"Healthcare outsourcing" is picking up among Americans

In its May 29th issue, Time magazine ran a full-length article dubbed "Outsourcing Your Heart: Elective surgery in India? Medical tourism is booming, and U.S. companies trying to contain health-care costs are starting to take notice."

The entire article is readable on Time's site (just click the link above), so I'll just post some of the highlights:

With this surgical sojourn, his first trip outside the U.S., Miller joined the swelling ranks of medical tourists. As word has spread about the high-quality care and cut-rate surgery available in such countries as India, Thailand, Singapore and Malaysia, a growing stream of uninsured and underinsured Americans are boarding planes not for the typical face-lift or tummy tuck but for discount hip replacements and sophisticated heart surgeries. Bumrungrad alone, according to CEO Curtis Schroeder, saw its stream of American patients climb to 55,000 last year, a 30% rise. Three-quarters of them flew in from the U.S.; 83% came for noncosmetic treatments. Meanwhile, India's trade in international patients is increasing at the same rate.

That's a lot more Americans than I expected flying to Asia for surgery through just one company. And that 83% figure surprised me since I had thought most surgeries done on Westerners abroad were cosmetic.

It's one that could put greater competitive pressure on U.S. hospitals as some of their most lucrative patients are siphoned off. Elective surgeries are key moneymakers for hospitals, and even a small drop-off can cut deep into their profits.

Hospitals, like so many industries, is feeling heat from the "flattened world," a Tom Freidman term for globalization. And as if there weren't tremendous domestic cost pressures already. Put another way, "'This has the potential of doing to the U.S. health-care system what the Japanese auto industry did to American carmakers,' says Princeton University healthcare economist Uwe Reinhardt." Dr. Reinhardt (official webpage) is a big supporter of commercialized healthcare, as this blog entry states.

What may accelerate the trend is that some pioneering U.S. corporations, swamped by rising health-care costs, are taking a serious look at medical outsourcing. Blue Ridge Paper Products of Canton, N.C., a manufacturing company, may soon offer employees outsourcing as a health-care option. The carrot? The patient would get to pocket some of the firm's substantial savings...

The calculus behind this interest isn't complicated. Many major employers in the U.S. are self-insured, which means they pick up the tab for much of their employees' medical care. That's why three major corporations that collectively cover 240,000 lives asked Dr. Arnold Milstein, national healthcare "thought leader" at the consultancy Mercer Health & Benefits, to assess the best places to outsource elective surgeries. Procedures in Thailand and Malaysia, he found, cost only 20% to 25% as much as comparable ones in the U.S.; top-notch Indian hospitals sell such services at an even steeper discount.

Yet another instance of American companies being forced to find solutions to alleviate its own cost pressures from healthcare. And even some unique types of insurers are offering the option of "medical tourism":

United Group Programs (UGP) of Boca Raton, Fla., a third-party administrator that sells a low-premium, bare-bones form of coverage called a mini--medical plan, this month began promoting Bumrungrad Hospital as a preferred provider to its customers. Employees of self-insured businesses who use the more conventional plans designed by UGP will also have access to the Thai hospital. This means that UGP offers the option of partly or fully covered medical tourism to some 100,000 people, including those who could use it most.

Why all this interest in "healthcare outsourcing" inside the USA, home of the most advanced healthcare system(s) in the world? Well, just check out the cost savings (in this rather group but legible -- I hope -- chart in Time's pages).



What's interesting is what hospitals abroad wanting to court Westerners are doing: seeking JCAHO accreditation, staffing themselves with American-trained doctors, and making attached hotel and restaurant complexes.

And Asia isn't the only place where Westerners are going for healthcare. People go to Mexico for dental work, and Europeans are flying to northern Africa as reported in a previous post.

This is how the Time article ends:

Mohit Ghose of the trade group America's Health Insurance Plans says many have taken note of medical outsourcing but are scared off by the regulatory and legal uncertainties. Aaditya Mattoo, a World Bank economist who has published a study on the potential of medical outsourcing, suspects that pure institutional inertia has something to do with the lack of interest.

Yet as the medical-cost crisis deepens, the corporations who pay insurers are likely to find the lure of outsourcing as irresistible in health care as it is in software.

Hand-offs are dangerous, but fixable

And I'm not talking football. It seems by the day, more hospitals are implementing simple innovations and thus reducing dangerous errors. A big reason why they're doing so is the push from the JCAHO, the body that accredits hospitals & regulates them.

