Tranexamic acid--why you may be less likely to bleed to death in Britain than in the US if you get injured

The other day at an interdisciplinary rounds meeting at the hospital, one of our nurses who is also an emergency medical technician mentioned that in Britain injured patients receive tranexamic acid before arriving at the hospital because it reduces death from bleeding. "What's that?" I said. I kind of barely remembered hearing this medication's name associated with the treatment of a rare disease, but not treatment of trauma. So I was guessing that this was some drug that was invented long ago which had been found to be quite effective in other countries, but has not been really optimally used in the US because it is generic and therefore unlikely to make drug companies money.

Bingo.

Here's the story, as far as I can determine.

Tranexamic acid is a relatively simple cyclic molecule that blocks the fibrinolytic process, that is the natural breakdown of blood clots in the body. In the setting of any injury, especially severe ones, fibrinolysis is intensified, leading to a condition of excess bleeding in trauma victims. This is hardly ideal, and tranexamic acid can help reverse this. It also appears to have an effect on reducing inflammation, which may be even more significant. There have been a couple of major studies in the last 3 years showing significantly better outcomes in patients who have traumatic injury and who are treated with tranexamic acid intravenously soon after injury. The most recent study, published in the Archives of Surgery, looked at 896 patients injured in the military from registries in the UK and the US and identified the subset treated with tranexamic acid. Although this group was generally more severely injured, the mortality rate was significantly lower, 6.5% lower, than the group that had not received the drug. In very seriously injured patients, those who received massive transfusion of blood products, the difference in survival was nearly 14%. It is not often that we see an effect this powerful, especially in a group like this who are healthy and will likely have long and productive lives after being saved. An earlier study, published in 2011 in the Lancet entitled CRASH-2 showed similar results in civilian trauma victims, with a double blind prospective design.

The Cochrane Collaboration, a group of researchers who review randomized controlled trials concluded that tranexamic acid was safe and effective in reducing mortality in trauma patients without increasing adverse events.

So maybe it's actually very expensive, then. I called our hospital pharmacy to ask about that. Apparently a gram of it costs about $44. The usual protocol for trauma is 1 gram intravenously right away and then another gram over the next 8 hours. So $88 times 100 equals $8800 to save 6.5 lives (using the data from the military study), $1353 per life saved. That's pretty cheap. And since it probably reduces the severity of illness in the rest of the patients treated, it may end up reducing overall treatment costs.

Presently the only FDA (Food and Drug Administration) approved indication for this drug in the US is an oral formulation to be used for women with heavy periods and intravenously for prevention of dental bleeding in hemophiliacs. It is also used, off label, to reduce transfusion requirements in total joint surgeries (that's why we have it in our pharmacy), also in some places for prostate surgery, general surgery, gastrointestinal hemorrhage, bleeding around pregnancy and delivery and bleeding within the eye. It reduces the frequency of attacks of swelling in a condition called hereditary angioedema, which is rare, and was why I had even heard of it in the past. It has been available over the counter for years in Europe, marketed for heavy menstrual bleeding. The injectable formulation is also on the World Health Organization's list of 350 essential medicines which are considered safe and effective and necessary worldwide.

So what are its side effects? It may increase the risk of blood clots in the legs and lungs, but studies have shown this to be far less of an issue than one might guess, and it looks like the lives saved far outweigh this risk.  The CRASH-2 study showed that there might be a slight risk of increasing mortality if it was given to trauma patients more than 3 hours after their injury.

Why is it not FDA approved for reduction of bleeding in trauma and other similar situations for which there is ample evidence of safety and efficacy? The FDA approves drugs and devices when approval is requested, and usually the drug or device manufacturers who stand to make money from an FDA approved indication are the ones to make the request. I suspect there has been no request for approval for these other indications. Just because it is not FDA approved to reduce bleeding in trauma and surgery doesn't mean it can't be used, but physicians have a certain hesitance to use unfamiliar drugs "off label."

