ONC’s Work to Stimulate Innovation and Diffuse EHR Best Practices

A recent New Yorker article by Atul Gawande skillfully draws an analogy between today’s health care crisis and the food crisis our country faced a century ago. Whereas the heath care system currently consumes about 17% of the U.S. economy, Americans spent more than 40% of their income on food at the turn of the last century. Like our current health care system, there existed a huge chasm between what science suggested could be achieved in improved quality and productivity and how farmers dispersed throughout the country were actually practicing.

Gawande describes how the federal government developed the agricultural extension program to bring the latest science to real-world practice. By finding practicing leaders in the community, developing pilot projects, providing implementation expertise and technical assistance, and continuously building on what was learned, these regional extension centers developed best practices that ultimately became embedded into U.S. farming practice. A century later, food consumes just 8% of household income.

Two recent and thoughtful critiques of Gawande’s argument appeared in the blogosphere—one from Alan Enthoven on the Health Affairs Blog and the other from Matthew Holt on The Health Care Blog—suggesting that Gawande made some critical errors in drawing this analogy. Notwithstanding some important issues raised by Enthoven and Holt, Gawande could have made the argument stronger if he had gone one step further.

In drawing his analogy, Gawande focuses exclusively on the pilot programs included in the health care reform legislation now being debated by Congress. Although Gawande is correct that these bills have critically important pilot and demonstration projects that have the potential to stimulate innovation and diffuse best practices, they are building on health care reform work the 111th Congress has already done. The critical piece missing from Gawande’s article is that Congress’s down payment on health care reform in the form of the American Recovery & Reinvestment Act. ARRA already has put in motion both the extension center model and the incentives to make it economically worthwhile for providers (in addition to other important infrastructure such as comparative effectiveness research).

Remember that the HITECH provisions (the portion of ARRA dealing with health information technology) not only tried to realign incentives by offering (in the neighborhood of) $35 billion for providers who become “meaningful users” of HIT. HITECH also included $2 billion of infrastructure support to promote the innovation, technical support and guidance necessary to stimulate that innovation.

And, very importantly, these are all linked together.  That is, ONC is crafting its extension centers, the associated HIT Research Center, the workforce programs, the health information exchange grants, the Beacon communities, and the SHARP innovation grants (and much more) to stimulate innovation and diffuse best practices in the meaningful use of HIT to improve health, health care delivery, and cost-efficiency. That cohesive, thoughtful approach helps pave the way for other important pilot and demonstration projects that will build on the progress made by ONC’s extension program.

In the coming weeks, we’ll be blogging about more specifics of our extension program efforts and how they will help guide us toward meaningful reforms of the delivery system.

32 Comments

  1. Brian Ahier says:

    My main concern with the REC model is a sustainable business model. The following information is from the extension center FAQ section:

    B5. How can Regional Centers generate program income to satisfy cost sharing requirements?
    It is expected that each Regional Center will generate resources to support cost sharing in ways that demonstrate provider and community commitment to the regional center and its goals of supporting adoption and meaningful use of health IT. Such sources of funding to support the center’s cost share obligation under the cooperative agreement could include per-provider participation fees. This statement does not preclude recipients using other legal sources of cost sharing contributions as governed by applicable laws, including Part 215 of Title 2 of the Code of Federal Regulations (CFR).

    B4. Are there any limitations on the ways that program income may be used by the Regional Centers?
    Fees and other funds generated by the project are considered program income under Part 215 of Title 2 of the Code of Federal Regulations (CFR). Program income generated by the recipient shall be retained by the recipient and first used to finance the non-federal share of the project. To support sustainability, ONC places no limits on the accrual of program income. After the federal cost sharing requirement is met, program income generated shall be added to funds committed to the project by the federal government and used to further eligible project or program objectives. In other words, funds generated using federal funds, including fees for services, will be used to meet the cost sharing requirement of the program. All funds generated after that requirement is met can be retained by the recipient and used for the same purposes for which the project was funded.