The push continues. The JCAHO recently reported that communication breakdown is "the single largest source of medical error," and it's now "for the first time [establishing] standards for hand-off communications," the communication between outgoing & incoming staff.

The stakes are high, as hospitals that fail to comply with Joint Commission patient safety standards risk losing accreditation, which is often required for reimbursement from Medicare and private insurers.

Luckily, "a few hospitals and health-care quality groups have been ahead of the pack, borrowing communication strategies used in aviation and the military..." One such group is the Institute for Healthcare Improvement, which has been promoting a "communication model known as SBAR -- an acronym for Situation, Background, Assessment and Recommendation," which was developed for use in nuclear submarines. Kaiser & the VA are also ahead of the pack.

"A hand-off is a precision maneuver, but in medicine it has been left to happenstance," says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.

What's the danger in hand-off errors? Well, they run the gamut "from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren't aware of a "do not resuscitate" order," says an internist at Yale University and the VA.

The most remarkable example of how communication models like SBAR can reduce fatalities and other medical injuries, as reported in the WSJ article "Hospitals Combat Errors at the 'Hand-Off': New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift," is at OSF St. Joseph Medical Center.

John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.

At first, nurses and other staffers were hesitant to provide the "R" -- for recommendation -- to physicians, Dr. Whittington says, but doctors were asked to encourage staff to do so. By last year, the briefing format was used by more than 98% of nurses and the rate of adverse events -- defined as an unexpected medical problem that causes harm -- fell to 39.6 from 89.9 per 1,000 patient days, Dr. Whittington says.

It's amazing how powerful this small inexpensive change in the way things are done in the hospital truly is. You would think hospital leaders would be all over it. Think again.

"It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine," says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network. Seton began using the SBAR model in its four labor-and-delivery units in January 2005, as part of an effort to eliminate complications for patients and make it easier for nurses to quickly brief each other and doctors.

Still, people inside hospitals are changing. And one of the catalysts of this change is technology, namely the electronic patient record system.

Brigham and Women's Hospital in Boston, for example, has used a computerized sign-out system for several years, and is developing a more-advanced version for the sickest patients in the ICU. David Bates, chief of the Division of General Medicine, says electronic systems are the only way to ensure the safe hand-off of large numbers of patients in a busy hospital, "so a standard set of information can get exchanged every time."

As part of its transition to electronic medical records, Kaiser has developed a Nurse Knowledge Exchange computer program, which allows departing nurses to create customized electronic reports on patients for the incoming nurses, such as lab results or medication changes. But the nurse coming on duty also makes bedside rounds with the outgoing nurse, and engages patients when possible in a discussion of treatments and progress.

It's awesome that a basic innovation in process, coupled with better info technology, are saving many more lives with little additional cost.

But jogging's so boring!

It's safe to say most people know that regular exercise (coupled with good diet) prevents an array of chronic diseases. But there's a host of issues that make exercising easier said than done, from no time to lack of motivation. Well, this US News & World Report piece says these issues are simply excuses, and presents techniques to deal with them.

Primary care docs are getting ready for consumer-driven healthcare

In a NYT piece titled "Market Forces Pushing Doctors to Be More Available" from June 24th, we learn that many primary care docs -- those who practice family medicine, pediatrics and internal medicine -- are gearing up for a more competitive, consumer-centric world.

It is not just a matter of moving to a small town. Ms. Kissell's doctor, Melissa Gerdes, is one of a rapidly growing number of physicians who have streamlined their schedules and added Internet services, among other steps, to better meet the needs of patients. For physicians like Dr. Gerdes, it is simply good business.

Those doctors know that as walk-in medical offices and retail-store clinics pose new competition, and as shrinking insurance benefits mean patients are paying more of their own bills, family care medicine is more than ever a consumer-service business. And it pays to keep the customer satisfied.

"It's about the patients — making people well and keeping them well," said Dr. Gerdes, 35, who has had her own practice for seven years.

The doctors' professional associations are urging their members to adopt new technologies to increase the ease for patients to see them and to reduce costs.

The academy is spending $8 million on consultants who visit doctors nationwide to suggest improvements in patient care. The advice is meant to "keep them from going to an in-store clinic," Ms. [Amanda Denning, a spokeswoman for the American Academy of Family Physicians] said, while also benefiting doctors by making office procedures more efficient.

