Upcoming Health and Healthcare Issues

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ccpetersmd
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Upcoming Health and Healthcare Issues

 

Not unlike the burgeoning problems with the economy, energy and the environment so cogently presented in Chris Martenson’s Crash Course, we are potentially facing equally challenging issues in another basic necessity, our health. By the way,I tried to think of an “E” for this item, but failed. One disclaimer, before I get started: while I am a physician and have been following these issues for some years, my background is as a thoracic surgeon, so I do not pretend to have expertise with regard to all aspects of medicine, preventative care, health administration, etc. I fully expect that I will be incorrect in some of my assessments, incomplete in others, and welcome any feedback. These are simply the concerns that I have been following, and there may be others.

 

To oversimplify, our health is threatened basically on two fronts, injury and illness. The success of our response to injury and illness depends upon several factors: the underlying state of our health, the severity of the injury or illness, the potential benefit of specialized treatment, and our access to such treatment. The definition of injury is fairly obvious, whether it be mechanical, thermal, radiation, etc. For my purposes, illness would include any "natural" or traditionally “medical” diseases, to include hypertension, diabetes, etc., but would also include malignancy (cancer), and a primary focus here, infectious diseases. Specialized treatment consists of anything a lay person could not accomplish on their own, whether that be antibiotics, surgery, etc. 

 

Taken in order, I will discuss injury, illness, and access to healthcare, as I see these as the most important issues we are likely to face. I will not discuss wellness or disease prevention beyond this sentence, except to state that the healthier you are now, the more likely you will be to recover from future insults.

 

I'm not certain whether or not to classify malnutrition and dehydration as an illness or an injury, as it seems a bit of both. Nonetheless, access to water and food will become an increasing issue in the years to come, even in "developed" countries, as it already is elsewhere. Perhaps the most important aspect of dehydration and malnutrition is that it makes one more susceptible to either injury or illness, and will likely be a prevailing underlying theme in all that follows. 

 

I would expect the incidence of injury to increase markedly in the coming years, as a direct reflection of the worsening economic crisis. Some of this injury would be obvious, in the forms of penetrating (firearms, knives) and blunt trauma due to domestic violence, civic unrest, suicide, etc. Some, however, might be less obvious, to include hypothermia (unpaid heating bills) and hyperthermia (unpaid cooling bills). To be clear, not many in the healthcare community are currently discussing this issue, but I believe it is a foregone conclusion.

 

Historically, illness, and in particular, infectious diseases, have had the most significant impact on human survival. With the insights of Lister, Pasteur, and others, that gradually shifted, and people survived long enough to ultimately succumb from coronary artery disease, cancer, or simple senescence. I fear that reversal in fortune may soon be lost.

 

As has been typical even in most wars, infectious diseases will easily trump injury in the coming years or decades, even in the “developed” world. Without going into great detail regarding each disease, my chief concerns are Influenza, the plague (Yersinia pestis), enteric pathogens (Vibrio cholera, Salmonella, Shigella, E. coli, etc.), multiple drug-resistant tuberculosis, particularly scary viral infections (HIV/AIDS, Ebola, Marburg, etc.), and some of the more common ailments we felt we have “whipped” due to vaccinations (Measles, Mumps, Tetanus, etc.).

 

Influenza deserves special mention here, as most virologists feel it only a matter of “when”, not “if”, that another major pandemic will occur. “Avian flu” gets a lot of attention in the media, and that attention is relatively well deserved, as it is highly lethal to the birds and humans it comes to infect. If it were to become more transmissible from human to human, it could be devastating. However, “avian flu”, or H5N1, is a variant of influenza A, and there are many subtypes of influenza yet to be discovered that could be the source of our next pandemic. As devastating as was the influenza outbreak of 1918, it is sobering to think of the effect of another pandemic now, with increased population density, frequency and speed of human travel, etc. Again, it is not a matter of “if”, but “when”.

 

Enteric diseases also deserve special mention, as I believe this will be an increasing problem in the years to come. Water quality, especially, will be important if there is a breakdown in community services. Food quality, also, will become an increasingly important issue, as we have seen with regard to the recent Peanut Butter contamination (Salmonella spread, I call it, even as I continue to eat it). If the quality of our consumer goods suffered even during the prosperous past decade, imagine how it might suffer with continued cutbacks in federal funding.

 

Finally, and I apologize for the long post, but access to healthcare will become more and more critical in the years to come. Even in the U.S., which has a relative overabundance of physicians compared to the rest of the world, physician and nurse shortages are continuing to worsen. Primary care (internal medicine, family practice, pediatrics) is most affected, due to low reimbursements that steer potential physicians to more lucrative specialties, or out of medicine altogether. Even in my specialty, thoracic surgery, a physician shortage is expected by 2010. For many other specialties, that shortage already exists. The situation is even worse in elsewhere in the world. And, with declining reimbursements and the worsening economic crisis, there seems to be an increasing trend in hospital closings. This also is not being talked about much in my circles, but I think the trend is real, and likely to worsen.

 

I apologize for not having any good news here. Some will reply that an influenza pandemic, or some other process, is just what we need to re-shift the balance with regard to economy, energy and environment. I will not say they are wrong, as that might indeed be exactly what is necessary. Like the “three E’s”, we may have lived beyond our means in terms of health, also. A resetting of the balance may be necessary. I just hope the reader does as much as he or she can to maximize the health of their families, educate themselves about potential risks, and maintain access to any healthcare that may be required.

 

In closing, I will provide a few  links that I feel might be of particular value to the lay person. Most of the sites below have abundant information on a number of the topics touched upon above, and I haven’t made the effort to link to each subheading, so you are encouraged to research as much as you see fit. As a physician, I really enjoy seeing a patient who has educated themselves, and knowing this audience, I expect that you will do the same!

 

http://cdc.gov/

http://www.pandemicflu.gov/

http://emedicine.medscape.com/

http://www.webmd.com/

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Nichoman
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Re: Upcoming Health and Healthcare Issues

Christopher...

 

Thanks for your thoughtful post.  Offer another perspective. 

My concern w/r/t Health Care is it...along with Education are examples of a relationship between the government and Health Care special interest institutions that are part of the problem.  

