Monday, July 27, 2009

Why public health insurance is essential to save American lives

The current debate on health reform is getting lost in the numbers and dollars game in Congress. The arguments have become about price. What is the cheaper option? How can we pay for it? What is the best value? It is about the health insurance industry defending its ground, and attempting to maintain the current status quo. It is about how this industry may continue to make substantial profits out of the misery of all those patients who are sick, while maintaining a system that encourages them to avoid making payments as much as possible, to either patients or doctors. It is about a system where large special interests are able to negotiate low payments to doctors who have little bargaining power or strength, and which leads doctors to increasingly insist that patients pay them directly, rather than go through their insurers, hence letting the insurers completely off the financial hook.

Let's put a real human face on what is happening in American healthcare at present.

As a physician working in a major academic medical center in California, let me tell a few stories of some of the horrors that I have seen that are directly caused by the appalling way that American healthcare is organized and paid for. These stories are clear evidence that we cannot continue with our current system of insurance funding, and simply have to have a public insurance option available to offer choice to all Americans, and to create competition for private insurance companies which they just don't have at present.

Firstly let me say that I am extremely proud to be working in this medical center, which last year provided over $160 million of uncompensated care to the uninsured. This is about double the year before, a fact that is directly the consequence of the recession, increased numbers of uninsured patients, and an increased level of social poverty.

Think of the middle-aged homeless woman with diabetes who was admitted yet again with pneumonia. She has been sleeping rough, and in great personal danger having been assaulted numerous times. She cannot get out of a cycle of poverty, homelessness, illness and peril, and every time she recovers in hospital, it is sickening for the medical and nursing staff to know that she is being discharged to the street, where the cycle will continue. She has no insurance, no family, no future and no hope. Her medical prognosis is dreadful, she is unable to receive any regular follow up care for her diabetes, and she will probably not live for more than a few years unless there are major changes in her situation. She desperately needs good medical and social care, but there is little for her to receive, and she ends up costing society a huge amount because of her multiple expensive hospital admissions, occurring because she has no regular outpatient care. She would be so much better off with regular public health insurance, and would at least have a chance of breaking this cycle.

Think of the recently unemployed father of three young children whose wife died a year ago. He lost his company sponsored health insurance when he lost his job, and is unable to afford to pay the quoted premiums from other insurance companies because of his possible prior history of high blood pressure, found on two medical exams in the past, andwhich is seen as a risk factor for possible cardiac problems in the future.

Think of the patient with chronic schizophrenia who has suddenly had his treatment program closed by a county mental health department desperate to save money and faced with the decision to close either their firefighting or mental health services to meet their budget. This patient has nowhere to go for treatment, eventually runs out of medication, becomes psychotic again, tries to kill himself because of his delusions, and is re-admitted to an inpatient facility for several weeks at great public expense.

These are the faces of the health reform debate. These are the people that President Obama is fighting for, and which the insurance industry will not help, which they prefer to ignore. This is why we have to have a public health insurance option. And this is why we have to have true health reform in this country.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Sunday, July 19, 2009

Health care reform - will Dr Obama be able to cure the US Health System?

Let’s pretend that President Obama is actually Dr Obama, and that his job is to diagnose and treat the US Health System. What will he find, how will he go about it, and what will be the outcome?

The process of diagnosis is relatively straight forward. Everyone acknowledges that the system is broken and that there are a number of agreed on symptoms of this disorder. Firstly the system is far too costly, consuming almost twice as many dollars per capita as health systems in other Western countries. And this expense is also poorly focused, with over thirty per cent being spent on administrative non-patient care costs (such as insurance companies costs and profits, and excessive administrative costs for providers), almost twice as much being spent on medications as other countries, and reimbursement inappropriately targeting piece rate medicine and rewarding doctors who perform interventions, (such as surgeons and radiologists) instead of prevention and the treatment of chronic illness (such as primary care physicians). Of course the existence of 47 million uninsured is a disgrace and a huge problem, as is the relatively poor quality of overall care provided nationally for the money spent. And finally the whole system is very patchy, with excellence provided relatively cheaply in some areas, and the opposite in many others, and this occurring in the setting of relatively little investment in electronic medical records and modern information technology, which could certainly improve the system.

So what should Dr Obama do? If he addresses some of the problems above, then the task becomes clearer. It is absolutely necessary to introduce some form of national public insurance program, both to insure the currently uninsured, and to provide competition for the excessive number of health insurance companies to make them reduce their rates, increase their cover, and provide better value services. It is likely that this process will lead to many of the insurance companies going out of business, and that is fine, because there are way to many at present, and it would be more rational for us to have fewer larger health insurance operations. At the same time the cost of pharmaceuticals has to be addressed – there needs to be a nationally negotiated formulary for core essential drugs that are paid out of the public purse. At the same time the payment structure for providers needs to be changed, and more emphasis paid for services for chronic illness and prevention, and less for interventional medicine, while also encouraging, as is happening, the use of electronic medical record systems and other health information technology initiatives. A single dramatic enhancement would come if he insisted on the introduction of a national health identifier number as this would greatly enhance the ability of providers to exchange health information when necessary, and would greatly simplify billing and administrative processes.