Meanwhile, the 119,000-member American College Of Physicians is promoting "patient-centric care," which it made the focus of a policy paper this year, calling for more consumer-friendly scheduling, electronic medical records and electronic prescriptions, among other measures.



Coming back to the featured physician, Dr. Melissa Gerdes of Tyler, Texas, there are some interesting changes afoot in her clinic that depart from conventional care, at least the care I got my whole life, which included waiting days if not a week to see a doctor from when I called (except at the Baylor Clinic, which has same-day appointments), waiting "forever" in the waiting room and again in the patient room, and having to pick up a paper prescription and take it to the local drugstore to get medications.

In Dr. Gerdes's office, the innovations include daily clinics at lunchtime called QuickSick, in which patients who have phoned up that morning can come in for routine problems requiring immediate attention, like an upper respiratory infection, and are guaranteed they will be examined, treated and on their way within a half-hour.

After a nurse checks the patient's temperature and blood pressure and types the symptoms into a computer, the doctor follows up with a brief exam. If medication is warranted, Dr. Gerdes can e-mail a prescription that will be ready when the patient arrives at the pharmacy.

"I can see three patients with acute needs every 15 minutes," she said.

The charge is $52 to $60, which is coverable by insurance and similar to prices at many of the new clinics springing up in places like CVS pharmacies and retail chains like Wal-Mart.

What are the goals of these changes? Lower cost and more convenience, based on the two following quotes. "People will change physicians for differentials of $10 or $15 in a co-pay," said Dr. Anne B. Francis, a pediatrician in Rochester and spokeswoman for the American Academy of Pediatrics... "We try to cut down on the waiting time," [Dr. Larry S. Fields, American Academy of Family Physicians] added. "We need to be more conscious of patients' time."

Are patients catching onto these changes? For some doctors, yes.

Dr. Ellen Blye, an internist with a busy practice on the Upper West Side of Manhattan, said about one in 10 of her patients used the online scheduling system she leased from NexSched, a start-up in Marcellus, N.Y., near Syracuse.

Michael W. Davis, executive vice president of Himss Analytics, a health care technology consulting firm, said that NexSched and a handful of competitors were "just beginning to penetrate the market" and that fewer than 1 percent of physicians offices had installed the technology so far.

"The patients who use it, love it," Dr. Blye said. "They can see what is available and do it any time." Although she does not offer same-day scheduling, her patients "can often come right in, if they see that someone has canceled."

Dr. Blye said that electronic scheduling, together with electronic medical records — a system made by GE Healthcare — enabled her staff of two internists and two nurse practitioners to save on overhead by eliminating one clerical employee.

One change using the simplest of Internet technologies seems promising: e-mail consultations. I have been doing this with my primary care physician, and it's been great. Over email I can get questions answered about when I can come in to see him and what kind of tests they have and how much they'd cost. I've even shared an article or two on medical matters with him via e-mail.

The same computerization that makes online scheduling possible can also open the door to online consultations, which usually involve questions that patients ask about routine matters like diet or possible changes in the strength of a prescription drug. The patient can go online at any convenient time, and the doctor often replies the next morning. But because health plans only rarely pay for these e-visits, such services have been slower to catch on.

I wonder if these changes are purely defensive, which seems to be the case presented in this article, or if some forward-thinking, technology-saavy iconoclastic doctors are driving these changes forward. While the primary care associations have caught on, and seemingly are improving care to improve their patients' healthcare, the big medical association seems to be reacting to a perceived threat to its members' monopoly.

And for all the new openness that many doctors are adopting, some efforts seem mainly defensive moves against the retail clinics, which are typically operated by nurses. At its annual meeting this month, the American Medical Association called on the clinics to accept a list of principles that would limit their scope to simple services and ensure that a physician oversees the operations.

Even Dr. Gerdes seems to be reacting defensively, discussing with her clinic planning group "how we will respond when retail clinics come to Tyler and what we can do to improve access for the patient."

Still, patients quoted in the article express their satisfaction with the changes made by Dr. Gerdes, and so, whether compelled by the desire to remain in business in the more competitive, cutthroat world of medical care thanks to new forces in the marketplace or nobler patient-centric reasons, changes in conventional healthcare are coming without a doubt, and they will be good for patients.