So the story of tranexamic acid is another excellent example of how simpler, cheaper and sometimes more effective treatments are not being widely used in the US, even though our patients may receive exorbitantly expensive medications and treatments of dubious or minimal benefit. This is because we allow powerful pharmaceutical companies to inform our practice. Sometimes this actually works, when companies produce groundbreaking innovations and encourage us to adopt them. It is unlikely, though, to help us find creative uses for inexpensive drugs that have been around a long time. This dynamic may mean that 6 or so people of the 100 who are probably just now being involved in accidents with bleeding will die when they would not have if use of this drug part of our routine practice.

Critical Access Hospitals--the 96 hour rule and other ridiculous and self defeating requirements in Medicare's payment for small hospitals

My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated "critical access" by Medicare because it is felt to be necessary to the health care of the community. Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to benefit from economies of scale. A small hospital needs to remain capable of providing services to small but significant floods of patients when everyone gets sick at once, and maintain skills and staff to care for a variety of different diseases. This can make such a hospital less financially efficient (though various other factors can partly offset this) and the critical access program spares my hospital some of the Medicare belt tightening that would make admitting Medicare insured patients prohibitively unprofitable.

Most larger hospitals are now paid for their Medicare insured patients according to the Prospective Payment System, in which a fixed amount of money is paid to the hospital according to what disease the patient has. This means that if a patient presents with pneumonia the hospital will get maybe $8,000 for all of the expenses involved in treating the patient, excluding doctor fees which are billed separately. If the patient does very well and only stays in the hospital 2 days, the hospital does very well and if the patient languishes and requires more resources, the hospital loses money. It is designed, ideally, to work out so the hospital survives, covers its costs and makes a profit. This encourages hospitals to make patients well as soon as possible by making sure that they don't profit from taking poor care of patients. It's generally a good system. Small hospitals, though, are very sensitive to individual patient disasters, and if a patient or two uses more resources than the Prospective Payment covers, the hospital can fail. For this reason critical access hospitals are paid "fee for service". Medicare pays 101% of its allowable fee for each service a patient uses in the hospital. Overall, this can end up costing Medicare more per patient, but it does keep small hospitals afloat.

In order to be critical access, a hospital must have 25 or fewer beds, though it can also have separate units for rehabilitation or psychiatric services, at 10 beds each. It must be 35 miles by primary road or 15 miles by secondary road from another hospital, or 15 miles in mountainous terrain. Up until 2006, it was also possible for the states to designate a hospital as a "necessary provider." Hospitals so designated remain critical access, though this loophole is no longer available. The 2014 budget will address this definition again, proposing to remove critical access status from hospitals within 10 miles of another hospital.

Because critical access hospitals don't have the usual built in incentives of the prospective payment system to limit the length of hospital stays, theoretically they can just make more money by keeping patients longer. Thus the 96 hour rule. Originally it was stipulated that critical access hospitals couldn't keep patients longer than 4 days. Since this was patently ridiculous, the law was changed to allow hospitals to average no more than 96 hours, which was a wee bit better.

So why do we even want to have little hospitals? They don't have very many medical specialists, they don't have dialysis units or cancer centers or cardiac cath labs. Sometimes they can't do MRI scans or nuclear stress tests, and the littlest ones can't even do surgeries. When you put all critical access hospitals (there are about 1300 in the US) in a big pot and average their results they have a higher mortality for many diagnoses than the bigger hospitals. Some of these hospitals are probably not good. But so are many larger hospitals. Communities often depend on the existence of hospitals. Businesses don't want to locate themselves far from a hospital. When a local hospital closes, the chronically ill and the poor who have trouble with transportation are prohibitively far from health care. Small hospitals support the work of primary care doctors with labs and radiology suites and emergency services. Communities without a hospital often have only very few and basic outpatient providers. Small hospitals often provide more appropriate care for patients because everyone knows everyone else, so we remember what happened last time, what worked, what didn't. The nurses know who drinks on the sly or is abused by their husband. The specialists and the hospital physicians know each other well and also know and share patients which makes care more personal and makes patients feel more secure. Communication is excellent and things get done right away. For those patients who have problems that are beyond the scope of a small facility, the emergency department can stabilize and transport. In our hospital we have a heliport on the roof and our patients can be up and out and at the major referral center that is 90 miles away in next to no time. The very old and very sick who want comfort rather than life prolonging procedures can get that right near home, with physicians who know them and often know their family and friends, and share their concerns.