In a broad sense, using data from US government, plus OECD; the percentage of USA GDP spent on Health Care rose from 4 percent to 19.5 percent from 1962 to 2007.   This by any reasonable measure I look at is not in any of our best interests and reduces our quality of life.

If were dealing with dwindling resources, how can this continue? 

We must develop systems of good management and leadership principles that incentivize and reward (i.e. prevention, lifestyles, etc) while dealing with inefficiencies, poor results that are tolerated, if not indirectly rewarded.

Example:  What are the 5 areas from other countries health care experiences that have shown limiting costs while providing and/or enhancing quality health care we don't do?

As a Health Care user...hard not perceive this is an area that institutionally and collectively doesn't want to deal with challenges and/or make real change.  Never hear this from key decision makers as ways to solve part of health care issue.  

So, if you partially agree the system is part of the problem to where were at today, won't they in many ways make things even worse?

 

 

Nichoman

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Re: Upcoming Health and Healthcare Issues

This is one of the most important systemic concerns, but which sometimes gets lost among the more sexy specters of depression, hyperinflation, Mad Max scenarios and such.

This health care system looks unsustainable even without the Triple-E crises which loom. Add those in, and we can see how prudence demands that each of us (1) preventively looks to our personal health and that of our loved ones, and (2) prepares for a future where health care is going to be far more localized and deindustrialized, and perhaps based more on barter.

Even the relatively moderate Peak Oil writers like Greer are expecting a near-future collapse of the existing health care system.

I'm not a health care professional and can't add specifics to Christopher's excellent overview, but I can add one recommendation to his list: Dan Bednarz is a medical doctor who writes on Peak Oil and energy descent with special reference to the health care implications.

Christopher says: "I tried to think of an "E" for this item, but failed." 

 

How about "health care Entropy", as part of a general terminology of the looming entropy of all sorts of industrial, hyper-centralized, hyper-technologized systems?

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ccpetersmd
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Re: Upcoming Health and Healthcare Issues

Nichorman,

I agree that the U.S. healthcare system has significant problems, with or without the upcoming crises in other areas. Reimbursement is uneven, with specialty physicians earning more for their procedures than the primary care physicians who should be instrumental in wellness and disease prevention. Reimbursement is also cumbersome, with multiple payers, to include the government, with different rules, reimbursement rates, etc. Physicians tend to order too many tests, whether from a "defensive medicine" standpoint of not wanting to leave any stone unturned for fear of a lawsuit, an unwillingness to trust in their clinical skills and instincts, or other reasons. Many procedures are performed unnecessarily, especially toward the end of life. Patients, too, are culpable, as many generally prefer to get problems "fixed" as they arise, rather than attending to basic "maintenance" on an ongoing basis. The pharmaceutical industry, obviously, has concerns, and physicians and patients are too often complicit, wanting the "new best thing" rather than an old, and usually cheaper, standby that will still adequately address the concern at hand.

We are seeing changes in healthcare, but they are coming slowly. "Pay for performance" reimbursement programs are growing in popularity, in which, hopefully, better physicians will be rewarded at a higher rate. Similarly, some insurance companies are going to stop reimbursing hospitals for complications that occur during a patient hospitalization, if those complications are felt to have been avoidable. Numerous individual physicians, including one of my partners in nearby Cedar Rapids, are looking at new ways to measure and promote quality care. This is a big, complicated machine, with lots of problem areas, so it is a very difficult to imagine and implement comprehensive changes that will address all problems.

Russ,

Thanks so much for the reference to Dan Bednarz! I hadn't heard of him, but have since read one of his articles. I'll give him a call! 

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Re: Upcoming Health and Healthcare Issues

Thanks so much, Christopher, for keeping these concerns before us!

As you recall, I raised some of these issues a few weeks ago which elicited your first post.

Today it is 3 weeks since my bilateral knee replacement surgery. The knees are working amazingly well. I get around on a cane mostly and can even manage without it for short trips around the house. Pain is now minimal although I'm not ready to give up the meds completely. I'm 60 and I still feel I'm in recovery from the overall trauma of surgery. I can't imagine going through this at an older age or of having other health issues to contend with.

I appreciate your admonition to maintain one's overall level of health as high as possible.

I recognize my own good fortune at having the opportunity to receive the care I've been given thanks to my wife's employee benefits. I am appalled at the cost and of the resources that I have consumed. The hospital bill alone was over $66,000. We're still awaiting bills from doctors, physical therapy and visiting nurses, not to mention Rx. I guess i did my part to stimulate the local economy. When I went for my appointment with my family doctor this weekk, I had the opportunity to ask him several questions.He is a good listener and always takes the time. When he asked me if I had any more questions, I looked him in the eyes and said "How's the economy treating you?" he smiled and said, "I'm doing fine...thanks to people like you."

I've been reflecting on what I can be doing to contribute to the emerging health issues in my community...wondering what simple skills I might learn such as First Aid etc. the growing of medicianal herbs as a small offering to my family and neighbors.

Perhaps there are some advocacy issues I need to be aware of that might have some 'bang for the buck' - not so much in terms of  fixing the broken system but more along the lines of how can we  maintain and improve accessibility to basic care? Can person to person or neighborhood  health networks be developed and/or strengthened?

If you ever decide to do a seminar on these topics, I'll gladly participate.

Let's call it "Primum non nocere" for the layman and the provider.

Jerry Lee Miller, Lancaster PA

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Re: Upcoming Health and Healthcare Issues

very good post

i have a medical travel facilitation business. i arrange for people to travel overseas for medical and dental care.

i work in india, thailand and costa rica. costa rica is the preferred destination for most people as it is much closer. 

the facilities i work with are JCI accredited and are among the finest hospitals in the world. most people initially use this healthcare option because of price but after having gone overseas they discover that in many cases the care they get is far superior than what they can receive here in the u.s.

jerry lee your bilateral knee operation would have been less than $20k (total for hospital and surgeon) at one of our facilities. costa rica has a unique feature in that there are a number of medical recovery inns which are hotels dedicated to recovering surgical patients.

it is well  to remember that dental health is an incredibly  important part of your health. low grade infections in your mouth can have a sytemic impact on your health.

if anyone would like more info my website is www.globalmedicalreferrals.com

prevention is the best healthcare..............clean food, water and exercise.