Many other things have to happen, of course, but will Dr Obama and his team be up to this task? We currently have a bloated and inefficient health system, and in any such system there are winners and losers. The winners in today’s health system are insurance companies, the pharmaceutical industry, and large numbers of providers who are used to receiving excessively high incomes for interventional services. The losers are patients, and the country. When looked at broadly, the diagnosis and treatment of our health system are actually relatively straightforward, but it has to be accepted that today’s “winners” will not necessarily remain in that position long term, and that there will be a number of losers as we change the system. Let’s just hope that Dr Obama, and his multidisciplinary team in Congress, are able to push through the reforms the US health system needs so that the patient is no longer the loser.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Monday, July 6, 2009

Jama reviews "Your health in the Information Age" very positively

I am pleased to say that a very positive review of my book, "your health in the information age" has been published in the Journal of the American Medical Association, the most prestigious general medical journal in the world. The reviewer introduced his review in the following way:

"If you have heard the joke" What kind of physician uses the Internet? A URLologist" then Your Health in the Information Age" may be just the ticket for you and your patients. This 188 page book takes on the monumental task of offering an excellent exploration of the exponentially expanding world of e-health for readers already searching for health information on the Internet, as well as for relative newbies".

And finishes with the following:

"Your Health in the information age" is not an "e-health for dummies". It is an academic and insightful look into the exciting and nascent world of online health care. Whatever your views on the flaws and failures of the US healthcare system, you have to admit that things are changing. Make no mistake: online care is a game changer."

It is very pleasing to read such a positive review, which also includes some very reasonable criticisms that I will be delighted to confront when I write the next version of the book. You can all read the full review by going to my website at www. and following the links. I hope you do, and I hope that this review encourages you to tell your friends and colleagues about the book, and to continue to think critically about all aspects of e-health on the Internet.

Online healthcare is a game changer

Dr Stanley Borg, in the Journal of the American Medical Association, recently wrote that "whatever your views on the flaws and failures of the US health care system, you have to admit that things are changing. Make no mistake: online care is a game changer."

I agree, but what did he mean by that?

Could he be talking about how technology is going to radically improve the way we deliver and receive our healthcare? Does he see new technologies as being around the corner, and about to envelop us and help us improve our health? What does he really mean by "online care"? Is it enough for us to communicate with our doctor on the Internet, or should we be becoming involved in online groups and counseling fellow patients? Should we have all of our medical records stored online, and be able to access them ourselves to make sure that they are correct. Should we be wearing electronic monitors of our heart, our breathing, our temperature, all of which constantly transmit our vital signs in real time to the database of our choosing? Or should we be undertaking robotic surgery using automated machines controlled by a surgeon hundreds of miles away?

Does this sound scary, or is it a form of "techno-utopia" that we should all be seeking? I can easily answer that one at least. Techno-utopia, as defined by Wikipedia, is “a hypothetical ideal society, in which laws, government, and social conditions are solely operating for the benefit and well-being of all its citizens, set in the near- or far-future, when advanced science and technology will allow these ideal living standards to exist; for example, post scarcity, changes in human nature and the human condition, the absence of suffering and even the end of death.” We are certainly not close to this.

In place of the static perfection of a utopia, others have envisioned online health as occuring in an "extropia," an evolving open society allowing individuals and voluntary groupings to form the institutions and social forms they prefer. Perhaps the web 2.0 is the beginning of this extropia?
We have to be careful not to be “techno-Utopians” - excessively, uncritically accepting of technologies. People like this don’t tend to use new technologies as effectively as they could because they view the technologies as ends in themselves, not as tools. It is commonly held that using new technologies uncritically implies bad habits of the mind. Taking television as an example, one could argue that this technology has led us to concentrate on superficial, rapid acquisition of knowledge rather than on deep thinking and careful consideration. Look at all the “news bites” prepared for TV – and how if you are trained in media skills, you are almost always taught to literally speak in short “bites” that are easily reportable but often meaningless.

Healthcare on the Internet, in partnership with your doctor, does promise huge benefits not only for us all, patients, clinicians and society in general, and is, to quote Dr Borg, a "game changer". But in embracing technology, the human factor must not be forgotten. It is not the cleverness of the technology that is important but how we use it to derive most benefit for us, for our children, and for society. We have to learn to improve, to control, and to effectively use the tools and techniques now available to deliver online healthcare to improve our health and, in doing this, to enrich the quality of our lives.

If we look at the future direction that online healthcare is moving in, and which is being supported by the Obama Administration, the following themes are evident:

§ Our future isn’t what it used to be, as we move to the era of virtual hospitals and global clinicians
§ Our health system is gradually changing and becoming electronic and distributed, with less dependency on buildings, and more on communication networks from the patients home to the operating theater
§ Research is opening up whole new ways of delivering healthcare, using all our senses, and in a much more personalized manner
§ Patients are demanding better and more accessible healthcare, and will obtain it from all around the world in future
§ The doctor-patient relationship is changing, and will become increasingly open and driven by empowered patients living in an information rich environment – where the Internet is increasingly influential and important in clinical consultations.

Online care is a game changer, and we should all embrace it and learn to use it to our best advantage.

Peter Yellowlees MD has recently published "Your Health in the Information Age - how you and your doctor can use the Internet to work together." The book is available at Amazon, iUniverse, and most online bookstores.