So I guess I am a fan of good little hospitals. But I am not necessarily a fan of the critical access system. Our hospital is occasionally so full we need to turn away patients, but we have more actual physical room and could definitely squeeze in a few more patients if we weren't limited to 25 beds. Also the fee for service system really does not encourage us to develop innovations that make patients get better faster. I think we do a great job at my local hospital of reducing over-testing and over-treatment, but there is no financial incentive to do so since we make more money if we do more. We would be better at creative thriftiness if it actually saved us money. Our creativity is stifled by the need to be little and by being paid fee for service.

Lately we are being encouraged to take the "96 hour rule" more seriously. We need to certify when we admit a patient that they will only require 96 hours in the hospital. If we think they are likely to be in our hospital longer than that, we theoretically need to transfer them to the larger hospital 90 miles away. Seriously? And if we think they will only need 96 hours but we are wrong, theoretically we should then transfer them. So our dear sweet 96 year old who is admitted with diarrhea and turns out to have a small bowel obstruction and then develops pneumonia would need to take an ambulance ride or a $40,000 helicopter ride on day 4 just as we have her really nicely stabilized. The alcoholic with pancreatitis who never gets better in 4 days but is perfectly appropriate for our level of care would go straight from the emergency room to the tertiary care facility. The overworked doctors at those hospitals are so definitely not going to love that, as they deal with their own sick patients. I've been on both sides of this situation, as the doctor transferring a patient and as the one receiving the patient. If a patient is being transferred solely because it is difficult to design an appropriate discharge, it is more difficult to do that from a hospital 90 miles away from their home. It is also extremely likely that subtleties of the history will be lost and that procedures and tests and mistakes will be repeated. Transfer to a different hospital is necessary if the patient's recovery is stalled because of lack of expertise or technology, but if it is only to save the payer (Medicare) money, I expect it will do the opposite.

What to do? I'm thinking that the whole critical access system needs to be reconsidered. Managing all small community hospitals the same way doesn't make sense. Clearly little hospitals need support in order to survive, but giving them arbitrary rules and paying them fee for service is hardly the way to make them function better and certainly doesn't encourage creative innovation.

The Hospital Dependent Patient--some people will be in and out of the hospital despite our best efforts to make them well

This week the New England Journal of Medicine published an article by David Reuben MD and Mary Tinetti MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Medicare. Not as dry as it sounds. You should check it out.) Physicians who readmit patients after less than a 30 day hiatus are made to feel that they have participated in some sort of failure of management. Sometimes they have, but sometimes that isn't the case at all. If a patient is readmitted with an illness that is still troublesome, but clearly improving out of the hospital, for which the patient has visited the emergency department only for reassurance, this is a failure of management, due to unfamiliarity with the patient's history, often because the doctors in charge haven't really read the chart, reviewed the history or talked to the patient. If a patient is readmitted because treatment has lead to a preventable complication, that is a failure of management. If the readmission could have been prevented by a timely visit to an outpatient physician, this is a system failure of some kind and potentially avoidable. If the patient returns, however, because he or she is just too sick and fragile to remain well outside of a hospital, there is no failure, other than that expectation of success was overly optimistic.