My ideas, part 1

During my neurology & psychiatry rotations the past few months, I had the habit of jotting down to-dos and thoughts into my Palm PDA. I also wrote ideas down, ideas that could improve healthcare or presented a problem that needed to be solved. Here's what I culled from mid-March until May, in chronological order:

1. Better manage hypoglycemia [or pathologically low blood glucose, a common effect in diabetics who take more medicine than needed] with a compliance tool to avoid stroke-like symptoms. (Esther Dyson, a noted "thinker" in the IT world, said whoever developed compliance tools for medications would be richly rewarded.)

2. Make diabetes care more humane and empower people with diabetes to live normal lives. One patient from a small Texas town was told by her endocrinologist that she ought not have a baby because her blood sugar was instable. This is untrue and bad medicine, and in her case prevented the woman from having her baby when she was younger [and being younger confers one definite advantage, lesser rates of birth defects].

3. If surgeons today use Da Vinci surgical robots to do mini-surgeries while they themselves are several feet from their patients and sometimes in different rooms while their staff wait at the patients' bedside, can't surgeons do this remotely?

4. Telemedicine allows doctors who don't need to conduct a thorough physical examination (think psychiatrists) -- or who have staff local to patients to do this for them -- to see patients far, far away from their own offices. Instead of focusing expensive incentives on bringing doctors and nurses to small towns and the countryside, let's build up telemedicine capabilities instead, which will be cheaper in the long-run and allow people more freedom to live where they'd like.

4. St. Luke's & Methodist, the two big Houston-area hospitals, use different Patient Management Records [PMR] systems vendors, McKesson and Hyperspace respectively. What happens if a patient is transferred between hospitals, or more likely if the patient comes to one hospital after having been hospitalized in another?

A layer of software could be constructed to draw patient data from both systems and displaying it on one interface, eliminating the need for re-entry of old data into each PMR system & improving medical persons' access to all the medical data out there on their patients. And this is a more feasible solution than getting all hospitals to buy from one vendor, or having them subscribe to a federal government invention.

That's it for now, future installments to follow.

Basic innovations saved 100K+ lives in US hospitals

Almost every post here is on a new technology, a novel way of looking at things of doing them, but I have not been able to cite how much these "healthcare innovations" are truly changing the way people's health are cared for.

So it was a stroke of fortune that the WSJ reported on June 15th about how new practices adopted by hospitals have indeed cut down on errors and thus saved lives, which has been a major goal of the Institute of Medicine. In the AP article titled "Hospital Initiative to Cut Errors Finds About 122,300 Lives Saved," Donald Berwick (the Harvard professor who headed the initiaitive) said, "I think this campaign signals no less than a new standard of health care in America."

About 3,100 hospitals participated in the project, sharing mortality data and carrying out study-tested procedures that prevent infections and mistakes. "We in health care have never seen or experienced anything like this," said Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations.

The JCAHO is the national board that regulates hospitals.

Medical mistakes were the focus of a widely noted 1999 national report that estimated 44,000 to 98,000 Americans die each year as a result of errors and low-quality care. That year, Dr. Berwick -- president of the Institute for Healthcare Improvement, a Massachusetts-based nonprofit organization -- challenged health-care leaders to improve care quality and prevent mistakes.

In December 2004, he stepped up the challenge by announcing a "100,000 Lives Campaign." He set a June 14, 2006, deadline to sign up at least 2,000 U.S. hospitals in the effort and implement six types of changes.

Among the six changes were "rapid-response teams for emergency care of patients whose vital signs suddenly deteriorate [operating] around the clock to other units," "checks and rechecks of patient medications to protect against drug errors," and "preventing surgical-site infections by following certain guidelines, including giving patients antibiotics before their operations."

The effort was endorsed by federal health officials, health insurers, hospital industry leaders, the American Medical Association and others. The roughly 3,100 hospitals that signed up represented about 75% of the nation's acute-care beds. About 86% sent in mortality data. Roughly a third said they were implementing all six measures, and more than half committed to at least three, Dr. Berwick said.

This is great news because it shows simple systematic changes (as opposed to increasing the education of medical professional) can make a big difference, akin to the introduction of hand-washing in hospitals causing a dramatic decrease in the number of deaths and infections in hospitals.

Innovations do save lives, especially it seems the simplest low-cost ones.

Incentives to be healthy - is it all about the benjamins?

Here are some of the incentives my medical school offers its students, faculty, researchers, staff & support people to stay healthy, as delievered in an email today.