    But the question remains, where will the income come from? Will there be a cap on per-provider participation fees? Will states be required to financial support extension centers? I’m sure that value-added services provided by the extension centers will provide some form of revenue generating, and this may vary by region, but there are many details still needed. Since grant announcements will be rolling out soon, I’m very glad to see a focus on this critical program from the ONC. Particularly in rural areas, there is currently insufficient support available to providers to assist in health IT adoption.

  2. Blue Oak Consulting LLC says:

    I agree that the financial model is critical.

    Supporting evidence for this conclusion is abundant in the prior failure of almost every RHIO, most of Revolutions Health’s units, and many other dotcoms and apps whose value propositions are simply “eyes=ad revenue.”

    The challenge for HITECH is to receive management support from dynamic teams that not only understand provider efficiency, HIT, network administration, privacy & security, database management, but also executive management: strategic planning, operations CQI, and in-depth financial modeling and forecasting.

    While Gawande’s analogy that healthcare revolutionized by HIT will imitate the incredible increase of agriculture productivity yields some valid insights; the analogy is lacking at its base supposition.

    And I believe this very oversight is the absolute most critical factor in what is yet to come: HEALTHCARE PROVIDERS.

    Unlike the share-cropper farmer of 1900 with a plow, a mule and 40 acres, our physicians, physician assistants, nurse practitioners, nurses, therapists, technicians are the most educated, trained and well-equipped (with incredibly sophisticated technology) and committed in the world.

    This is not to say that with regards to healthcare, everything that can be invented/improved already has been.

    But it is to say that like the ONC itself, every aspect of HITECH needs to be informed and guided by experienced healthcare providers if we are to achieve something more than a national database of dated and irrelevant PHI of cosmic proportions.

    • Joe Moore says:

      Health IT is most widely known for its failures because IT solutions so often leave out the end user. I think most clinicians would agree with that statement. Things have gotten better but there are still plenty of failed health IT projects today wasting billions of dollars nationwide.

      It is imperetive that any HIT initiative be led by clinicians with IT involved to help support the needs of clinicians. I know how IT thinks because I’ve been working in HIT since 1991 and even to this day I’m constantly amazed at the arrogance and lack of understanding that IT has of clinical operations. IT people care more about storage networks than improving the core business of providing care. Hospital administration has been led to believe it’s a good idea to hand the reins over to IT so they can squeeze every dollar out of technology. This in most cases leads to frustrated clinicians who will later fight you to the bitter end when you suggest change. It’s not just an overall fear of change; it’s based on historical failures that they’ve had to endure because IT was focused on how much money they can save with their SAN.

      HIT needs to be a tool that improves the core business of providing care and not the savior of the budget. Taking care of the core business will lead to a more prosperous enterprise and help reach the goal of improving care IMHO.

  3. Going further on Mr. Ahier’s comments, I feel that physicians are not driving this reform, are not involved enough in the process, and this will result in very painful growing pains for all. I am involved in my state’s efforts to start both HIE and extension centers, and physicians are somewhat lacking from the discussion. I have joined an Advisory Group which is mostly physicians, so maybe that will help, but it is still mostly healthcare administrators, hospital officials, educational institutions and other third parties that are controlling most of the conversation. Physicians are certainly not being blocked from the process, but they are not being courted as they should be. Without physician buy-in, the process will be bogged-down and even thwarted by those who do not see the need for change. “One percent penalty in 4 or 5 years? No problem, we’ll just see less Medicare patients..”

    The other issue I am concerned with is again what Mr. Ahier brought up. Where is the funding going to come from for the extension centers? I know where it is thought to come from – physicians and physician groups. While we are not well-engaged in the reform process, the result of all this is more revenue out of our pocket and out of our already-stretched office budgets. Physicians are not only expected to purchase expensive EHR systems that are still not yet standardized and still in evolution, but it will be expected that physicians will be paying these extension centers for their “expertise” in choosing a vendor and implementing a system. EHR companies will not be robbed – they will get their money, which always includes installation and implementation, and now extension centers will ask for their piece, all this leaving less and less for the physician who, especially if he is in primary care, is already being hit hard by rising overhead costs, reduced reimbursements, increased healthcare costs of his own staff, and trying to care for an increasingly less-employed patient base. Oh yes, there is ARRA money, but it is a reimbursement, not an upfront infusion, and if you don’t use “meaningfully” then you may lose every bit of that reimbursement.