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Re: Upcoming Health and Healthcare Issues

Joe2baba

 I visited your site before. Most eye opening! Thanks for the info on what my surgery could have cost.

On the issue of 'prevention is the best healthcare....clean food, water and exercise."......I was visited by one of the hospital's food service managers on day 6 of my stay.(I was in 7 days). He asked me if I was pleased with the quality of food. But, I was not at all pleased. I follow a vegan diet and found few options on the daily menu. Also, for several days I was on an all liquid diet. The choices then were abominable! Half of them involved high fructose corn syrup with fruit flavoring. It made me wonder just how many acres of corn are being planted just to provide this insane thrist for corn syrup!?

I limited my comments to the manager, who didn't seem to understand the difference between vegetarian and vegan. However, I asked him if I could send him some information. He gave me his card and said he would welcome my input. I still need to follow up with him.

 

 

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Re: Upcoming Health and Healthcare Issues

Christopher,

That was a most excellent post. Thank you for your insights.

I am fortunate to be a member of Kaiser NW and my wife and I have received excellent treatment across the years. Naturally, except for small co-pays, everything has been free - a great deal for us if not Kaiser. This included my cancerous prostate operation done with the DaVinci robot in January 2006. Been clean and clear ever since, happily.

From what I read about the expensive health care others are burdened with, I wonder where you see managed health care going in our future? Do you think it will continue to function or collapse or something in between?

I would appreciate any thoughts you might have in this area.

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Re: Upcoming Health and Healthcare Issues

Dr. Peters,

I finally got around to reading your post and I think it is one of the most important posts on this site. I say that because I believe it will be an unforeseen event that will most likely send our very vulnerable economy into a tailspin, if not chaos. What that unforeseen event will be, I have no idea - but top on my list is an influenza pandemic, along with a terrorist attack and a dollar collapse caused by outside forces. So as I was reading your post - I kid you not - my high school-aged son came home and told me that one of his fellow students (in a small school) has been diagnosed with a MRSA infection. Sure enough, I got onto my email and found a warning from his school that one of his classmates has been diagnosed with MRSA. MRSA is a dangerous infection; even in a functioning health care system, it is an infection to be reckoned with. As your post so clearly amplifies, in a weakened economic system, health care is another front that will go down for the count. I shudder to think what would happen if this MRSA infection spread among others in my son's school and we had an inadequate health care system to turn to.

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Re: Upcoming Health and Healthcare Issues

Dr. Peters, thanks for sharing your thoughts. You have provided me with some deep subjects to consider.

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Re: Upcoming Health and Healthcare Issues

Jerry Lee, I'm glad to hear your bilateral knee replacements went well, and that your recovery seems to be uneventful!

I don't have any specific recommendations with regard to layperson advocacy, at least not any that would necessarily apply equally to all areas of the U.S. There are many directions the healthcare industry could take, and it is likely that many different approaches will be taken in different areas. My personal belief, at least at this time, is that the best course might be to develop community-based healthcare cooperatives, which would effectively function as insurance companies to pay for member's healthcare problems as they arise, but also potentially employ, or contract with, primary care physicians whose role would be enhanced to serve as "gatekeepers" for the healthcare of their assigned patients, and, especially, to emphasize wellness and disease prevention. What might happen to specialists, like myself, is less clear. Hospital-employment is once again becoming increasingly common, is likely to expand, and may be a good solution for many specialists. However, it is also possible that some specialists would remain in private practices, negotiating reimbursement rates with various community-based healthcare cooperatives, much as we currently do with insurance companies. I think we will see a further consolidation of specialized care, with specialists congregating more in larger communities, and with smaller community hospitals continuing to offer basic care as they do now, with less specialty representation. Community-owned hospitals seem to be a better idea, and we may see communities attempting to purchase many of the hospitals in their communities currently run as nonprofit hospitals by religious groups. For-profit specialty hospitals (surgical hospitals, heart hospitals, etc.) seem likely to diminish in importance in the future.

I don't see a seminar in my future; I'm just not that kind of guy.

Joe2baba, I know nothing of healthcare in Thailand or India, but Costa Rica certainly has a good reputation! A decade or more ago, Costa Rica made an active investment in their healthcare delivery and medical training, resulting in vast improvements, from what I understand. In the past, it was common to find semi-retired physicians from other countries providing much of the healthcare in Costa Rica. Now, it is generally not possible for a foreign physician to practice in Costa Rica, as they have very good physicians of their own. I participated in a medical mission in Bolivia last year, and am poised to return again this year. While one of the two poorest nations in the western hemisphere (the other being Haiti), I found the surgical care I witnessed to be excellent, even though the resources available were extremely limited. When I returned to the U.S., I had the feeling that we are simply spoiled by all our technology and resources.

Sam, I have some knowledge of the Kaiser system, from a rotation at Kaiser Moanalua during my surgery residency in Hawaii, and from friends who have worked with Kaiser. Generally, I think it is a very good system, although I have been told that some of the regions are better than others (I understand Kaiser NW to be one of the better regions). While individual managed care organizations may fold, I think the future of managed care as an entity is fairly bright. As mentioned above, this might be in the form of a community-based cooperative rather than as a business, but I would not be at all surprised to see growth in managed care in the years to come.

Lisa, I agree with your thoughts about an influenza pandemic, and there are many scientists and physicians who are much smarter than I who agree as well. A highly virulent and easily transmissible respiratory illness is my main healthcare concern, followed by disruption of healthcare delivery due to limited resources and limited providers. Again, it is not a matter of "if", only of "when". Regardless of what happens with the economy or energy, a pandemic seems almost certain, likely sometime in the next decade or two (although I hope that I am wrong). If such were to occur, it would absolutely overwhelm our current healthcare resources. If one just considered mechanical ventilators, which were not available in 1918, and which could save many with a severe respiratory ailment in the modern day, there are simply not enough ventilators around the country to meet a massive demand, even considering the fact that there already are hundreds of machines in storage for just such a calamity. In addition to your other preparations, I would recommend considering what you would do if (when) a serious influenza outbreak were to occur. As for me, I would keep the kids home from school, close my office, ensure that we have enough to food and other resources to survive in isolation for several weeks or months, and have a ready supply of masks in the event we did need to venture outside (I would, of course, given my profession).