The summer is a great time to get healthy. BCM has some exciting programs with nice financial incentives to help you get through Houston's sizzling months and come out in better shape:

Weight Watchers at Work: If you sign up for convenient Weight Watchers at Work classes during the summer, BCM will pay for 20% of your enrollment fee. It's normally $180 for the 15-week session, but now BCM will pay $36 and you pay only $144...

24 Hour Fitness: BCM has a special corporate rate with 24 Hour Fitness, and the gyms have reduced their family add-on fee to only $49...

Smoking cessation: Our EAP provider... will be providing four-session courses for BCM employees and students and their significant others... Each participant is encouraged to bring a buddy... The fee for the course is $125 per person. After completing all four classes, each participant (both BCM folks and their buddies) will be reimbursed $100.

It is funny to see this line at the end of the smoking cessation deal, in case you didn't realize it: This is a very good deal.

Do financial incentives change people's behavior? On the surface, and intuitively, the answer seems yes.

But the Douglas Rushkoff of a neat book called Get Back in the Box (about work & life in today's internet-based renaissance) disagrees. He frames the ineptness of the financial carrot stick in the world of work: "The more frequently you reinforce "good" behavior with cash, the more you disconnect employees from their own experience of the work itself... [shifting focus] from the task and onto the reward."

Is that a bad thing per se, or ineffective? Well, no. The writer himself backs off a bit from his strong assertion by writing there are people who need money desperately or want money in order to fill a psychological emptiness (think Maslow's hierarchy and about how the need of love & belonging is below self-actualization), and for these people money is most ideal motivator.

However, I think for an educated guy or girl who wants to quit smoking for health, even moral reasons, money is not as good a motivator to quit as making the process of quitting fun (which is the book's point: intrinsic rewards drive a person to work harder at something because that work is approached as play), painless or full of meaning.

In fact I know people who quit by spending more money -- a clear disincentive in the conventional sense -- because quitting simply meant so much to them.

And more obviously, kids are more interested in fun. For the average obese kid, what would compel him to lose weight, being given $500 to exercise 3 times a week for a year or making the experience fun? I think kids, who aren't as entrenched in the real world where money means so much, would rather have fun. In fact, a professor at my school says his dream is to combine elements of a gym and video games to get obese kids skinnier.

These are just some thoughts and anecdotes. I'll post more when I find some scientific evidence to back up these positions.

Web tools enable price comparison & push consumer-driven healthcare

Insurance companies are begin to comply in earnest with a policy of greater price transparency, something the Bush administration has long been advocating as it pushes "consumer-driven healthcare." From the June 13th WSJ article Patients Get New Tools To Price Health Care:

Aetna Inc., which last year in the Cincinnati area became the first major insurer to reveal rates it negotiates with local physicians, is expanding that program to eight more areas. Other major insurers, including Cigna Corp., Humana Inc. and UnitedHealth Group Inc., are adding or expanding their own online pricing tools. And Medicare early this month posted online1 the ranges of what it pays hospitals for 30 common procedures and treatments, the first in a series of disclosures the agency says it will make. Several state governments and hospital associations, including in Florida, New Hampshire, Utah and New Mexico, are launching Web services that list hospital charges.

The information provided by these new tools comes with caveats, but the services do show that, in principle at least, comparison shopping can make a difference: While prices of simple services in doctors' offices are fairly consistent according to some online data, hospital costs often vary widely. For example, a Web-based pricing tool offered by Humana shows that at hospitals in a Humana network in southeast Wisconsin, a knee replacement ranges from a minimum of $16,900 at one hospital to a maximum of $34,050 at another, reflecting in part discounted rates that the insurer has negotiated with health-care providers.

What's behind the further push into this direction?

The new pricing services are popping up as consumers are being asked to shoulder an ever-greater proportion of their health-care costs. Employer-sponsored and other health plans are shifting more of the cost of health care to consumers by raising co-payments and cutting benefits. That dovetails with efforts by the Bush administration to promote so-called consumer-driven health care, mainly through high-deductible insurance policies paired with health savings accounts that offer financial incentives to shop wisely for care.

The problem for consumers has been finding the prices in order to make the comparisons. Until recently, doctors and hospitals had little incentive to disclose prices, since insurance would generally pick up the tab. When patients do seek cost information, health-care providers can be hard-pressed to explain the often-byzantine pricing systems. And the discounted rates that insurers negotiate with doctors and other providers are held close to the vest for competitive reasons.

