Moving Intelligent Change Forward.

Evidence-based Medicine

Trendy Thoughts

philosophyImage Every other day I read an article about “trends in healthcare.” Newt Gingrich said recently that anyone claiming to know the direction of healthcare in the future should be thrown out on his or her ear. Well, I agree no one can predict the future with full accuracy, but here are some policy, research investment and practice change trends to embrace and promote!

  • Prevention as a primary focus in health care
  • Free health apps for patients and providers to share and monitor key metrics of health
  • Patients involved in care planning, self-management, records review and research
  • Providers and payers embracing fully integrated care
  • Community health workers involved in care transitions and coordination
  • Healthy behavior promotion
  • Better stewardship — of drugs, diagnostics and treatments
  • Patient-Family-provider Dialogue about end of life care

Change the Incentive; Change the System of Care

philosophyImage  What if healthcare really focused on outcomes that matter to patients?  What if payment for services was based on whether someone’s cholesterol level went down, diabetes was under control, they quit smoking, lost ten pounds, returned to work without complications from surgery? What if effectiveness for mental health services were shown by number of individuals able to hold a job (or get a job) or maintain a living situation of their choice. What if cancer care effectiveness was measured by whether a patient could maintain normal routines for family and work and whether their emotional well-being was valued on equal basis with the “stage” of their tumor?

What if we stop measuring events that shouldn’t happen and start really aiming for the outcomes we want in healthcare?  What if we truly focus on prevention – the version that is focused on promoting an individual’s best health opportunity rather than wasting hours and dollars chasing after non-hand washers, vaccine shirkers, “non-adherent” patients, fraudulent billers and innovators out to make a quick buck with no commitment to improving health.

That’s why a focus on value and payment based on care “episodes” is intriguing. Pay for care that accelerates an individual toward the good health outcome they want and deserve. The burden is on everyone involved – patient, family, provider – to think about methods and interventions to achieve their goals, instead of focusing on units of service and time, or ticking a box for monthly contact.  It’s certainly no guarantee that the outcome will be achieved. That’s another discussion about our need to accept the realities of illness and mortality.  But it’s a best shot at a system that focuses on health and care for the individual first.

The Power of One

servicesImage  I read a recent first-hand account from an ER physician about her experience as a patient with disbelief, at first, and then with frustration. She had access to well-educated caretakers and a well-resourced facility, but suffered as the result of misdiagnosis and a distinct lack of patient-centric care delivery. Health care has been commoditized to the point that every “intervention” can be tracked and measured to determine whether it’s valuable for a patient. In the process, the equally vital element of humanity in health care is nearing extinction.

This doctor’s story is a reminder that patients have a vital and productive role to play in their care. And yet, for all the buzz about “patient-centered care,” the reality remains that unless an individual makes herself a pest or is lucky enough to have an advocate present, even the most educated and aware patient becomes the victim of inefficiency and detached neglect. Recent news about the years of neglect in the veteran’s health system is another example writ appallingly large. Growing obsession with metrics for value and “quality” are drawing resources and attention away from the “care” part of health. And with disastrous health outcomes.

In the midst of all the lofty debate (and more often arguing) about the cost of new technologies, drug A over treatment B, who should pay for insurance coverage and which hospital or physician offers the “best” care, we’re forgetting the fundamentals. Healthcare is a customer service. The patient is the customer. And, the first step toward a universal “culture of health” is simply, truly this: one person, offering one touch and taking one moment to ask “what do you need?”


In Search of Appropriate Evidence

The ongoing conundrum of what is high quality evidence and when is it applicable to an individual patient’s situation always gets my attention. I was just at the doctor’s office where I discussed the never-ending debate about annual mammograms before or after age 50 (I’m an annual girl, for sure). Then, I read Lisa Rosenbaum’s excellent piece in the New Yorker ( addressing similar questions about appropriateness of stents in the world of cardiology. How does the patient and his/her provider know what evidence is valid (is generalizable) to the situation they confront together?

Government agencies, professional societies and even payers weigh in on “what we know from the evidence,” and this drives everything from what’s presented to us as treatment options to what is reimbursed by our health plan. The truth is that we cannot have a well-funded, well-designed, appropriately-powered answer for every medical situation and combination of health history, gender, ethnicity, lifestyle and access. I support all the attention being paid to better evidence, transparency and patient inclusiveness in research. Surely these efforts will yield information that is more likely to benefit patient decision-making down the road. And yet, I’m concerned about the emphasis on “defining value” or “identifying waste” based on such evidence, when the reality (in Dr. Rosenbaum’s example with stents) is that the percentage of inappropriate use may be far less than such studies reveal.

Ultimately, value should be based on the patient outcomes — did they get better? were more procedures or hospitalizations required that might have been avoided with earlier/more aggressive/different treatment? did the patient’s quality of life improve? Our health system tries to put all the calculations of comparative effectiveness, appropriateness and value into a neat box that can “fix” practice and arrest spending growth. We know, in reality, that appropriateness of care is determined one on one between the patient and the treating provider. For my part, I want a doctor who is well-versed in the latest research, but who is willing to discuss how the evidence may or may not apply to me and who listens to my preferences for outcomes. And, I hope for a system of care that supports that interaction and our ability to decide on a course of treatment that is right for me.