Engage With Grace

November 26, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

Many bloggers are posting information today about a initiative to encourage conversation about a very difficult topic: How we want to die. This collective effort to prompt discussions about this topic at the beginning of the holiday season is very timely, and it is a good complement to my post last week about empathy and compassion in healthcare.

What follows is essentially the same text that appears on many other blogs along with a picture of the “One Slide” listing the 5 conversation promoting questions that are at the core of the Project:

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Engage with Grace: The One Slide Project is an astonishingly simple idea that literally touches everyone.…

Proposals for Expanding the Full Range of Compassionate Care

November 20, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety / 3 Comments

Two recent events made me think about how traditional medical care and medical education address the issue of compassion.

The first was at the annual dinner for the Kenneth B. Schwartz Center when they gave out their annual Compassionate Caregiver Award, and reviewed the accomplishments of previous awardees. These individuals have all made remarkable differences in the lives of patients and families through their empathy and personal connections.

The second event was reading about the passing of Florence Wald, the former Dean of Nursing at Yale who organized the first hospice in the United States in 1974 because of her interest in compassionate care at the end of life.…

Personalized Medicine – Fulfilling the Promise of Genetic Research

November 17, 2008 / Michael D. Miller MD / Access to Healthcare, Comparative Effectiveness, Delivery of Healthcare, FDA, Information & Communications, Innovation, Quality of Care & Safety / No Comments

It has been 55 years since the discovery of the structure of DNA, and 40 years since James Watson published his account of that discovery in his book, “The Double Helix.” (A picture of my autographed copy is below.)

Ever since DNA was discovered to code for the structure of most living things, there has been the hope that understanding abnormal genetics would lead to the ability to treat or cure a vast array of illnesses. Unfortunately, that progress hasn’t been as rapid as originally hoped. But medical science is now beginning to put genomic research discoveries into actual medical practice, and start customizing medical treatments based upon each individual patient’s genetic makeup – the fundamental concept of “Personalized Medicine.”…

Medical Homes, Hammers and Nails

November 10, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 2 Comments

Medical homes are being promoted as a way to improve health care delivery by increasing the coordination of patient’s primary and specialty medical care. The goal of medical homes is to ensure that patients’ care is comprehensive, appropriate and patient-focused.

One of the benefits to the patients and the healthcare system is that medical homes can help sort out the confusion that can arise from the phenomenon sometimes described as, “When you’re a hammer, everything looks like a nail.”

In healthcare delivery what this means is that sometimes the diagnoses or treatment recommendations from specialized clinicians will reflect their expertise – and thus their may be inconsistencies or conflicts in the recommendations coming from several specialists.…

New Challenges for Life Sciences Companies to Communicate Value

October 16, 2008 / Michael D. Miller MD / Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Health System Reform, Information & Communications, Therapeutic Substitution & Interchange / No Comments

Life sciences companies have always faced challenges communicating the clinical and economic value of their products and services to different groups of stakeholders. These challenges arise from the technical nature of research information, the different perspectives of various groups, (e.g. clinicians, payers and patients), and marketing regulations. However, with costs continuing to rise, political, business and advocacy leaders are all agreeing that health care spending is growing out of control. Therefore, no matter who wins the White House in November, “cost containment” will be the embodiment of “change” for health care in 2009 and beyond – and the current economic downturn and expanding government deficits will only fan those flames.…

Patient – Doctor Communications

October 7, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications, Quality of Care & Safety / 1 Comment

In the last couple of weeks there were two interesting articles in the New York Times about patient-physicians communications.

Value of Empathy
In the first piece, Dr. Pauline Chen discusses an academic article that explored the way physicians communicate empathy to their patients who have serious and life threatening illnesses. The conclusion of the research, (which looked at the experience of people who had lung cancer), was that physicians miss 90% of the opportunities to connect empathetically with their patients.

