  |  Health Care Reform | Health costs are skyrocketing and the health care system faces numerous pressures and conflicts. What are the major factors driving these growing issues? | |
| | Story of the Week | June 30, 2009 | | Why Obama Deserved the AMA Standing Ovation | By Mike Magee, MD When President Obama recently addressed the American Medical Association (AMA) and signaled support for malpractice reform, he received a standing ovation. No surprise there. But the truth is this reform is long overdue, and will better serve the people as well as those caring for the people.
Medical malpractice law was designed to accomplish certain specific social objectives: addressing poor quality, compensating patients for injuries resulting from negligence, and making future malpractice occurrences less likely.
In theory, this law makes sense. Courts provide oversight when professional oversight breaks down. Doctors and hospitals are insured and therefore assured that a claim will not lead to financial ruin. Patients show restraint. And lawyers pursue only claims that have merit. But in practice, reality does not come close to this theory.
Three well-known scholars noted in 2004, the medical malpractice system "has internal logic but falls far short of its social goals of promoting safer medicine and compensating wrongfully injured patients."1
The biggest problem? The medical malpractice system is fundamentally adversarial and built on a culture of blame. Doctors, hospitals, insurers, and lawyers are locked in a battle. Patients are routinely caught in their crossfire.
One major issue with the current system is that it doesn't bring relief to those who deserve it. A famous study was conducted in 1984, when Harvard examined 30,000 medical records and 3,500 malpractice claims. Only two percent of the patients who had suffered from negligence filed claims. Only seventeen percent of the claims that were submitted were in any way tied to negligence.1,3
A second big problem with the malpractice status-quo is that it doesn't improve long-term safety measures. Here's why: the tort system uses litigation as its lever for change. The safety movement uses quality improvement analysis. Tort law focuses on the individual. Safety focuses on the process. The tort system's punitive style drives information down, encouraging secrecy. The safety movement requires a collaborative approach. This encourages openness, transparency, and continuous improvement. With tort law, exposing oneself can end one's career and harm one's mental health. In the safety movement, contributing is career-enhancing and therapeutic.2
It may seem counterintuitive, but for medical malpractice to achieve its stated social purposes, we must abandon the emphasis on a tort-based approach and embrace safety. Alternate dispute resolution, no-fault systems, raising fault to the institutional level, and exploring the use of special courts all have merit. 3,4,5,6,7,8 The key? Break the cycle of blame and provide a level of security necessary to ensure openness and transparency in our health care system.1,2
For Health Commentary, I'm Mike Magee.
References
1.Studdert DM, Mello MM, Brennan TA. Medical malpractice. NEJM. 2004; 350: 283-292.
2.Leape LL, et al. Promoting patient safety by preventing medical error. JAMA. 1998; 280:1444-1447.
3.Robinson GO. The malpractice crisis of the 1970's: a retrospective. Law Contempt. Probl 1986; 49:5-35.Quoted in Studdert et al.
4.Kinney ED. Malpractice reform in the 1990s: past disappointments, future success? J Health Polit Policy Law. 1995; 20: 99-135. Quoted in Studdert et al.
5.Localio AR, et al. Relation between malpractice claims and adverse events due to negligence: results of the Harvard Medical Practice Study III. NEJM. 1991; 324:370-6. Quoted in Studdert et al.
6.Mello MM, et al. The new medical malpractice crisis. NEJM. 2003; 348: 23, 2281-2284.
7.Kakalik JS, Pace NM. Costs and compensation paid in tort litigation. R-3391-ICJ. Santa Monica, Calif. Institute for Civil Justice, RAND, 1986. Quoted in Studdert et al.
