health care reform...

this op-ed in the new york times gives a bipartisan snapshot at one way to improve health care.

the issue of health care reform is broad and difficult. op-ed piece tackles one element of the system (with a nod to IHC in utah...) i believe that wwell-informed guidelines with free, easy access and then integration of guidelines into doctors offices and hospitals could be helpful. the guidelines would have to be minimalist and carefully crafted or they could increase health spending, worsen care and have major health risks. potentially, some of these guidelines could be built into electronic ordering systems that would remind physicians that certain costly tests or imaging may not be necessary based on the patient's current vitals, results, symtpoms and chief complaint (with a link to the evidence based guidelines.) such suggestions would always need to have the option of being overridden, but it would make efficiency improving efforts more widely acknowledged and utilized. other preventative guidelines could be built in for automatic mail notification of patients for continuing care and screening.

a few examples... fairly recent guidelines on mild traumatic brain injury (kid gets knocked out while playing football) and CT scanning of the brain. one group from colorado put a small line in the print of it's guidelines stating that if the person is knocked out they should receive a CT scan--this one line is potentially devastating. the possible effects on cost and radiation placed on the american people if these guidelines are adopted more broadly could be very high. (all people knocked out DO NOT necessarily need a CT scan.)

conversely, a fairly recent set of canadian head injury guidlines were published that could reduce CT scanning in traumatic brain injury by approximately 30%+ in canada.

implicit in creating guidelines would be an approach that is scientifically rigorous and independently verified (without drug company or political sway.) the devil is in the details as seen above and if done wrong...a policy of this magnitude could be disastrous...

the guidelines would then need to be protected from tort-lawyers. america's current health tort system results in only 15% or so of jury awards going to patient's where there was an identifiable 'medical error'. the highest predictor of jury payout is characteristics of the patient's story (sympathetic or not.)

it would follow that patient's would be better protected from medical errors by independent committees of impartial experts in the field of medicine and patient advocacy to look fairly at mistakes and fair compensation. leaving lawyers out of it would be better for all involved...(i'm not biased:)

guidelines that are rigorously protected from lawsuits could potentially curb some of the defensive medicine and testing that takes place to avoid the constant specter of a suit. defensive medicine is not good for patients and it's not good for america.

however, even rigorously established guidelines could backfire and cause massive problems in the medical community (an example is the recent government mandated "antibiotics within 4 hours of pneumonia diagnosis" initiative.) antibiotics within four hours of pneumonia diagnosis has not been shown to improve outcomes, but medicare payments became tied to achieving this goal. some hospitals started giving out antibiotics to patients with cough before they saw the doctor because of long ER wait-times and fear of misssing the deadline and not being compensated for care rendered. this type of mis-conceived policy saw big increases in antibiotic use with potentially increased antibiotic resistance, drug costs and side-effects to patients that could have been avoided...

this particular health care reform is not straightforward...but intriguing.