MRSA (Methicillin-resistant Staphylococcus aureus) gets a lot of press, some deserved, some not. MRSA is not necessarily any more virulent (damaging) than regular S. aureus, just more difficult to eradicate. We see lots of MRSA in the hospital, to the point that some even consider it now a "natural" contaminant. It is certainly a problem bug, but in my opinion, not the most serious drug-resistant organism we see. Still, as you point out, MRSA is increasing in prevalence outside of the hospital and nursing home environments, to include schools, exercise facilities, etc., and that does make it a significant problem. Prevention begins with good hygiene, especially frequent hand-washing and/or use of alcohol-based hand gels. And, if you have an open cut or scrape, I would avoid the use of public facilities until the wound has sufficiently healed (e.g., any scab has been replaced by scar tissue).

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Re: Upcoming Health and Healthcare Issues

Take a look at www.miraclemineral.org

I've been taking this solution for 4+ months and have been perfectly healthy. Not ONE single cold this winter, which is unusual for me! My friend, an alternative medical professional, recommended it to me after it cured his Lyme disease. Basically, it cleans out your immune system, allowing it to function correctly and to do it's job. Originally, the inventor of the solution discovered it cured malaria. He even cured himself of malaria. Along the way, he discovered it cured the common cold, aids, even cancer. You can read Part 1 of his book online for free to see some of the pictures of his patients and letters from health ministers.

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Re: Upcoming Health and Healthcare Issues

More references regarding pandemic influenza:

http://www.icfi.com/markets/homeland-security/pandemic-preparedness.asp?_kk=pandemic%20influenza&_kt=131dd89f-d565-4d2b-a308-d69e6d3f59eb&gclid=CMKyirPtmZkCFRWbnAodvHMUDA 

http://www.who.int/csr/en/ 

 

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Re: Upcoming Health and Healthcare Issues
ccpetersmd wrote:

More references regarding pandemic influenza:

http://www.icfi.com/markets/homeland-security/pandemic-preparedness.asp?_kk=pandemic%20influenza&_kt=131dd89f-d565-4d2b-a308-d69e6d3f59eb&gclid=CMKyirPtmZkCFRWbnAodvHMUDA 

http://www.who.int/csr/en/ 

 

Hi Doc,

Pleasure to see you on these forums again. Thank you for the links. Are you subtly trying to tell us something? Wink

I recently observed, on ABC, a story that Tamiflu has ceased to be effective against the flu in many cases. Are there any drugs that can be stockpiled safely at home that would provide some, if any, protection against a pandemic?

 

EU's First 2009 Bird Flu Case Found in Germany

http://abcnews.go.com/International/wireStory?id=7048972

 

Resistance to Tamiflu Growing

http://abcnews.go.com/Health/Healthday/story?id=6992692&page=1

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Re: Upcoming Health and Healthcare Issues

Sam, I'm back, to some degree, but steering clear of the Religion and Politics thread!

Yes, resistance to Tamiflu is being reported, but I don't pretend to be an expert in this regard. Also, the current influenza vaccine is reported to be less effective to this year's variant than expected.

No, I am not trying to suggest anything, other than I think that influenza is likely to be our next major health problem. No idea when, mind you, but sometime.

And, no I don't believe there are any effective home remedies beyond prevention. I would recommend stocking up on some good masks that could protect you in the event of a serious outbreak, however. These are very inexpensive, and can be found in most pharmacies or medical supply stores.

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Re: Upcoming Health and Healthcare Issues
ccpetersmd wrote:

Sam, I'm back, to some degree, but steering clear of the Religion and Politics thread!

Doc, I certainly understand! Wink

ccpetersmd wrote:

Yes, resistance to Tamiflu is being reported, but I don't pretend to be an expert in this regard. Also, the current influenza vaccine is reported to be less effective to this year's variant than expected.

No, I am not trying to suggest anything, other than I think that influenza is likely to be our next major health problem. No idea when, mind you, but sometime.

And, no I don't believe there are any effective home remedies beyond prevention. I would recommend stocking up on some good masks that could protect you in the event of a serious outbreak, however. These are very inexpensive, and can be found in most pharmacies or medical supply stores.

Hmmmm - guess the drill will be to stock up on the masks and avoid going out unless absolutely necessary. Since food and water could be an issue, let me ask this:

Water - Would the water coming out of the tap or the refrigerator be suspect? Should it be boiled before use?

Food - When I go to the grocery store (wearing three masks one on top of the other!) and get food, milk, produce, should I assume all packaged goods are contaminated? What about fresh produce? If so, what steps should I take to decontaminate? Would alcohol wipes be good to use on the packaged goods? Should all produce be boiled to a certain temperature before consumption? Am I over-reacting?

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Re: Upcoming Health and Healthcare Issues

Epidemic could be another E to be added to the CC.  Whether its an influenza pandemic or the aging of baby boomers, there are obvious problems with our current health care model.  Although, I'm really not in favor of healthcare nationalization any more than I am of bank nationalization. 

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Re: Upcoming Health and Healthcare Issues

Well,

First, thanks to Dr. Peters  for bringing healthcare into the light. You seem to be much more "enlightened" than your other surgical brethren. ( I am an old CT-surg / vascular ICU nurse)

There are many reasons persons are "not compliant" with their health regime. As a nurse I have been trained to look at the "whole" person and how their psychological/spiritual/socio-economic  conditions effect their "health state" or recovery from surgery/illness.

Prevention is harder than treatment, because it requires commitment of the individual. Doing "whatever" then going to the practitioner to get "fixed" is easier. (genetic anomalies aside) McDonald's three times a day then going in for stomach banding to loose the weight is easier. Smoking until "if and when" lung cancer develops and having it "cut out" is easier. We are dang good in this country at providing "sick-care".  -- I am no saint. I could loose 50 pounds. That surely would reduce my hypertension, cholesterol, cardiac risk.... and potentially my baldness.(OK, I made the last one up).I am allergic to exercise, every time I do it, my muscles get sore and I become short of breath! Perhaps, in the Crash Course preparedness section, "healthy lifestyle" could be one of the easier things to do?