8.Weiler PC, et al. A Measure of malpractice: medical injury, malpractice litigation and patient compensation. Cambridge, Mass. Howard University Press; 1993. Quoted in Studdert et al. | | |
| Story of the Week | June 02, 2009 | | By Mike Magee, MD Two years ago, the major national primary care organizations went public with their patient-centered "Medical Home" concept.1 Since then, the AMA and 17 other specialty societies, as well as many Fortune 500 companies have endorsed the movement. This includes a vote of confidence for primary care, patient centrality, coordinated team care and payment reform to acknowledge the management of data and logistical complexity. Today there are 22 pilot projects under way in 14 states with Medicare and Medicaid planning to test out the concept in 400 practices in 2009. Ten states currently have supportive legislation in the works.2
I contributed to some of the original trend analysis - namely in aging, the internet, and health consumer empowerment - that pointed to the home. In a recent Institute of Medicine presentation I summed up my concerns about this currently under-powered vision in six words, "Too Much Medical, Not Enough Home."3
At the core of the problem is an insufficiently powered vision of the transformative power of modern information technologies, and their capabilities to reposition health care around a virtual primary loop. This virtual loop should be able to go from home to care team and back to home. Information technologies should also have the ability to coordinate and rationalize highly productive health care, community and family resources, and the ability to redefine health as a forward-facing strategic planning exercise with a 100-year preventive horizon.4
Instead, what we have is the old standard medical office, now called "home." It is a place where patients still need to physically travel to for many activities that could be done more conveniently in their own homes. We also have an electronic medical record which is little more than a passive repository for disparate past information, rather then a 'Lifespan Planning Record' that provides the proper scaffolding to support anticipatory planning and improved adherence with better long-term health outcomes.5,6
On the other side, many traditionalists feel that my vision goes too far, not philosophically so much as technologically. They feel that such a revolutionary re-centering of the system nationwide and overnight is unrealistic. I think they are wrong. So do some of this nation's digital leaders who contributed to D7, the Wall Street Journal's seventh 'All Things Digital' Conference last week. What the information experts see is a shift from Web 2.0 to Web 3.0. This software is embodied by the Apple iPhone which is described as a "thin client, running clean, simple software, against cloud based data and services."
What do they mean by this? They mean, "the complete integration of computing into every part of our lives in a way that is seamless, ubiquitous and ideally, dead simple." They go on to say, "...no one knows where it will lead. More importantly, few can predict the impact it will have on all kinds of businesses."2
Arun Ravi, a Health Digital consultant for Frost & Sullivan thinks he knows. "With over-crowded hospitals and millions of uninsured patients in the U.S., the next wave of health care innovation will involve technologies that make it easier to treat or monitor patients from their homes."2
So,I may be crazy, but I'm certainly not alone.
For Health Commentary, I'm Mike Magee.
References:
1. American Academy of Family Physicians (AAFP), et al. Joint Principles of the Patient-Centered Medical Home. March 2007.
2. Swisher K., Mossberg W. All Things Digital. Wall Street Journal. 2 June 2009. R1.
3. IOM Summit on Integrative Health Care. 25 Feb. 2009.
4. Magee M. Connecting Healthy Homes To A Preventive Healthcare System: Leveraging Technology For All It Is Worth. Harvard Health Policy Review. Fall 2007. Vol. 8:2, 44-52.
5. Magee M. Health Records of the Future. Health Politics. 6 Nov. 2006.
6. Yoediono Z, Snyderman R. Proposal for a new health record to support personalized, predictive, preventative and participatory medicine. Personalized Medicine. 2008. 5(1), 47-54
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|  I think we should have health care paid for by the government for everyone. It doesn't have to be elaborate, but a socialized medical system like Canada has."  Hard for the insured, too  Keep health care private!  Work to stay healthy  Testing is important  Please keep it affordable  Everybody deserves a chance  | Dr. Tom Linden's Health Blog | | |  Water Disinfection for Developing Countries No Time for Health Like the Holidays Don't go to the Hospital Without these Ten Safety Tips Ain’t Nobody’s Fault But Mine An Open Letter to the Obama Health Team Post-Election Healthcare Reform Yearning for Universal Coverage Is Not Universal Is America's Health Care System Failing? Probiotics: Hope or Hype? |
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