There are certain limitations to the insurance companies' push for better price transparency. For one, they have limited price information to their enrollees, and then only in certain test cities. Also, [a]nd while some tools, including Aetna's and Cigna's, are adding information on quality of care, comparative data in that area are still hard to come by. So patients may simply opt for the costlier options in the absence of any other gauge of quality, even though one of the goals of consumer-driven health care is to lower costs.

"It's not like going to Wal-Mart and saying, 'I'm going to buy tuna fish now, it's cheaper,' " says Regina Herzlinger, a Harvard Business School professor who is an advocate of consumer-driven health care. "This is a more complex kind of decision."

An important factor in all this is the Internet. Web technologies allow consumers to see prices without having to call the doctor's office and ask what some consumers themselves may see as pesky questions. And besides, for the insured they have not been in the habit of asking for prices since all they pay is the co-pay (which is beginning to change as the insured are beginning to pay more -- and variable amounts -- for their healthcare. But the web presents its own problem.

The tools are mostly Web-based, so many patients won't have the resources to access them.

And a price listing isn't the end-all-be-all in medicine.

Charles Murray, a human-resources manager at a South Milwaukee, Wis., manufacturing firm, used Humana's hospital-cost tool before his knee replacement in March. The hospital he preferred turned out to be among the least expensive listed. Humana says the tool shows that a knee replacement at that hospital costs $18,150 to $19,650, taking into account discounts the insurer has negotiated with the hospital. When Mr. Murray received the bills, he says, the cost totaled $20,220 (though insurance did cover most of the costs). Costs can fall outside of the range for a variety of reasons, Humana says, for example if a patient stays in the hospital longer than others typically do.

Still the insurance companies press on, imagining having to provide price information readily soon.

Aetna says it didn't expect the program to cause tangible changes in its first year, but that as more consumers have plans with high deductibles, prices will become more important to them. "All of a sudden, they're going to demand the information, and if we're not ready for it, then we'd be very concerned," says Robin Downey, Aetna's head of product development.

And they're not limiting this to just medical care.

UnitedHealth Group early this year added a tool to its consumer Web site that lets enrollees in its dental plans nationwide look up the rates the insurer has negotiated with individual dentists for nearly 600 procedures, plus what they'll have to pay out of pocket. Some insurers, including UnitedHealth and Lumenos, a unit of WellPoint Inc., have online tools that let enrollees look up drug costs at specific pharmacies in their areas.

Perhaps another reason why insurance companies are changing their tune is because governments are beginning to demand it.

On the state level, in the past year and a half a number of bills on price transparency have been introduced in legislatures. Among laws that have passed, South Dakota requires hospitals to report annually their median charges for their 25 most common inpatient services. That information was posted online in early June, at hospitalpricing.sd.gov2. A Minnesota law requires the development of a public Web site on common hospital charges by Oct. 1.

The New Hampshire Hospital Association last month launched a site, www.nhpricepoint.org3, that provides average charges and lengths of stay for a variety of procedures at hospitals in the state. Similar sites are available in Wisconsin and Oregon, and the Utah and New Mexico associations plan to offer similar sites later this year. The Wisconsin site, www.wipricepoint.org4, had about 320,000 page views since it was launched in February 2005, according to Wisconsin's hospital association.

Florida's government late last year launched floridacomparecare.gov5, which provides individual hospitals' average charges and lengths of stay, plus some quality information. Another Florida site, myfloridarx.com6, provides retail prices at individual pharmacies for the 50 most-commonly used prescription drugs in the state.

Framing universal healthcare to get support from big business

"Mrs. Clinton often frames the problem today as one of economics as much as social justice. She asserts that soaring health costs are weighing down American corporations and hindering their ability to compete in a global marketplace, against countries with government-financed health benefits or no expectation of health coverage at all."

From "Wounds Salved, Clinton Returns to Health Care" run on June 11th in the NY Times.

Don't change the channel, this may be important to your health

The NY Times ran an article about psychiatrists and their use of Talmudic in "TV Screen, Not Couch, Is Required for This Session" on June 8, 2006.

To me it seems psychiatry lends itself better to telemedicine than other specialties since shrinks do not conduct physical exams on patients.