The reason that we have hospital dependent patients is that our hospitals are really quite good at keeping people alive, even when they are balanced on a knife edge of medical stability. Twenty-four hour attentive nursing and frequent visits by physicians, respiratory and physical therapists, dietitians, patient educators and social workers along with spare-no-cost life saving technology is wondrously effective at shoring up the nearly dead. For many people, though, life without all of this is hard or impossible, so after a few days at home or in a nursing home, they will return to the hospital to be saved again.

Solutions involve difficult decisions. Is it worth the staggering amount of cash it takes to keep people in marginal health marginally healthy? How can one enter into the discussion of allowing natural death with a patient who feels mostly pretty good with ordinary hospital care? Herein lies the fallacy: once we get to this point, hospital dependency, it is hard to back off. The trick is to not get there in the first place.

Most people who are independent and in full possession of their faculties do not want to be a burden on others. There are many moments between this point and full dependency when decisions could be made to withhold life prolonging medical care, and it is important that we present patients with these options without making them feel that they need to at least try what we have to offer. Although we as physicians are becoming more accepting of withdrawing life support or at least not intensifying it as people become desperately ill, most of us feel justified in allowing natural death only in people who have become truly miserable. Our patients, however, would usually prefer not to be truly miserable ever.

Many of our hospital dependent patients have survived some last ditch attempt at keeping them alive. Given the opportunity to do it all again, from the standpoint of their well selves, many would say no.  It is interesting, though, that from the standpoint of being rescued and now dependent, many patients will continue to undergo painful and progressively disabling medical treatments until at last nothing will work.

I'm wondering if it is possible to end our love affair with medicine that defies death in our waning years. Might it be acceptable, at least sometimes, to allow our patients to die without a diagnosis? No cause of death. Death certificates could say "old age" or "natural causes" without further clarification. When death comes knocking, sometimes, if the time is ripe, we might let him in the front door, bid our loved ones goodbye and depart. Or have we as a society really decided that lengthening life is pretty much always a good thing? If we have, hospital dependent patients will be increasingly part of our jobs. Shaming ourselves when they are readmitted is misguided and very unlikely to change anything.

Requiem for ABC David.

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor's office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was "ABC DAVID." This is how it worked:

1. Admit: to medical surgical unit
2. Because: diagnosis--Congestive heart failure
3. Condition: guarded
4. Diet: sodium restricted
5. Allergies: no known drug allergies
6. Activity (sorry, 2 A's): bedrest with bathroom privileges
7. Vital signs: every 4 hours while awake
8. Investigations: chest x-ray, morning labs - chemistry panel and blood count
9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.

It worked pretty well. It did allow me to forget certain things that I really didn't want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn't forget the main things.

Today I admitted a patient with congestive heart failure and used our hospital's brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It's huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago. It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don't take them at home, including laxatives, sedatives and nicotine replacement. I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End of life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things. Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I'm sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don't even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples' memories. (I can still evoke that particular wood and paper smell as I type the words "card catalog.") But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics. This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it's not too bug infested. I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.

Mammograms don't help--and the dog that didn't bark in the night

In the short story "Silver Blaze" by Sir Arthur Conan Doyle, Sherlock Holmes remarks that it was very curious that when a race horse disappeared and its trainer appeared to have been murdered, the dog was not heard to bark. Dogs are supposed to bark when odd things happen in the night. If they don't, it means something.

Today Reuters commented upon the most recent article in a series over several years showing evidence that mammograms do not reduce death from breast cancer. Although this is not actually a new finding, it is still big news in the US where the wisdom of having regular mammograms is rarely questioned. In my junk email folder I get commentary on the most influential news from medical meetings and journals from organizations such as Medscape and Internal Medicine News, organizations primarily funded by drug and device manufacturers, but also by other aspects of the business of medicine. These organizations successfully take it upon themselves to educate physicians via email communications and throwaway journals. Most of us would never believe information directly given us by companies that make a profit off of our activities, but we still read the headlines and article links these news services put in front of us. This means that those companies have a powerful influence on what medical news physicians read. There was no mention of this new article by these proprietary news organizations, despite the fact that it was headline news at Reuters and the New York Times.