A pandemic is a much greater threat than what is realized. This season, different "flu-bugs" have struck and they tend to linger longer now than in the past. They also seem to "reoccur."  Look at MRSA. Once confined to the hospital as a "facility acquired" infection, as was discussed, it has spread to nursing homes and outside the facility. When I was growing up, folks got "staph" infections from being in the hospital and being compromised. Now, resistant strains are being acquired in the community.

I now work in the medical device industry, and get to many hospitals in the region. Inadvertently, I could become a vector for the spread of a airborne pathogen like "the flu" (pick your strain).

My wife works as a case manager for one of the medical schools in the state and a year or so ago, she had to take some "pandemic awareness" training. Spooky, they told them that the training just fulfilled some "required training standard". Yet, they assured everyone that the state had "stockpiled" some vaccines for them if "something happened."

My hope is, that we will be able to be informed soon enough if there is a "breakout" and can keep the kids home from school and not go to work.

As for the healthcare system, it could not stand the stress of all the additional patients that would be thrust upon it if a "universal" type of coverage was enacted. There simply isn't the capacity given the cutbacks in beds and shortages of trained physicians and nurses.

 

Gee, during the crash, I may have a barter-able skill I hadn't quite realized the potential.

 

FWIW - C.

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Re: Upcoming Health and Healthcare Issues

Sam,

 

Fortunately, most bacteria/virus' do not live long on the surfaces of inanimate objects. There are exceptions of course. The HIV/AIDS virus comes to mind. As for produce........ think about the E. coli outbreaks from the tomatoes. I'd pass on "fresh" food unless I grew it or was dang sure of its whereabouts prior to coming into my possession.Yes, you could cook it, but why risk the exposure.

 I know masks have been suggested as an effective way to combat airborne contamination. Unfortunately, they really only marginally protect one from droplet exposure such as a sneeze or cough. If the pathogen is actually airborne.... eh!

BUT, I would WEAR a mask. Some defense is better than no defense. Just remember its limitations. Limiting exposure is best. Vigorous HAND-WASHING is the number one defense against transmission of disease.

 Alcohol wipes are ok. A dilute bleach solution is better.

 The websites listed by Dr. Peters will hold the answers to your questions Sam.

 Another place to look is at the world Health Organization (WHO). http://www.who.int/en/

 

HTH - C.

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ccpetersmd
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Posts: 799
Re: Upcoming Health and Healthcare Issues

RNcarl, welcome to the thread! I don't know if I'm much more "enlightened" than some of the other thoracic surgeons I know, as a number of them share the same concerns. And, yes, you do have a skill set that will serve you well no matter what the future brings. The physician assistant with whom I used to work in Colorado has begun stockpiling antibiotics and basic medical supplies, in addition to his personal items, in case he would find a need to open his own clinic when TSHTF.

Sam, influenza is, for now, at least, transmitted directly through the respiratory system, so I agree with RNcarl that you don't have to concern yourself too much with transmission from surfaces, water or food products. But, the enteric pathogens, to include E. coli, Salmonella, Hepatitis, V. cholerae, etc., are transmitted through these other routes, and they remain a significant concern, even now. I would recommend decreasing your reliance on "processed" foods, a catch-all phrase if there ever was one. But, if you consider that the more steps involved in bringing your food from field to table, the greater the opportunity for contamination at one of those steps. For me, it's not as much a matter of "processed", alone, but how many people and/or machines were likely to have come in contact with what I might put in my body?

Good and frequent hand washing is of prime importance. I am also a big fan of alcohol-based hand gels. In the OR, I like Avagard, which is fast, easy, and more effective than a 5 minute scrub with Betadine. At home, however, we use the usual consumer products, such as Purell.

For influenza, and other respiratory illnesses, avoidance of exposure to potentially infected individuals, and the use of masks when such potential exposure cannot be excluded, are key. Masks come in a variety of configurations, some designed with a better "fit" to limit the amount of outside air that can be inhaled around a mask, some with smaller pore sizes to better capture smaller particles (such as viruses), and some that better withstand fluid exposure (such as blood in the OR). I don't have any specific recommendations, but I'll look into that and get back. Any mask, however, is better than none.

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ccpetersmd
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Re: Upcoming Health and Healthcare Issues

Here's some stuff from US government websites regarding masks and respirators (I actually learned more than I expected to learn):

http://www.pandemicflu.gov/vaccine/mask.html

http://www.fda.gov/bbs/topics/NEWS/2007/NEW01630.html

http://www.fda.gov/cdrh/ppe/masksrespirators.html 

http://www.fda.gov/consumer/updates/respirators061107.html 

For common use in hospitals, and I think for "casual" use at home, the typical masks are fine. In the hospital, staff likely to be exposed to serious pathogens in the event of an outbreak are fitted for the N95 respirators.  I'd suggest stockpiling a small supply of basic surgical masks, but also consider being properly fitted for N95, and keeping a supply of those in reserve, as well.

For basic use, protection from fluid droplets, comfort, and prevention of fogging of my surgical glasses, this is my current favorite:

http://nacrm.kcmkt.com/scripts/wgate/zkcnab2c/!?p_shop=ZKCHCSHOP 

 

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RNcarl
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Re: Upcoming Health and Healthcare Issues

As I recall, the story about the PA - physician assistant role was created when the medics returned home from Viet Nam. There was a shortage of surgeons there and minor surgery was left to the "medics".... Perhaps even some major surgery if truth-be-told. When the medics returned home, because they were neither licenced or "certified" their skill set went by the way-side.

I was a volunteer EMT when I was 18 and the college I entered to take engineering courses had just started this program called "physician assistant". They must have looked through the entrance records because I was approached by someone who was recruiting for the program and wondered if  wanted to apply. I recall saying something like, "No thanks, I'm going to be an engineer. I don't want to be any doctors, assistant." Ah youth, if I had only realized.