    It is imperative that physicians of all types are involved as much as possible in these efforts, and that no more financial burden is put on physicians and physician groups.

    • Tony Dotson, MHM says:

      I too have overheard physicians expressing the opinion you quoted about seeing less MCR patients to offset the 1% loss and therefore not adopt EMR etc. However, I believe there will be secondary effects of adoption vs. non-adoption. For example, when systems are interoperable and physicians (and staff) become accustommed to receiving info from other docs using HIT then referral patterns will change for those physicians failing to adopt. The lack of convenience for meaningful users dealing with non-users will dictate the patterns. This phenomenon will exist among facilities, pharmacies, labs, etc. The physicians who buy in will want to benefit fully and use all the systems’ capabilities.

      Yes, I agree physician involvement is imperative and I hope that these extension centers are not operating on revenues generated from physicians. A sweeping change is imminent, so physicians need to protect their futures by thinking ahead and participating now. I hope that Dr. Blumenthal will always consider the physicians since he himself is a physician.

  4. Thank You Josh for fostering open conversation!

    There is one common denominator between your blog post, Atul Gawande’s article and the 2 earlier comments to your post: all are still talking about a healthcare system where the patient is just a passive recipient of care, and of course, the main reason for the uncontrolled HC costs. What would it take for your agency to foster serious research about the economic impact of informed patients, working together to get better care in a much more organized fashion that what happens now? How come none of the ONC programs are fostering direct patient involvement in their care?

    I know this sounds like a repeat of many conversations but IMO the problem remains the same: there can be no effective healthcare reform unless the country starts to actively promote the benefits of the informed, engaged and activated patients. The definition of HIT should start to include patient-driven IT systems like PatientsLikeMe or ACOR.org. There is no longer any reason to keep the patient centered IT systems separated from the professional IT systems that have until now represented 100% of the ONC attention.

  5. Linda Spalding says:

    The farmers in Gawande’s article were reluctant to listen to outside advice and healthcare providers are not immune to this syndrome. HITECH will require multidisciplinary teams in order to be successful and healthcare providers are essential team members. But I wonder, will they listen to non-clinical experts?

    I have worked in healthcare information technology for 15 years and, prior to that, worked in finance and IT for other types of businesses. Healthcare is the first (and only) business model I have encountered that prefers to hire non-IT professionals for information systems jobs. I worked for a large health network where one of the senior IT leaders (a nurse with no hands on IT experience) said time and time again that he would hire an individual with clinical experience before one with technical experience because “technical skills can be taught”. He has since been moved to another position because so many systems initiatives failed under his leadership.

    It is true, if you have the aptitude, you can learn technical skills. It takes many years, but, like clinical skills, technical skills can be honed through long hours of practice and training. Much like the surgeon who develops an excellent track record with a given procedure, after many years of experience, IT professionals develop an understanding of what works and what doesn’t. They know how and why complications develop and, like Atul Gawande proposes in his new book “The Checklist Manifesto”, they develop detailed checklists (in the form of project plans) to avoid these complications. Gawande describes the complexity involved in building a large office building and points out that one of the essential elements of success in a project of this size is frequent communication between experts. I wonder whether plumbers have to deal with electricians who refuse to acknowledge or value their skill set because they have never wired an outlet?

    I recently spent several hours with a highly intelligent physician who wanted me to teach her how to query a database. I did not bother to tell her in advance that I had spent more than 10 years developing my proficiency with this particular tool. After three hours, when we had barely scratched the surface of the knowledge she would need in order to retrieve the data that she wanted, she looked at me and said, “This isn’t going to work, is it?” I told her that I had no doubt that she could learn the technology, but questioned whether it was a good use of her time. She chose to dedicate many years to learning how to practice medicine, and I respect that. I chose to dedicate my time to learning a different profession. I believe that I possess a set of skills that complement and support hers, and that these skills are in no way diminished by the fact that I have never diagnosed a patient.

