Demystifying Medicine One Month at a Time

Category: movies

“The Future, Mr. Gittes. The Future!”*

The announcement of the proposed takeover of Aetna (a health insurer) by CVS (a drugstore chain calling itself a “pharmacy innovation company”) has become a big news story. What does it mean for U.S. health care? More importantly, how will it impact us as individual patients (what some like to call “customers”)?

I don’t know.

I’m not sure anyone has clarity on this yet. We’ll have to wait and see if the deal goes through, and then how the behemoth merged company brings efficiency or monopolistic pricing to the market.

Or both.

But if you want some other visions of the health care future, think about a hospital without patients as is detailed in this article from Politico.

Mercy Virtual, which opened in 2015, calls itself “the world’s first and only facility of its kind.” The 125,000 sq. foot building houses health professionals who remotely monitor and consult for dozens of hospitals and ICUs. It’s all done telephonically, er, remotely, errr, virtually.

[Another article in that same Politico issue makes the case against hospital beds, on the basis of bed rest being counterproductive for nearly every medical condition we treat. I used to get frustrated watching people ‘decondition’ while laying around in bed. It’s a serious problem, especially in the elderly.]

Which leads directly to another future question: is the age of the virtualist upon us? Yes, as predicted in a recent JAMA column by Dr. Michael Nochomovitz, who makes the case for a medical specialty devoted to care of patients through technology.

It may be the way of the future, but it sure makes performing physical exams harder.

These times. They are a changin’.

*Chinatown. Noah Cross (played by John Huston) to private investigator J.J. Gittes (Jack Nicholson). 

Deja Vu All Over Again

In addition to providing coverage to millions of uninsured Americans, one of the key attributes of the Affordable Care Act (aka ObamaCare) is reforming the way that we finance health care in the U.S.

Since the rise of the health insurance industry (as a job benefit or under Medicare, etc.), we have operated under a system known as “fee-for-service,” in which every little nugget of health care provided (from an operation to an aspirin) incurs a charge. There are exceptions to the rule (cf. Group Health Cooperative in WA, Kaiser in CA, et al.), but in practice the more doctors, hospitals, and health providers do, the more we charge. This is what’s become known as volume-based care. It has enriched many, as health care for the most part has inelastic pricing, steady high demand, and very little transparency or information symmetry.

groundhog_dayAs is evidenced by its name, the Affordable Care Act seeks to bring down the costs of health care. At nearly 20% of our GDP, there’s a collective will to bend the cost curve.

How can we do it, you ask?

We need to switch from volume-based care to a system of value-based care, in which payments are based on the quality of care delivered, not simply the quantity of care. Should we pay for hundreds of thousands of open-heart surgeries just because we do them, or should we pay for them in bulk based on outcome data that shows recipients live longer, symptom-free lives?

It’s anybody’s guess how to make the transition from volume to value. But there are myriad pilot programs underway racing us all to a new era. Perhaps no pilot idea has gained more traction than the creation of ACOsaccountable care organizations.

ACOs align the insurer with the provider of service (e.g. your doctor or hospital), such that monies are paid in advance, rather than after the fact for itemized bits of service. The advance payments are then creatively used with a goal to keep people healthy (and out of, for example, hospitals) instead of ringing the cash register every time you get sick.

ACOs put the incentive on thrift (using best available evidence and high quality practices—all requiring lots of data so we’re not flying blind) instead of on simply doing more. Savings derived from providing less (but more effective) care are shared with providers in this model—in essence rewarding utilitarian health promotion ingenuity. However, the potential downside is that the emphasis on thrift means some necessary care may be denied in the name of cost savings or cost-effectiveness.

We experienced something like that in the 1990s with the rise of managed care, or what became demonized as HMOs, health maintenance organizations. HMOs saved money by tightly regulating networks of providers and rigorously negotiating prices with them.

It’s far too early to tell if ACOs will make any dent in our national health expenditures, or if they will even turn out to be feasible. My fear is that they’re a high-minded idea that will fail to catch on with a confused public. The up front investment in ACOs is considerable, so even with public support the idea may never make it to prime time.

The more things change…

The Outsiders

One of the things that helps adapt to a new environment (read: routinely above 100 this summer) is to immerse one’s self in the culture.

Over the last week, we’ve viewed two Tulsa films; one a classic, the other, well, less so.

Ah, where have they gone?

S.E Hinton’s The Outsiders, published in 1967, is set in Tulsa. The 1983 film version directed by Francis Ford Coppola was filmed in the city and its environs. Neither the film nor the book paint the most flattering portrait of the city.

Having come from Chicago, the usual rich-poor dichotomy is inverted: here, South Tulsa is the moneyed side of things where the “Socs” (pronounced sosh, with a long o sound) live. The “Greasers” come from much grittier (and still hardscrabble) North Tulsa.

The population of North Tulsa is now mostly African-American and Latino. We’ve been told that the average life expectancy of an African-American male in North Tulsa is fourteen years less than that of the average south Tulsan.

Pretty staggering.

North Tulsans have less of everything: educational opportunities, parklands, commercial ventures, grocery stores, safety. The only thing that’s in abundance is poverty. Our medical school is working to improve access and health on the north side.

A quick web search of fan sites reveals that S.E (Susan Eloise) Hinton was born, raised, educated and still lives in Tulsa. All of her books are either set in or have some connection to the city. Her legacy in the pantheon of young adult authors is secure. Seems she’s a very private person; her website gives you just enough information to keep you wanting more.

The other film is called Leaves of Grass, starring Edward Norton and directed by Tulsan Tim Blake Nelson. Norton plays a set of identical twins, one an ivy league classics professor, the other an industrious but underachieving hydroponic marijuana grower with some big debts.

The plot is far fetched, but worth watching for a couple of reasons. Norton is great as divergent twins. It reminded me a little of his breakout performance in Primal Fear (1994), where he showed similar range between a dimwitted ‘victim’ of justice to a psychopathic cold-blooded killer. Director Nelson is great in a sidekick role to Norton’s country twin, and Richard Dreyfuss plays a compelling Jewish drug kingpin named Pug Rothbaum.

***Addendum: True fans of The Outsiders film and Tulsa cinema will remember the Admiral Twin drive-in theater. It burnt down in September 2010, but the owners have pledged to rebuild it. A recent story related that it will reopen in 2012.

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