 

I'd like to know what you all think about my comments on universal health-care being "unsustainable". I just think that there are too many uninsured folks that would over burden the system if all of a sudden they could "go to the doctor" and their illnesses treated. My hypothesis is that the system would crack under the added pressure. However, there would be a swell at first, meaning everyone would run out and try to be treated. then, "non-compliance" issues and general procrastination would set in and numbers of those seeking treatment would still  remain high but not so high as to "break the bank."

If the system could survive the initial tsunami of patients, the system might not fail. I just don't have the public health background to know if the system could survive the onslaught.

 

Certainly if you look at that bulge in the population that we call the "baby-boomers" it and of itself will begin to out strip the current health-care system. To some point it already has. The president has called for medicare "reform."  I find that interesting. What is hinted at is medicare payments will decline. The only way to do that is to reimburse less for the increasing number of services provided. The president also said that "savings" could be made by expanding electronic medical records (EMR) usage. That may well decrease costs in administration but I fear that there is a clear and present danger that EMRs can exponentially compound a problem.

 

Please read the example and input:

An example is when a patient is admitted and information is taken by an under-trained medical assistant (cheaper help used to cut costs) and the question is asked if the patient has any allergies. Since common allergies occur with sulfur drugs, the patient may respond that they have an allergy to antibiotics. The patient is 75 years old and had a "reaction" 30-40 years ago to a sulfa drug. Not knowing any better the medical assistant writes "antibiotic allergy unknown type" and the next thing you know the patient is prescribed a very expensive high powered antibiotic when a simple cheaper one is all that is needed. Now, in a paper system, that recording error begins and ends with that visit. Yes it persists in the chart but the data can come into question each time the practitioner sees the entry and who did the recording of the entry. Now enter EMR. Instantly, "antibiotic allergy" is propagated throughout the patient's entire medical  record. From pharmacy to nursing to the O.R. and (if the system goes online like is proposed) back to the patient's primary care. BOOM! treatment goes from inexpensive to expensive in one step. Where a dose of penicillin ($6) or Kefzol ($50) could be used, a dose of Vancomycin ($500) is given to CYA.

Which brings me to what I think the REAL excessive cost in health-care can be attributed to: lawyers! Liability costs add more to health-care than even the most expensive treatments.

 

Sorry for the long post. Health-care is my passion.

C.

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ceci1ia
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Re: Upcoming Health and Healthcare Issues

It would be useful to compare other countries' experiences with
introducing universal health care. In actual operation, it seems to
work in countries with funding, like Canada. It also seems to be a
pretty good solution in Cuba, a place with no money.

I remember
hearing about the PA program back in 1977 or 78. It must not have been
presented very well Carl, because I was left thinking so what.

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jerry_lee
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Re: Upcoming Health and Healthcare Issues

RNcarl mentioned the public health issue of MRSA. Did you catch Nicholas Kristoff's (NYT) column? it was in our Lancaster PA paper this morning, first of a 2 parter. He tells the story of a doctor in Camden,IN who had contacted him last fall. The doc had encountered a HUGE number of MRSA cases in his small town practice and suspected a link to the large hog farms in the area. Kristof planned to visit...the doctor dies before the planned visit. Blood tests indicated a heart attack or aneurysm.

It turns out the doctor had contracted outbreaks of MRSA himself 3 times. A Dutch researcher cited by Kristoff claims MRSA can cause inflammation of heart.

Kristoff also cites growing evidence of a link between pigs and human cases of MRSA, perhaps related to'insane use of antibiotics' in their feed.

On antother public health related subject... yesterday Johns Hopkins had a day long public health conference on "After Peak Oil" . I tried to watch it online, but couldn't make the link work.

 

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ccpetersmd
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Re: Upcoming Health and Healthcare Issues

Carl and others,

I think you might be correct regarding the genesis of PA's. I certainly worked with a lot of them during my years in the Army, most all of whom were very good.

I don't pretend to have exhaustive knowledge of our healthcare problems, or unique insights into their solution. I do agree that simply taking our current government programs (Medicaid, Medicare, VA and TRICARE) and making them universally available would be unsustainable. Partly, this has to do with an increased patient load on a largely overburdened medical delivery system. Perhaps more importantly, it would be unsustainable due to economic factors, running into the same problems we foresee with Social Security.

Ideally, I would like to see wide access to primary care and health maintenance, which would be the equivalent of an investment in infrastructure, but we must develop systems to more reasonably distribute resources to more costly items on the healthcare menu, such as advanced diagnostic testing and procedures. For a variety of reasons, too many diagnostic tests are performed in this country, and some procedures are simply unnecessary. These reasons can include patient insistence (in fairly rare cases), healthcare providers practicing "defensive" medicine (leaving no stone unturned in an effort to avoid liability exposure), an unwillingness to make the difficult decisions involved in rationing care, greed, and the all too frequent failure of providers to simply trust their clinical instincts when an expensive test is available, but not always necessary.

It seems that in many, if not most, of the countries with a nationalized healthcare system, there typically develops a parallel private-practice model. Public and private hospitals. Public and private clinics. Providers that may limit their care to one environment or the other, but frequently cover both. The public system is for the universally covered patients only, typically. The private system is for wealthier patients who self-pay or have private insurance, and frequently also serves as overflow for the public system. Not a bad compromise, actually, given the realities of financing healthcare, but prone to the development of one system that is very good, and one that may be so-so.

I may be in the minority of healthcare providers on the impact of lawyers and malpractice on the cost of healthcare, but I do not see that as the biggest problem. Perhaps this is because my exposure to malpractice cases has been very limited, even given my specialty, and therefore my malpractice premiums are quite low. I have a few friends who are attorneys, and I believe they are correct when they say that it is actually very difficult to win a malpractice case in most areas of the country. I'm not saying things couldn't be better, mind you, just that I don't see this as important a part as some other areas.

As to electronic medical records, I am in favor of them. We adopted a very good but inexpensive system in my office a few years ago, and I've been very pleased. My files are right where I need them, every time. Electronic billing is much easier, and when payment is received, that goes right into the same system. Plus, it runs on my Macs, which makes me very happy!