The Canadian Breast Cancer Research Initiative and 9 other primarily cancer research organizations funded this study, published this week in the British Medical Journal. It looked at nearly 50,000 women ages 40-59, half of them randomized to be offered yearly mammograms and half to clinical breast exams alone. These two groups were followed for 25 years to look for differences in mortality from breast cancer. There was no difference in mortality. If doctors paid attention to this, it would follow that we would not universally recommend mammograms at all. There may be subsets of women who will benefit from mammogram screening, but it may also be that bad breast cancers kill people, and discovering them a little bit earlier by mammograms rather than when they can be felt on a clinical exam, and removing them just that little bit earlier doesn't change this.

So why the spotty news coverage? I saw the Reuters article on Google News, as a top story, then researched the actual study a bit, then went back to find the article on Google News and it was gone. It was replaced by a study that said that removing both breasts if you have the BRCA breast cancer gene mutation saves lives, even if one of those breasts has no cancer. I had to go to my history to find the Reuters article again. It was nowhere on Google News. Suppressing a story like this until people with a stake in the outcome have their official responses polished may have a profound effect on maintaining the multi-billion dollar revenue associated with regular screening mammograms.

Am I being a paranoid conspiracy theorist? Perhaps. But I am hearing a strange lack of anything about how maybe we don't need to be doing mammograms.

Sick patients with chronic diseases and the wisdom of Dr. Bernard Lown

I have been doing admitting shifts at a large hospital, as hospitalist. It is flu season, so volumes are large. Even people without the flu are sick. It often happens that way. And they are so very sick!

The thing about the very sick patients I see is that they are generally what might be called "medical train wrecks." They are very sick because they have had interventions over the years that have caused them to be dependent on more medical interventions. In some cases this means that they are alive when they would be dead otherwise, and in some cases medicine has allowed them to make more terrible choices in their lives and be subsequently more miserable than they would have been if forced to face the logical consequences of their behaviors. Often these two stories are played out in the same people. It is hard to take care of these people because they have had so much done to them, have taken so many medications, had so many complications that the landscape of caring for them is like a mine field.

I saw a former smoker whose lung disease was so severe that he couldn't stay out of the hospital for more than a week, and lived at a nursing home. His disease process had progressed to the point that he no longer was able to breathe off the carbon dioxide in his system and when this would build up he would become more sleepy and breathe even less. He also was prescribed strong opiate pain medications for his back and neck pain, worse because he stayed in bed all day and struggled to breathe, but which made him sleepy enough to not move or cough or breathe adequately. He was aware of how this worked, but unable to imagine life without pain medications for his numerous aches. He had been discharged from the hospital only a week before, on intravenous antibiotics through his nursing home which he was still getting when he returned. I suspect he had been on antibiotics for much of the last year, and these were the ones designed for resistant bacteria, which he probably harbored. I was probably the 100th doctor who had seen him and it was unclear what intervention I could make that would improve things at all.

I saw two people who were immigrants from very poor countries, but now in the US for decades. Neither of them could tell me about the medical history of their parents because their parents had never seen doctors. Both had end stage kidney failure, one had received a kidney transplant after 8 years of dialysis, certainly well over a million dollars of medical costs in 10 years. The US takes special care of patients whose kidneys have failed, usually finding money to pay for their expenses either from Medicare or Medicaid funds, or often both. The patient's own funds are almost always completely sapped as well, but no individual can afford long term kidney replacement therapy, which can run thousands of dollars a week, even without the decompensations that are so common in such patients. These were interesting people, but they had suffered physical pain as well as the shame of uselessness and dependence as America's often generous and certainly technological medical system kept them alive.