    There are many problems facing our healthcare system. Our care is fragmented and our payment system rewards excess. Insurance company billing and reimbursement requirements are ridiculously byzantine and add millions in unnecessary administrative costs. EHR systems do not interface easily with existing software and stories of delayed or failed implementations are commonplace. Each of these problems could be improved through the appropriate application of technology. Accountable Care Organizations armed with timely, actionable information would reduce fragmentation, provide better care, and discourage overutilization. Requiring insurers to implement a standardized reimbursement form would cut millions of dollars from the system. Developing standards and roadmaps for successful EHR implementations would reduce the risk and cost of failure. But every one of these initiatives will fail unless those of us dedicated to reforming our broken healthcare system learn to respect each other’s skills and to put our heads together to work toward a solution.

  6. Patrice Kuppe says:

    The DOD established an extension center program back in the mid 90s when they wanted all of their contractors to embrace Electronic Data Interchange (EDI). I wish I still had the information to share with HHS. They could learn from this highly successful extension center implementation.

  7. Margalit Gur-Arie says:

    This is intriguing. As far as I understood Dr. Gawande’s unfortunate analogy to agriculture was aimed at pilot programs contained in the health insurance reform bill, not HIT adoption per HITECH. Those pilots are supposed to be geared towards exploration of novel reimbursement and care delivery models.

    I assume that successful adoption of HIT will be a prerequisite for participation in those pilots in order to be able to measure and asses success or failure and generally learn from these projects. I also assume that those pilots will have separate funding sources and not rely on HITECH appropriations.
    Are we proposing to use RECs to support these pilots? Will the RECs involved in such pilots receive funding outside HITECH and will they have to have different competencies (less IT, more business & clinical)? I know it’s probably too soon to answer, and the bill needs to go through first…. :-)

  8. Lindsey Hoggle says:

    Thank you–It is refreshing to have this open venue for discussion. While the original analogy may have had limitations, it does provide a foundation for continued elaboration on RECs and how the HITECH Act will come together. For many, the concept of HIT and interoperability is still abstract. The more visual representations, analogies and descriptions made possible by ONC and others certainly faciliates understanding how the next 5 years will unfold.

    I agree with the need for financial sustainability and most importantly the need for “all hands on deck” in the adoption of health IT: appropriate support for physicians/hospitals to adopt EHRs using best practices, participation by non-physician providers of the health care team as standards are harmonized, education and participation by patient/consumers as HIT becomes the norm.

    Having patients “expect” a CCD (or like report) each time they go to the physician, knowing how to use it as a useful adjunct to their care and understand that they should be an active participant is a critical cultural shift which will help embrace HIT use for improving health care. Just as the most successful EHR implementations utilize a team with diverse skills, diverse stakeholder collaboration is necessary for assuring that patients participate in receiving the best care. Thanks again for hosting/encouraging this conversation.

  9. Perhaps we should not be so quick to discredit Atul Gawande’s analogy. While arguably more skilled and intelligent than the independent farmers of days gone by, private practice physicians (at least in Michigan) seem often to be just as splintered and disconnected from one another.

    We are experienced as a provider of implementation services for EMR/EHR systems. When we go to market with our services we do not endorse a particular software solution, but rather we advise our client as to the most beneficial solution given their current situation and goals. Our earliest implementations had nothing whatsoever to do with HITECH and its vague requirements. They had simply to do with good business strategy. As pointed out by Blue Oak above, an EMR implementation in private practice must at minimum be in alignment with a provider’s strategic vision. Lacking that, unless much more significant penalties are added to the bill, the unbelievably fragmented provider system in this country will never come close to 100-percent adoption.

    That said, the case can be easily made that EMR/EHR systems have a short ROI and create dramatic opportunities for cost reduction. The impact of a fully-integrated system with e-prescribing, EDI, exam-room charting, scheduling, and Web-interaction is an increase in the capacity of the practice and the elimination of costs tied to a litany of non-clinical support staff. This is not to mention the wonderfully dramatic impact a system such as this has on cash flow.