As to chart errors you mentioned, I don't know if they would be more or less likely to be propagated with electronic medical records. Even back in the paper chart days, these were not at all uncommon. We referred to them then as "chart fiction" or "chart legends", and they were difficult to eradicate even then. When a patient is admitted to the hospital, it is typical for providers to review old records, whether they be electronic or paper, and those "chart legends" would then live on in future iterations of the patient's chart, unless one made a concerted effort to point out the previous error.

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ccpetersmd
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Posts: 799
Re: Upcoming Health and Healthcare Issues
jerry_lee wrote:

RNcarl mentioned the public health issue of MRSA. Did you catch Nicholas Kristoff's (NYT) column? it was in our Lancaster PA paper this morning, first of a 2 parter. He tells the story of a doctor in Camden,IN who had contacted him last fall. The doc had encountered a HUGE number of MRSA cases in his small town practice and suspected a link to the large hog farms in the area. Kristof planned to visit...the doctor dies before the planned visit. Blood tests indicated a heart attack or aneurysm.

It turns out the doctor had contracted outbreaks of MRSA himself 3 times. A Dutch researcher cited by Kristoff claims MRSA can cause inflammation of heart.

Kristoff also cites growing evidence of a link between pigs and human cases of MRSA, perhaps related to'insane use of antibiotics' in their feed.

On antother public health related subject... yesterday Johns Hopkins had a day long public health conference on "After Peak Oil" . I tried to watch it online, but couldn't make the link work.

 

Jerry Lee,

I finally read a version of the article you mentioned, just yesterday. In this article, and perhaps also in the one you read, they quoted a University of Iowa researcher (we're big hog producers here in Iowa) who performed a small study testing pigs and farmers for the presence of MRSA. I can't recall the percentages colonized, but it was alarmingly high for both populations. The argument, as you mentioned, is that the prevalence of MRSA colonization is due to the indiscriminate use of antibiotics which in turn leads to antibiotic resistance. This is, of course, absolutely true. 

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RNcarl
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Posts: 382
Re: Upcoming Health and Healthcare Issues
ccpetersmd wrote:

Carl and others,

...As to electronic medical records, I am in favor of them. We adopted a very good but inexpensive system in my office a few years ago, and I've been very pleased. My files are right where I need them, every time. Electronic billing is much easier, and when payment is received, that goes right into the same system. Plus, it runs on my Macs, which makes me very happy!

As to chart errors you mentioned, I don't know if they would be more or less likely to be propagated with electronic medical records. Even back in the paper chart days, these were not at all uncommon. We referred to them then as "chart fiction" or "chart legends", and they were difficult to eradicate even then. When a patient is admitted to the hospital, it is typical for providers to review old records, whether they be electronic or paper, and those "chart legends" would then live on in future iterations of the patient's chart, unless one made a concerted effort to point out the previous error.

 

I agree, it often becomes "chart lore". A medical student is sent to do the H&P and reviews the "old chart". Right there on the front is a mention of allergy that isn't questioned by the student and is propagated.

I am for EMR as long as there is a check and balance in it. I don't currently chart (since I'm more of a consultant) using EMR so I'm not aware of built in safeguards.

I too prefer the Mac platform. I find it easier and less "buggy" than Microsoft offerings. Your EMR is stand alone for your practice? I think the president envisions a "global" patient record. I understand that there has been some legislation that speaks to wanting an across the board record. Personally, I don't think I would want that for just the reason I outlined and as you mentioned, "chart lore".

 

As for the MRSA in pigs.... That's interesting. I will need to read up on the transmission. I love pork chops and would hate to have to give them up. Wink

 

So, as someone above mentioned, the fourth E should be for epidemic. I know you mean pandemic, but a little poetic license could be taken, no?

 

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ccpetersmd
Status: Martenson Brigade Member (Offline)
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Re: Upcoming Health and Healthcare Issues
RNcarl wrote:
ccpetersmd wrote:

Carl and others,

...As to electronic medical records, I am in favor of them. We adopted a very good but inexpensive system in my office a few years ago, and I've been very pleased. My files are right where I need them, every time. Electronic billing is much easier, and when payment is received, that goes right into the same system. Plus, it runs on my Macs, which makes me very happy!

As to chart errors you mentioned, I don't know if they would be more or less likely to be propagated with electronic medical records. Even back in the paper chart days, these were not at all uncommon. We referred to them then as "chart fiction" or "chart legends", and they were difficult to eradicate even then. When a patient is admitted to the hospital, it is typical for providers to review old records, whether they be electronic or paper, and those "chart legends" would then live on in future iterations of the patient's chart, unless one made a concerted effort to point out the previous error.

 

I agree, it often becomes "chart lore". A medical student is sent to do the H&P and reviews the "old chart". Right there on the front is a mention of allergy that isn't questioned by the student and is propagated.

I am for EMR as long as there is a check and balance in it. I don't currently chart (since I'm more of a consultant) using EMR so I'm not aware of built in safeguards.

I too prefer the Mac platform. I find it easier and less "buggy" than Microsoft offerings. Your EMR is stand alone for your practice? I think the president envisions a "global" patient record. I understand that there has been some legislation that speaks to wanting an across the board record. Personally, I don't think I would want that for just the reason I outlined and as you mentioned, "chart lore".

 

As for the MRSA in pigs.... That's interesting. I will need to read up on the transmission. I love pork chops and would hate to have to give them up. Wink

 

So, as someone above mentioned, the fourth E should be for epidemic. I know you mean pandemic, but a little poetic license could be taken, no?

 

Yes, my EMR is a stand alone program, called MacPractice. There are several modules, but I purchased little more than the bare essentials, which includes a very good PM (practice management) portion and what amounts to a rudimentary EMR, but adequate for my purposes. It also allows e-prescribing, but since, as a surgeon, I do only a limited amount of this, I haven't yet used it. There has been ongoing talk of a nationwide standard, but I don't see any consensus developing for some years. The newest annoyance is the plan to switch to the new ICD-10 diagnostic codes by 2013, which are apparently already in use elsewhere in the world, but increase the number of codes, and therefore the complexity, by a factor of 10 or 100 (I can't recall which).

Yes, chart lore, chart fiction, chart legend. All too common.

E for epidemiology would also work. I'll have to think on that. Hard to beat the "Three E's", however.