It may not sound like it, but I do respect these people and enjoy the opportunity to work with them. I also feel conflicting loyalties, because these, my patients, are part of a dynamic that wrecks opportunities for other people to stay healthy and alive. I just read an article from the US News describing how healthcare costs, specifically insurance for city employees in this case, resulted in a community budget that couldn't afford after school programs and struggled to support even minimal recreation programs. School kids collected thousands of pounds of old shoes to raise $6000 to save their after school activities. It is the work of an hour to spend $6000 in health care.

Many of the patients who find themselves in these dependent relationships with the medical profession are poor or old or otherwise disadvantaged, leaving them less able to make decisions about their lives and less able to advocate for their own wishes with healthcare providers. They are carried along in the flow of "this is what we do with people with your condition." Once saved by medicine, it is very difficult to take a different course.

I was feeling kind of sad about all of this when I found something in my email that cheered me up.
Unsolicited, in my primary inbox, was a letter from the Lown Institute. In the email they linked the article I mentioned a few paragraphs up about the school kids who had to raise money for after school programs because their community spent so much money on healthcare. I went to their website and was surprised to see that the group is full of super high functioning people interested in health, mostly doctors but also public health people and even the founder of the Panera Bread Company. Per their website "We seek to create and foster a new social contract between the profession of medicine, the business of healthcare, and civil society." What this appears to mean is that they are working with powerful people to move medicine in the direction of providing thoughtful and considerate care for the human beings who are our patients. The founder, Dr. Bernard Lown, is originally from Lithuania and practiced all of his life in the US. He invented the defibrillator, which has saved countless lives of patients who lose circulation suddenly because of a heart arrhythmia. He also won the Nobel Prize for starting the physicians group that became Physicians for Social Responsibility, which advocated against nuclear weapons. He is a well spoken advocate for really good medical care, meaning listening to patients, examining them and not doing stupid and harmful excessive testing or treatment. I would happily sit at his feet. He continues, in his 90s, to advocate for the right stuff, and I could probably  simply link to his article which is beautifully steeped in over half a century of being a doctor and now a patient, rather than writing anything at all. 

It is heartening for me to see that there are good, kind people with excellent minds who are outspoken and influential at the highest levels of discussion. People like Dr. Lown remind us to be doctors rather than highly educated data managers and test orderers.

Paul Lee--a Washington healthcare lobbyist talks about why it's all good

A few nights ago I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib and sauteed snow peas from some far away place where it's Spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the healthcare lobbyist who spoke had to say about where healthcare reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with.

How could this be? Healthcare lobbyists generally want the industry they represent to get as much money as possible. I generally want the healthcare industry to rein in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don't understand. Either that or efficiency and reining in excesses is beginning to align itself with the success of the healthcare industry.

The Speech

Mr. Lee, the speaker, bravely faced an audience that included many doctors and administrators who believe that healthcare is going rapidly to the dogs and that the Affordable Care Act (or Obamacare as they prefer to call it) is the end of all that is good. His message was quite succinct and described a scenario in which the growth in healthcare expenditures would continue to slow and populations would become healthier and more people would be insured and access care in an environment that would include more non-physician caregivers and less specialists. His visit and presentations were paid for by the CEO's of the three local hospitals who seemed to approve of his message. He showed graphs of trends and briefly touched on the specific issues of rural hospitals, which all three of the local hospitals are. He talked about how new requirements for hospitals to curb complications would lead to a safer environment for patients and fewer unplanned readmissions.

Population Health

He also used a couple of terms that had the feel of buzzwords, but which were actually very interesting. He spoke of the inevitability of focusing on "population health." We presently do fee for service medicine, though not entirely (there are health care coops and other pre-paid models and quite a few physicians are salaried.) This means that we get paid when patients are sick. We are moving in the direction of being paid for how well we take care of patients, otherwise known as "pay for performance." According to Mr. Lee we are heading toward a goal of "population health" which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick. There is an article in the Journal of the American Medical Association this month which looks at exactly this. Emma Eggleston MD and Jonathan Finkelstein MD write about how population health could be attractive to the stakeholders who pay lots of money when people get sick, but might be less attractive to entities which make their money only through treating sick people. Also, if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.