    From personal experience I can assure you that so far this bill has stalled, or at best slowed implementations in private practice. This is anecdotal, and I have no data to support the claim. I base it solely on the fact that implementation specialists have had tremendous difficulty assuring potential clients that any of the currently available software offerings will be in alignment with the pending mysterious certification requirements. When HITECH first became law, we were naturally thrilled with the promise of an expanded market for our services. Instead the bill’s lack of clear language produced a brand new array of quite reasonable objections.

    We have always approached EMR/EHR systems from a standpoint of efficiency and process improvement. We believe in the technology and are willing partners with clinicians and staff. As time goes on, this point has been lost. Many physicians view this bill as a cash grab by EMR/EHR developers and implementers instead of a way to increase their efficiency and improve patient care. As that impression grows and persists, I’m afraid the penalty-avoidance behaviors laid out above will come to fruition.

  10. Dom Nicastro says:

    Any word on when proposed meaningful use guidelines will be released?

  11. Joshua Seidman PhD says:

    I appreciate all of the thoughtful comments and will try to answer the questions that were raised.

    I don’t know Dr. Gawande and have not spoken to him, so I can’t comment on whether he thought about the connection between HITECH/ARRA and the agricultural extension program. Dr. Gawande was clearly more focused on the health care reform bills. Through this comparison, I wanted to help demonstrate that ARRA was designed as much more than a stimulus to the economy; it was also a “reinvestment” in infrastructure necessary to lay groundwork for a reformed health care delivery system.

    The regional extension centers (RECs) are expected to develop long-term business models relying on funds outside of HITECH funding. As has been pointed out by many experts — large, commercial medical practices have considerably more resources to hire consultants and RECs to support their health IT evolution. For this very reason, the focus of the HITECH funding of RECs is to support priority primary care practices. These are smaller practices and include those serving safety-net populations.

    Patrice Kuppe is correct that we can learn from other extension programs besides agriculture (Kuppe mentions Department of Defense). The manufacturing extension program also provides important lessons for us. We have experts from that program sharing their insights with us as we think about the similarities and differences vis-à-vis health care.

    The points about multidisciplinary teams are right on the mark. Indeed, multidisciplinary teams are something that we have emphasized in developing our programs. We need everything from clinical experts to technology experts (and skills in between) in order to make this work. And we will!

    Gilles Frydman is absolutely right that the healthcare system cannot work, “where the patient is just a passive recipient of care.” Engaging consumers is fundamental to health care reform. ONC, in collaboration with the newly formed HIT Research Center (HITRC), will ensure that expertise and best practices in this area are disseminated to RECs and integrated into the core of their work. In addition, there is considerable additional work (through contracts, grant programs, and other internal agency efforts) being done at ONC, AHRQ, and other areas within HHS and the federal government. These efforts will ensure learning from, and about, patients and will stimulate patient-centric innovation. We also expect to learn a lot in this regard from the Beacon communities. Beacon communities will provide another corollary to the agricultural extension program in terms of their focus on innovation and learning from progressive communities. We welcome additional input on strategies for ensuring progress in this arena.

    • Joe Moore says:

      The Institute for Healthcare Improvement has already identified 10 communities of various scope and size that demonstrate high quality and low cost. Why not just work with them as the “Beacon Communities”? They’ve obviously already demonstrated the capability without any taxpayer funding; imagine what they could do with a little extra cash? I know for a fact at least one of these communities performs this well out of necessity. Cedar Rapids, Iowa is consistently one of the top communities in the U.S. in quality while they have 16% lower Medicare costs than the national average. Don Berwick, M.D., president and CEO of the IHI said if all communities operated like Cedar Rapids the healthcare crisis would be over and we could afford to cover all Americans. Iowa is also at or near dead last in Medicare reimbursement because of the horrendously flawed geographic variation in healthcare spending.

      This is just another great example of how the government feeding trough encourages higher spending, corruption, and deception. Those places like Louisiana that have high cost, low quality, and are at the top of Medicare reimbursement are the proof.