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ccpetersmd
Status: Martenson Brigade Member (Offline)
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Posts: 799
Re: Upcoming Health and Healthcare Issues

On a slightly different tack from issues discussed above, I'd like to invite interested forum participants to share their views on healthcare reform in the U.S. The ideas of "universal coverage" and a "single-payor system" have been percolating through the industry for many years now. I have been quite attentive to the discussions, but I must admit, I still haven't come to any firm conclusions of my own. The shortcomings of our system are clear, to include excessive cost, complex bureaucracies, and less than ideal results. At the same time, our system is so large and so intertwined, that is difficult to see a way through to fix the problems.

Of course, the complexity of the problem will not prevent policy makers from offering solutions, regardless of which side of the aisle they may reside:

http://www.barackobama.com/issues/healthcare/

http://www.gop.com/2008Platform/HealthCare.htm

Still, the need for some changes is evident from many reports, one of which comes from the Commonwealth Fund, most recently updated in 2007, in which the U.S. was compared with Canada, U.K., Germany, Australia and New Zealand. Healthcare in the U.S. was found to be more costly, but consistently underperformed the other five countries on most measures. The one big difference between the six countries? The U.S. was the only country without universal coverage:

http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2007/M...

However, the costs of comprehensive healthcare reform in the U.S. would be great, and given the economic issues we already face (discounting the issues related to an energy crunch, for now), simply may be too much to bear:

http://news.yahoo.com/s/ap/20090318/ap_on_go_pr_wh/health_overhaul_cost 

So, I'd like to assume that we might end up with a state or community based healthcare system. Even if we still ended up with a nation based system, I think doing the exercise at a local level is useful. Also, for this purpose, let's largely ignore economic as well as energy issues, and try to imagine how we might better improve our healthcare system, as if we were starting from scratch in a small community.

I'll propose that we, as a community, might agree to fund a local healthcare system that would provide universal coverage for basic issues, such as health maintenance and care of commonplace medical illnesses. This would likely include periodic screening tests, such as mammography, PAP smears, colonoscopy, etc., if done in accordance with accepted guidelines. These would be basic needs that would promote individual health, and thereby the health of our community. We might also be willing to provide for emergency funds that might cover catastrophic illness or injuries that would jeopardize the health of our community and our individual members.

Beyond this, however, it gets quite murky for me. Do we as a community, and ultimately as individual tax payers, feel we want to pay for expensive surgical procedures or advanced diagnostic testing? How about for the care of those who hadn't taken the steps to adequately care for themselves (stop smoking, lose weight, etc.)? What about care for those who have recently arrived in our community, or those in our community who don't contribute to our healthcare system?

For more advanced medical care, I think I still see a need for either insurance, or individual (or family) responsibility for those costs. Even with insurance, I feel that the individual should have to bear even more of the burden, as this might tend to make the choices we make in our healthcare more immediate and personal. I suspect we would see a decrease in emergency room visits as a substitute for making a doctor's appointment, better decision making when it comes to expensive diagnostic tests and procedures, and promoting a greater awareness of making health choices in our lifestyles. Furthermore, while it might take some time, I think it likely that we might see a resetting of costs, with surgeons like myself being willing to accept less money for some procedures, insisting on more for some others, allowing primary care physicians to actually be better compensated for all the work they already perform, and forcing hospitals and other organizations to become leaner and stop "padding" their costs to cover what they lose in providing care for the uninsured.

I had a few examples to illustrate my points, at least from a surgical perspective, but this is getting long, so I'll close for now. If any readers have insights they would like to share, whether their background is in healthcare or as a recipient, I would very much like to read them.

 

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ceci1ia
Status: Bronze Member (Offline)
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Posts: 79
Re: Upcoming Health and Healthcare Issues

Concerning lifestyle issues that need medical treatment: 

In the UK, if I understand correctly, under their national healthcare system, a liver transplant would not be an option for a drug addict. However, if the drug addict took their issue to a private doctor and paid for it himself, then he could get in line for whatever treatment/transplant was available.

So as I understand it, you can get anything you want if you pay for it. But if you want the free health system, you have to participate and make changes, etc.

As long as nationalized health threatens for-profit drug companies and insurance providers, I am cynical there will ever be relief for taxpayers/clients/patients. I cannot see lawmakers in a capitalist society signing into law something that would eat into a whole industry's profits. Shareholders are more important than patients.

 

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SamLinder
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Re: Upcoming Health and Healthcare Issues
ccpetersmd wrote:

<snip>

If any readers have insights they would like to share, whether their background is in healthcare or as a recipient, I would very much like to read them.

 

Chris,

In yesterdays Wall Street Journal (Personal Journal section) they had an interesting article (http://online.wsj.com/article/SB123733342732563543.html) on using electronic medical records.

As you know, here in Oregon I use Kaiser Northwest. They have had electronic patient records and online capabilities for some time now. They also have instant internet access right there in the patient exam room. One time my doctor wanted to show me some information so she instantly brought up a medical website she subscribes to so she could give me the information right away. Pretty cool!

When I need to refill a prescription, it's an easy online task from my home PC. I can request the pills (if they don't require a signature) be mailed to me or kept at the local pharmacy for pickup. I can make a medical appointment, view test results, send emails to my doctor, etc.

I noticed part of a thread you were involved in that discussed chart errors being propagated electronically. I don't know how other facilities handle the problem but I'll briefly describe Kaiser NW. I have a mild allergic reaction to Naproxen and similar drugs (it gives me stomach pain). It's in my electronic chart.

However, every time I go to the pharmacy for something, they always ask if I'm allergic to anything. Keep in mind the prescriptions are sent directly to the pharmacist from the doctor via their network so no paper changes hands.

Anytime I visit my doctor - even for my annual physical - they always ask me if I'm allergic to anything. This provides a good check against the electronic record. They also ask me what drugs, if any, I'm currently taking (no - I don't tell them about my marijuana habit! Wink ) so that they are always verifying their records against what I say.

Bottom line, as a patient, I find Kaiser's use of electronic records and online services to be an excellent system. Certainly it's a lot more efficient and safe than the "old days" when you would see the doctors writing ferociously in bulging charts!

Hope this gives you some insight into the patient side of the picture. If you have any questions, I'll be glad to answer them.

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