services research. Wikipedia defines it as ” to examine how people get access to health care practitioners and health care services, how much care costs, and what happens to patients as a result of this care.” quoting Academyhealth in the references.

Putted more simply, and according to Academyhealth, HSR tries to give responses to 4 questions in the field of health care in a community:

What works?
For whom?
At what cost?
Under what circumstances?

Read more here

 

Californian court rules nurses can give anesthetics

4 Apr

Nurse Anesthetists Do Not Need Doctor Supervision according to Schwartzy

nurse anesthetist students at UH

nurse anesthetist students at UH (Photo credit: UMDNJ School of Nursing)

Governor Arnold Schwarzenegger.

Governor Arnold Schwarzenegger. (Photo credit: Wikipedia)

Arnold Schwarzenegger, LA, USA

Arnold Schwarzenegger, LA, USA (Photo credit: Wikipedia)

Thanks to Arnold Schwarzenegger, the Austria origin actor, the state of California is now in quasi bankruptcy while the richest of its citizens are more and more rich and the others are very poor, even homeless. This is a good example of what might become Europe if the ongoing right-wing policy is to be continued.

A solution that the CEOs and health care policy makers have found to cut spendings in hospital cares is to let nurses make the job of medical doctors. It is particularly frightening when it happens that those doctors in question who have been replaced by nurses are the anaesthetists.
Will the next step be to replace pilots by hostesses in Californian airplanes?

Well spending cuts is now directly threatening the patient health in the aim to protect the tax payer wealth!

More content:

http://www.californiahealthline.org/articles/2012/3/19/court-nurse-anesthetists-do-not-need-doctor-supervision.aspx

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2012/03/17/BA8J1NM636.DTL

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