      Our healthcare reform initiative is taking the same ugly turn. Those that are honest and hardworking are getting the shaft while those wily congressmen from states like Nebraska, North Dakota, Wyoming, etc. benefit from their dishonesty. Union representatives just cooked a deal with the Democrats to exclude union workers from the proposed tax on high end insurance policies. What’s fair about that? Why should union workers get a break but I don’t? I pay taxes too and apparently I’ll be paying more to offset union worker health insurance policies. You’re welcome!

      I just don’t know how effective the government can be at solving big issues like the healthcare crisis. By the time a bill reaches the president’s desk it seems to support nothing that was originally intended and it becomes just another grab for cash, entitlements, and benefits. I’m really getting tired of the punishment for being hard working and honest. When will it end? When will the incentives encourage such behavior instead of punish it? I’m still waiting for the change…

  12. Teri says:

    As a new physician in the Veteran’s Administration, I was looking forward to the “best medical records in the United States” per IOM. It is likely to be a model for HIT. It is true that there are many wonderful features especially finding consult reports which are actually legible so therefore helpful, med lists and problem lists in one place.

    Yet in many ways it is inefficient. Nurses, pharmacists, and physicians do their own “silo” and cause each other re-work. One example is the “alerts” the physician gets. These take hours at home since not enough time to do. The “alert” is supposed to be important yet there is “appt scheduled” with subspecialties, “prosthetics comment: taught use of …” “urine specific gravity is…” “HgbA1C is 7.8″ etc. “vet wants more alcohol swabs” etc.etc.

    The physician sees a pt q 20 min. In that time, the doc is on his own (no teamwork here) with dozens of items to cover—did the vet have a colonoscopy, if so when, what did it find, is he willing to go and why it’s important, checking for med list changes, refills, why is the blood pressure or HgbA1C elev, when were his last labs, find abnormal labs mixed in with normal labs. Order new labs (insstead of standing orders for diabetics), find the CT in another separate system that requires log in password again, that logs you out of the entire system if you’re not careful (is HIPAA supposed to keep caregivers wasting so much time logging on?) tell the vet the results, review of systems to find out if any abnormal signs, do a physical, talk w family, try not to get hurt when telling narcotic seekers “no”, discuss PSA ramifications, flu, pneu, fill out ins papers, etc. etc. AND TYPE IT ALL INTO THE RECORD by the end of the 20 min visit.
    A nurse might have asked a few of the questions like flu/pneu, alcohol use, depression but that is recorded in a different spot requiring more searching instead. Patients wonder why we don’t find the info from outside the VA that was sent a month or two ago but it is on hard copy and takes too long to find and there is no standard on how to get it onto the chart let alone onto the patient’s problem list even though an abnormal may be buried somewhere.

    The best EMR would have rapid access to key info in one place and filler info like normal labs, normal exams, etc in a completely separate place. It would stop requiring “sign in” “password” “id” pages going blank in the middle of the exam when the only info on the screen is nonsensitive. Allow pharmacists to automatically re-order alcohol wipes, syringes, insulin at the appropriate time intervals along with routine diabetic labwork, yearly lipid level, etc. based on the goals of patient care and not requiring vauable physician time. Use the nurses to coordinate and work to their highly trained limits. Have every caregiver checking the patient problem list, not just the physician and work toward true pt centered care. The VA system has many great EMR advances and it probably is one of the best….scary isn’t it?

    • Joe Moore says:

      It’s no surprise that the EMR considered to be the “best” still leaves clinicians frustrated and without the tools needed to accomplish the goals of better patient care and safety. This is the typical IT approach that has been hammered down on healthcare workers for decades. It’s more important to have a great storage system than to support the end user. Why can’t you doctors just fall in line and deal with entering a password 100 times a day? I do it why can’t you? Why can’t you wait for the refresh so you know you have the latest information?

      The capabilities of the technology we have today cannot meet both the needs of the clinician and the technical zealots. As you mention HIPAA has turned in to a roadblock for care as well but all the government does is look for more ways to make it difficult to share information while demanding we do so. Isn’t it great?