Dr. Gibson said the lack of smelling and touching, at least when it comes to psychiatry, has proved to be a good thing. Being physically in the presence of another human being, she said, can be overwhelming, with an avalanche of sensory data that can distract patient and doctor alike without either being aware of it.

"Initially we all said, 'Well, of course it would be better to be there in person,' " she said. "But some people with trauma, or who have been abused, are actually more comfortable. I'm less intimidating at a distance."

States are pushing the trend since they want more mental health services for underserved rural citizens.

Psychiatry, especially in rural swaths of the nation that also often have deep social problems like poverty and drug abuse, is emerging as one of the most promising expressions of telemedicine. At least 18 states, up from only a handful a few years ago, now pay for some telemedicine care under their Medicaid programs, and at least eight specifically include psychiatry, according to the National Association of State Medicaid Directors. Six states, including California, require private insurers to reimburse patients for telepsychiatry, according to the National Conference of State Legislatures.

Does the use of telemedicine harm the personal connection made when doctor and patient are in the same room? No, according to the interviewees. (Of course, this is anecdotal evidence; there should be real research done on this question.)

"I just feel like she's here," said a 24-year-old mother of three who asked to be referred to as C. C was struggling with depression, anxiety and fantasies of suicide. "I sometimes forget we're not in the same room."

Dr. Gibson spoke up from her room in Flagstaff: "That's funny, I would say that I feel the same way."

We want you! (Your DNA, that is)

Plan to Build Children's DNA Database Raises Concerns

By ANTONIO REGALADO
June 7, 2006; Page B1

Why do some children become obese when they eat junk food, while others don't? Which kids are most susceptible to asthma?

Attempting to answer such questions, the Children's Hospital of Philadelphia, the nation's oldest pediatric medical center, is launching a major effort to collect and analyze detailed DNA profiles on as many as 100,000 of its child patients, the first effort to collect DNA on so many children.

CHOP plans to create a database which hospital researchers can use to study children's genetic profiles, research that could guide the development of diagnostic tests and drugs. The plan is one of the most ambitious yet to take advantage of new DNA-decoding methods that may help scientists identify the genes that put people at risk for common diseases. The 151-year-old hospital, known locally as "CHOP," says it will spend around $40 million over the next three years collecting DNA profiles of children who visit the main hospital and its network of clinics.

Similar DNA database efforts are cropping up across the U.S. and overseas. This spring, the U.K. began collecting blood for a national "biobank" expected to encompass 500,000 people. Kaiser Permanente, the big Oakland, Calif., health-maintenance organization, is developing plans to request DNA samples from its two million adult members.


If their parents consent, children receiving treatment or participating in new-drug clinical trials at CHOP or its clinics will provide a blood sample. Hospital scientists will then use a DNA scanner to create a map, or profile, of the patient's genes. Each DNA profile will contain information on about 500,000 genetic markers; markers varying among patients may be linked to disease.

The new research makes use of information generated by the Human Genome Project, which yielded a map of human DNA in 2000, and follow-on studies. But the new efforts also raise difficult privacy and medical-ethics questions. The issues are magnified in CHOP's project because it involves DNA data from children.

CHOP says the DNA data will be kept in an anonymous database, reducing the risk that any individual's private information could be disclosed. But ethical questions remain. "When you hand over your DNA, you don't know what information is in there," says Patricia Roche, a professor of health law at Boston University's School of Public Health. "Is it OK for parents to give it away?"

Another question is how "informed" the parental consent will be: Once the DNA is collected, patients won't be informed every time the data are studied. Philip R. Johnson Jr., CHOP's chief scientific officer, says parents will sign forms that say, "You can study my DNA and access my medical information." He says the wording is "very broad" to allow different kinds of research.

Some worry that researchers could use a DNA database to carry out searches that some patients would find objectionable, such as attempts to find factors particular to ethnic groups. Others worry that patients asked to participate in a research study would be less willing to discuss health problems with their doctors.

In spite of privacy concerns -- and high costs -- some hospitals and health organizations are rushing to collect their patients' DNA. By linking genetic information to electronic medical records, hospitals are well placed to obtain research funds and patents and to strike partnerships with drug firms. "Over the last four or five years it's been snowballing," says Boston University's Dr. Roche.

It isn't certain that DNA databases will pay off. Several private efforts have folded in recent years. John Glaser, chief information officer for Partners HealthCare, a Boston nonprofit health-care provider, maintains a research database of medical records for 2.5 million patients. Partners says it has considered whether to collect DNA from its patients, but "a lot of people are nervous and concerned about how all this might be get misused," he says.