The researchers speculated that physicians don’t engage patients empathetically because they are concerned that this would take too much time. However, according to Dr.…

Incentives for Everything But Primary Care

September 10, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Innovation, Medicare, Politics, Public Health / No Comments

Two interesting and related items recently dropped into my inbox concerning the future availability of primary care clinicians. As most people are aware, primary care services are becoming increasingly scarce – and has been seen here in Massachusetts expanding insurance coverage may only increase this strain. In addition, there is some good evidence that a major reason for our higher health care spending is having too many specialists and not enough primary care clinicians. So increasing the number of primary care clinicians might be part of the solution to controlling health care spending.

Incentives to Become a Specialist
The first article in my inbox was a Washington Post story stating that only 2% of graduating medical students were contemplating going into primary care. …

Importing and Exporting Health Care

August 18, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Patents & IP, Politics / 1 Comment

The August 16th Economist had an interesting article (and commentary) about patients traveling to other countries for medical treatments, a.k.a. “medical tourism.” The article focused on the US healthcare system, and mentioned other parts of healthcare that are being exported, (such as transcription of medical records, reading of imaging studies), and imported, (such as physicians and nurses). But there are two aspects of this issue that the article didn’t touch upon – chronic care and pharmaceuticals:

Medical Tourism Doesn’t Work for Chronic Care
Patients are traveling from the US to other countries for expensive procedures like heart surgery and joint replacements. …

Questions and Answers About Pay-For-Performance (P4P)

August 14, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Health System Reform, Information & Communications, Therapeutic Substitution & Interchange / 1 Comment

An article in the July/August Health Affairs about Massachusetts health plans implementing Pay-for-Performance (P4P) incentives for physicians raised more questions than it answered.

The study found that P4P programs from 5 private sector payers “wasn’t associated with greater improvement in quality” compared to the overall upward trend in the factors measured. But the study didn’t address some overarching questions and basic realities about P4P, such as:

How the payers P4P incentives to the physician groups was actually translated into incentives for the individual physicians – or smaller groups of physicians inside the larger groups?
How the P4P incentives compared to the other financial incentives the physicians are facing?

…

Colon Cancer Insights – Vitamin D and Cannabis – “Good and Good for You”

August 7, 2008 / Michael D. Miller MD / Delivery of Healthcare, Innovation, Nutrition, Public Health / No Comments

A couple of recent reports provide new insights into preventing and treating colon cancer. These studies remind me of the scene in Woody Allen’s movie Sleeper, where he wakes up in the future to find out that all the things he thought were bad for you are really healthy.

The first study was in the Journal of Clinical Oncology which found that people who had higher levels of circulating Vitamin D and later developed colon cancer had a better survival rate than people with lower Vitamin D levels. An accompanying editorial points out that this could be because people who exercise more are outside for longer periods of time – which gives them more sun exposure leading to higher Vitamin D levels – and that more exercise itself might provide a better survival rate. …

Literacy, Communications and Star Trek – Cores for Reforming Healthcare

July 30, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 1 Comment

In talking to people about the problems with the US healthcare system, two fundamental truths have become apparent.

First, people really want the type of healthcare that is envisioned in science fiction such as Star Trek, where almost any ailment is treated with a single injection or pill, or a few waves of a healing wand. Unfortunately, medical science hasn’t accomplished that, except in a few instances – antibiotics for a bacterial infection, or perhaps relocating a dislocated finger or shoulder (and those still require weeks to heal and therapy to regain strength and mobility).

And second, the ongoing problem of healthcare literacy and communications may be getting worse as the complexity of medical treatments increases.…

Financial Returns from E-Prescribing – Saving Medicare $2.1 billion

July 23, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Information & Communications, Innovation, Medicare, Quality of Care & Safety / 5 Comments

The leadership of HHS had a tele-conference on Monday to highlight the new Medicare incentives for physicians to adopt e-prescribing systems. What the Washington Post and Kaiser Family Foundation reported about this press briefing that wasn’t in the HHS press release was that the Acting Administrator of CMS said that the per physician cost of e-prescribing systems is about $3,000 up front, and then $80-400/month for operation and maintenance.

These numbers caught my eye, because with the incentives in the Medicare bill, the break-even point for physicians is as follows:

First, let’s assume that the per month cost is $240 (the mid-point between $80 and $400), or $2,800 per year.…

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