      Now consider the luxuries of control that he VA has that few other healthcare facilities have. Patient identification is one example. They can get a valid ID that absolutely identifies the patient across the entire enterprise. In the private world we have to hope that Jane Smith at hospital X is the same Jane Smith that was at hospital Y two weeks ago. Without a national patient ID information exchanges are much more of a challenge. Of course the lobbyists that fear positive identification will make sure our government doesn’t require that. I’m not sure how payment works in the VA but I’ll bet it’s a lot easier for a VA hospital to get paid than for most others.

      I think the biggest reason for the VA’s recognition of developing the best EMR has more to do with the model than it does the bits and bytes of their applications or technology. In most every successful implementation of a technology solution it seems the model has more to do with the success than the technology itself. Often the model creates a success in spite of the technology. In the private world we don’t have the luxuries of control like they have in the VA so how are we supposed to come up with something even better? Scary indeed!

  13. Brian Ahier says:

    Chief Research and Strategy Officer of Microsoft Craig Mundie and Google’s CEO Eric Schmidt had an interesting back and forth with Atul Gawande at a recent President’s Council of Advisors on Science and Technology meeting:

    http://ahier.blogspot.com/2010/01/pcast-meeting.html

  14. jmsxyz says:

    Hello and thank you for allowing me to comment concerning this growing fear what effect will this Health Care Plan just passed in Congress have upon the American People.
    What I mean is this: In Canada about a year ago a young woman was having severe head pains so her parents took her to the doctor and was told she would be placed on a waiting list for about three months. After a couple of weeks the pain became so intense her parents brought her to the U.S. where she was diagnosed with a brain tumor. She was immediately placed in the hospital and she was operated on which saved her life. The doctors stated she would not have lived for the three months to get the medical attention she was in need of in Canada.
    As you know, we have adopted the same kind of Medical standards the Canadians have. This is what I’m mostly concerned about.

    • Ken Vandiver says:

      I have the same concerns. From everything I have read or heard about the Canadian and British Health Care systems they are grossly inefficient, costly and extremely slow. We should be able to reform the current Health Care system so as to provide appropriate care to those who don’t have it without punishing those who currently have decent health insurance.

      • Barry says:

        I too have heard stories about people dying on the waiting lists, but as an American Citizen currently residing in Canada (British Columbia) I was also blown away when my friend Greg was in the hospital for two weeks and never received a bill. My friend Glenn has been in there for 6 months and had a leg amputated…I do not believe he will be receiving a bill for that either…other than the $54/month for the MSP (BC Health Insurance). I find that just as shocking as somebody dying on the waiting list.

    • Free service says:

      This is very common in the countries with govermental regulated public health care. And if it is combined with public and private systems side by side, those who have money can get to private clinics at once while for the public clinics they should wait for months.

      • I can only speak from experience in the Australian healthcare system where we seem to have a fairly good balance of public health care access and private options (using private health insurance or patients paying privately) so you actually have the option to be covered by the commonwealth health system, and add on top the private cover which will grant you access to care sooner through private providers.

        It is true that the public waiting lists can be excrutiatingly long (even dangerously so), but that is not the only choice you are left with in this system so those who can afford private health care are not disadvantaged.

  15. Please allow me to voice my “European” point of view… In France we have a system of health care that is very similar to the one recently proposed in America… I think this is a great news and US people should not be scared by this reform. I can say things work very well for health care here in Europe (and in France in particular) and if the proposed system will come close to the European standard you will have huge benefits in the coming years…

  16. David Dunham says:

    It is obvious for all to see, that most government run National Health Services are inefficient and costly to maintain. Is it not that the job of governing a country is not aimed at such a specialized area which is healthcare. Would it not be wiser then to direct this field of public interest to the Private sector of the medical industry, where recognised specialists could better manage an area of which they are recognizably capable.