The CHOP project is one of dozens using DNA-chip technology to develop comprehensive genetic profiles. The chips, some no larger than a postage stamp, are used to detect hundreds of thousands of DNA markers from a sample. Research centers have been pouring money into buying the new equipment, sold primarily by either Affymetrix Inc., of Santa Clara, Calif., or Illumina Inc., of San Diego. CHOP will buy machines and supplies from publicly traded Illumina.

Steven Altschuler, president and chief executive of the Children's Hospital of Philadelphia, says the new DNA-chip technology has made it cheaper to get very detailed genetic information about patients. "We are really talking about doing a very large number of patients very fast," says Dr. Altschuler. CHOP and its 29 private clinics see one million children a year.

With enough children in the database, researchers may learn which genes underlie problems affecting children most, from diabetes and obesity to asthma and cancer. "The ultimate goal is to discover predictive diagnostic markers and later use them on every child in the future," says Hakon Hakonarson, director of the hospital's new Center for Applied Genomics and formerly a senior executive post at DeCode Genetics Inc., an Icelandic gene-hunting company.

Dr. Hakonarson says children make good research subjects because their health problems are more apt to be caused by genetics than by the effects of aging. For instance, finding the genes that predispose children to obesity could help guide the creation of weight-loss drugs.

The rush to build databases has some researchers worried about who will control new discoveries about genetic risk factors. CHOP says it will seek to patent its discoveries. Other research groups say they won't, because the information is so fundamental to medicine. "I would rather see this information in the public domain without patent restrictions," says David Altshuler, head of medical and population genetics at the Broad Institute, of Cambridge, Mass., which this year plans to scan genes of about 10,000 people. Dr. Altshuler says there is a "sense of urgency" to study important diseases before others make discoveries and file patents.

Corporations "continua" to push healthcare to the home

How will the healthcare system(s), burdened by a predicted shortage of doctors and nurses and costs ever-spiraling upwards, handle a boom in one of the most vulnerable populations, the elderly, who are especially vulnerable to chronic diesase like hypertension and diabetes?

Thanks to improving technology, healthcare providers and their patients will monitor and manage their conditions at home, according to the June 7, 2006 WSJ article "Corporate Alliance Aims to EaseUse of Technology in Health Care" (suscription needed). The biggest stumbling block to making it all work is a lack of standards. And this what Intel et al are hoping to change through a new joint nonprofit.

Twenty-two electronics and health companies announced a joint effort to help patients by making high-technology tools work better together.

The companies are forming a nonprofit organization, called the Continua Health Alliance, with initial members that include Intel Corp., International Business Machines Corp., Cisco Systems Inc., Samsung Electronics Co., Motorola Inc., Philips Electronics NV, Medtronic Inc., General Electric Co.'s GE Healthcare unit, Kaiser Permanente and Partners HealthCare System Inc., among others. Additional companies are expected to join.

Participants said they were responding to an impending crisis, as a fixed number of doctors and nurses will confront an expected explosion in chronic diseases.

"We've lost the capacity battle already," says Joseph Kvedar, vice chairman in dermatology at Harvard Medical School and director of a Partners unit that offers remote health-care services. "We have to move quickly."

The only solution, Continua backers argue, is to shift more care to the home, using devices that monitor the condition of patients and transmit data to medical professionals for analysis and recommendations.

Besides helping patients help themselves, the companies hope to make it easier for family members to remotely monitor the condition of patients.

But there are many obstacles, including outdated paper-based record systems in many doctors' offices, as well as incompatible products coming from hardware and software makers.

Standard-setting bodies already have been formed to address some of those issues. Continua hopes to go a step further, publishing guidelines so manufacturers can be assured that products they make will work with those from other firms.

"We will use the certification process to anoint different standards," said David Whitlinger, an Intel executive who is chairman of Continua.

Products that meet its guidelines will sport a logo that consumers can look for, as can hospitals trying to marry their information systems with home sensors. The venture also plans to lobby regulatory agencies to develop policies that help spread the use of certified technology, and make it easier for consumers to get reimbursed from insurers for using monitoring technology in the home.

Intel, which helped spearhead the effort, has made health care a priority, viewing the sector as an opportunity to sell more devices that use the company's microprocessor chips.