How it works

I know that in our small community there could be some non-hospital interventions which might significantly reduce hospitalizations. If physicians or midlevel caregivers would see patients on an emergency basis in nursing homes and maintain good continuity of care with those patients and their families we would see fewer emergency room visits and hospitalizations. If there were a community crisis center that was robust and effective, we would have less emergency mental health visits. If acupuncture and massage were easily available and covered under insurance, we would likely have fewer pain medication prescriptions and fewer hospitalizations for complications of these medications. If our hospital was paid a certain amount of money per year to take care of the patients in the community regardless of whether they were admitted to the hospital, low cost ways to reduce hospitalizations would be very attractive, and the hospital would likely invest in them. If the hospital made money only when patients were admitted, they would not be inclined to do so. Mental health hospitalizations and emergency room visits are almost always a drain on hospital resources since we don't have a psychiatrist or mental health capabilities and can't hospitalize these patients. Traditionally these patients have also been poorly insured or uninsured as well, so there was no hope of reasonable reimbursement for the hours of care (however that may be defined) that they received in the emergency room. Hospitals such as ours might well save money by funding a community crisis center if it actually kept patients out of the emergency room.

A nearly viral piece of news this week was the fact that Utah has drastically reduced homelessness by giving the homeless homes. There is an initiative in Utah, begun 8 years ago, to reduce homelessness and poverty, which has several strategies for reducing costs related to chronic destitution. It costs a significant amount of money to treat the homeless in emergency rooms and intermittently put them in jail, and there is less of that if they live in apartments rather than on the street. Utah does not provide housing for free, but does make it very affordable, charging about 30% of government funded income. Utah also has programs to prevent homelessness including interventions to keep people in their homes who are at risk of losing them. President Obama's 2009 American Recovery and Reinvestment Act (the much derided "stimulus package") has been partly responsible for funding these projects. This is an excellent example of "population health." Not only does it reduce emergency room related costs, but the no-longer-homeless are much more likely to get and hold jobs than if they were on the streets.

Compressed Morbidity

The other term that our speaker, Mr. Lee, used at the end of his talk was "compressed morbidity." He explained that this was the overall goal of a good healthcare system. Most people, he asserted (and I agree) would like to be sick for the least amount of time possible, and die when they are not yet miserable or have only been so for a short time. The concept of compressed morbidity was first introduced by Dr. James F. Fries, now an emeritus professor of rheumatology at Stanford University, in 1980. He wrote a more comprehensive article on it in 2005. Dr. Fries noticed that almost everyone dies by the age of 110 and most people by the age of 85. As we get better at maintaining health, more people live to be older, but the true maximum age of a human doesn't increase much. With better prevention of disease, be it vaccination or quitting smoking, people live to ages that are closer to the maximum age and spend less of their lives sick and requiring medical care. He suggests active encouragement of all of the behaviors that we know make us stronger and smarter, including such revolutionary ideas as providing alternatives to nursing homes as people age. Although we will live longer if we do those things which slow disease and decline, we will overall use less medical resources. This goal is the end result of a "population health" approach.

I am mostly but not entirely excited about all of this. I personally would like to live healthy and then drop dead, or get eaten by a bear or something, while I remain mostly independent. But I still do respect the rights of people with different values to practice them. That sounds pretty good until I think about the rights of people to become addicted to injectable drugs, get HIV and multiple abscesses all over their body, spend years in the hospital and nursing homes lingering with their stroke related brain damage and chronic pain and eventually die after costing the system many millions of dollars. I suspect that it is not really up to me and does not rest on my sensibilities whether the US moves in the direction of population health and achieves progressive compression of morbidity. It will most likely be determined by how much money we are willing to spend on healthcare and what kind of outcomes we are willing to accept as being adequate for our money.