  17. I was moved to respond to David Dunham’s reply;

    Both my husband and I have spent most of our working life in the medical field before moving to France and the following are some comments which with the benefit of hindsight (always a luxury) I feel could be taken into account when discussing the NHS (the state funded health service in Great Britain) and the reasons that it seems to be under such strain.

    The National Health Service in the UK worked well at inception – that is when the balance of people paying a subscription via their taxes (known as National Insurance) was (almost) equal to the demand on the service. When my husband entered the service many years later in the 1970’s as a clinical nurse he recalls unoccupied beds occurring on both acute medical and surgical wards. Now waiting lists in the UK have reached untenable proportions and we might conclude that the following could be viewed as possible contributing factors;

    a) the number and variety of ‘advanced’ and ever more costly treatments has soared (I’d love to see patient outcome data comparing mortality in 1970 to 2007 across a broad range of treatments so that we could tell which ones really worked at a national level. This data seems not to be available but I think would be very telling.)
    b) the large number of ‘medical tourists’ who come to the UK, attracted by the free medical treatment – this has to be anecdotal as again, data is not collected. Rightly so, those showing up sick at a hospital get treatment. This ‘tourism’ is bound to be a side effect of greater global mobility and we should prepare for it – and collect the data so that a good level of service can be provided for all.
    c) sums spent on ‘consulting services’ for every imaginable hospital offering which have and continue to soar and and again no data is available to show savings when compared to what was in effect before.
    d) outsourcing services such as cleaning which have delivered lower standards and higher costs when compared to the hospitals own services which they replaced. If a new service is being considered let’s have a proven case for the cost saving or increase in care quality/patient outcome etc and a total cost, not a sliding scale.
    e) We have become litigation crazy – doctors are now carrying enormous professional insurance bills and this obviously has to be reflected in their remuneration.

    That’s not to say that it’s all broken there are some great teams, often working shorthanded and producing amazing results but on the whole the model has been adapted so frequently and so often without thought to the effect on the whole, that the organism is inevitably now showing the strain.

    So to sum up – the government run health service in the UK actually worked at the start – it perhaps only became unworkable when we started to tinker with it later on, although again, there is the case to be made that as society changes our infrastructure needs to keep pace and so change management should also be built in.

    The private sector has to turn a profit – it’s the nature of any ‘for profit’ enterprise. But should it not be the case that there are certain aspects of society that whilst they shouldn’t be allowed an ‘open wallet’ they shouldn’t be run as if they are designed to make a profit – medical care for instance?

  18. Our emergency rooms are almost always filled to overflowing. One of the problems I see in the ER is that because primary care physicians these days have to see so many patients each day and for minutes at a time, more often than not the patient’s problem is either only “patched” or becomes acute and can then lead to more hospitalizations or deterioriation in the patient’s condition. In the primary care setting as medical professionals there isn’t enough time to make sound judgements in most cases or get to the root of a problem, but then in the ER we tell people we aren’t there to diagnose, we are only there to stabilize them and get them basically out of the ER as quickly as possible. It is frustrating, I wish there was a way to reimburse physician’s more appropriately in the primary care setting so that they would have a more optimal amount of time to do the job that most of them would like to do. It is simply not possible in my opinion, to see a patient for 10 minutes (which is the amount of time in my area) that a primary care physician is allotted per visit, and manage the patient’s care appropriately. Just like the studies which show that reducing the numbers of RN’s on a floor actually increased health care costs and increased patient complications, at some point we’re going to have to realize that in order to improve health care efficiencies we’re going to have to have a solid basis in place that gives primary care providers more time and reimbursement for each patient so that there can be more emphasis on health prevention and not just treating disease.

  19. I agree Mollie, we say we want to focus on prevention, but then we tie the PCP’s hands by only allowing them to bill one type of visit at a time, so if a patient comes in for one thing and has another question, the PCP either can’t be payed for the extra time spent with the patient or else the patient has to make a new appointment – so many times the issues fall through the cracks until it becomes an ER situation.

  20. John Wesley says:

    the majority of People are bound to find this really important. I really like the point you are making with your last paragraph.

  21. Johnny says:

    This can be regulated well with both goverment and private setup.

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