A sadly growning market

The US Census announced today (pg 26-28 of pdf) the latest numbers on income, poverty and health insurance for 2006.  For the 6th year in a row, the number of uninsured Americans rose.  For 2006, the number was 15.8% of all Americans or 47 million were uninsured.

While this is a somber fact, I would like to look at it another way:  a growing market.  Whoever figures out how to provide inexpensive health care to this population has a steadily growing market on their hands.  It could be good business.  Again, I refer you to retail health clinics.

Will consumers fix healthcare?

All the rage of late in the medical business world is about retail medical clinics (or more aptly named, "convenience health clinics").  For Wall Street Journal readers, you know what I’m talking about.  You may also know that the American Medical Association has declared war on these clinics.  You may read their declaration here.


So far, customer satisfaction for this clinics has been high, around 97%.  Its not surprise then, that this business model is taking off, with clinics popping up in Walgreen’s and Wal-Marts all over the country.  It is obvious that the AMA’s opposition to these clinics is simply a turf battle and not legitimately about patient care quality.  It reminds me of physician’s opposition to direct access to physical therapists, and the battle over referral for profit arrangements; both battles also fought under the guise of physician’s altruism.

The all-seeing Seth Godin, had a nice post a while back on "Stuck Systems."  Here is a quote from that post:

"So, the marketer faces a challenge similar to the disruption challenge that most marketers face–how do you take a system filled with an inefficient, annoying, time-consuming, wasteful and yes, even stupid task and make it better in a way that serves all sides? 

If it were me, I’d focus on being cheap and fast and viral. And the more you break the system, the better your upside."


Healthcare is a stuck system.  I don’t think it can stay that way for long.  In the end, consumer choice of convenient services will rule the day.  It could be an incredibly ironic moment in the upcoming presidential election, where health policy is expected to play such a large role, that consumers have already chosen their "fix" for healthcare in the marketplace.

Physical Therapists must acknowledge they are part of a stuck system!  Third-party payment, regulatory woes, and limited access characterize our jobs.  The convenience model needs greater attention.  We are continually growing the research evidence base to support this model for physical therapist practice.  We might think about acting quickly, it could be embarrassing for a physical therapist to get beat in a race by a nurse practitioner!

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Some medical exam comedy

An entertaining article in Slate magazine by Emily Yoffe, describes her experiences as a "standardized patient" for a group of Georgetown medical students conducting their first physical exam. Yoffe is well known for immersing herself into the issues she is covering, having previously entered the Mrs. America pageant as part of her coverage of the event. This time, she may have been in for a little more than she expected:

"Then he stood in front of me, looked at my gown like a colonel contemplating an incursion, and struck. He peeled off the top of the gown, dropping it into my lap, slipped the bra off my shoulder, and left me hanging while he protractedly listened to my heart."

This story is good comedy and speaks to both patients, and anyone who has ever had to learn how to perform a physical exam.


Smoked Ligaments Not A Good Idea

This study from Washington University in St Louis found that exposing mice to smoke resulted in significantly decreased healing in medial collateral ligaments. While the news bit mentions that smoking among athletes is lower than the population, I can think of one population who suffers ligament injuries quite often, and smokes quite a bit.   Soldiers.
Don’t we pay for their medical care through our taxes?
When will the military decide the costs of smoking are too high to allow it to occur?
This news report from 1995 seems to have been a bunch of smoke and mirrors.


An Economist Checks In on Health Care

I like to keep a lookout for when the smart economists provide some of their thoughts on health care.  Ultimately, it is these economists that the government consults with to initiate ideas about how to manage our health care system.

Tyler Cowen, a well respected economist, checks in with a piece called, Smart thoughts on health care.  He doesn’t say too much, but it sure sparked a conversation in the comments!

When I read this, I try to read between the lines about what people are saying and see how Physical Therapists might act to fill a need economically.

My favorite line from the comments:

"90% of the time I see a doctor it’s to tell them, "I have X, and I need a prescription for Y." After reviewing my symptoms and medical history they always agree with me and write me the prescription. So why am I paying an extra ~$100 just to get a medication I already knew I needed, for a condition I already knew I had, before seeing the doctor? It’s just a waste of my time and money."

Perhaps it is this lack of perceived value in routine care which prohibits a move to a retail-like system.


A Sports Cream Fatality

The sad case of Arielle Newman proves that anything taken in excess can be bad.  I have never seen the benefit of sports creams, instead using self-remedies such as stretching and relaxation, maybe an ibuprofen here and there.  I could never imagine that sports creams’ active ingredient could ever cause some one’s death!

In other news, check out my shared items section of the sidebar. I marked a number of New York Times Health articles about healthcare: spending, reform, and risk-benefit calculations.  If your reading this blog via e-mail, this means that you need to click the link at the top of this page and go to the NPA Think Tank website.

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The Protective Ability of Radiology or How Radiology Saved My…

The radiological image on the left is a femoral Osteoid Osteoma. On the right is a T8 compression fracture. Both of these images are CT scans. The military clinic where I work affords Physical Therapists the privilege of being able to order imaging like this when needed. This is an ability not available to Physical Therapists who do not work in military settings.

Both of these patients had been referred to me after first seeing their primary care physician. They arrived in my office with diagnoses of “knee pain” and “muscle spasm,” respectively. Since I know that primary care physicians are not musculoskeletal experts, I made no assumptions as I began my examination.

The person with knee pain had displayed a gradual onset of pain in his left knee. He was vague in locating the area where the pain was felt. There was no injury or event that provoked the pain and the knee had some mild swelling despite all special tests for mechanical structures returning a negative result. In other words, my clinical exam could not determine what was wrong.

The “muscle spasm” patient was even more tricky. There was a well documented incident where the patient, a nurse, had assisted in a transfer and felt pain and spasm immediately. The transfer was a simple slide up in the bed and seemed to have no ability to create any sort of serious injury. There was some red flags, however: extreme tenderness and protection upon palpation and the inability to sleep due to aching pain.

On both of my requests for radiology I included the term, “rule out underlying pathology.”

I was glad I did, and even more grateful for my ability to have access to these tests. Neither case was an emergency, but I fear that if I saw these same two patients in a civilian clinic, I might have been tempted to try a few session of therapy before deciding to send them back to their physician for more tests, which might or might not happen, and could take several weeks!

These two cases, at the very least, speak volumes about the importance of a thorough physical examination. It should also speak to the importance of being evaluated by an expert in musculoskeletal care.

The ability of Physical Therapists to obtain radiological images seems like the next logical step in a move towards autonomous practice. There are many hurdles to this concept and a great debate is pending. Stay tuned…

"Name Your Price, Doc"

At least the drug companies are not alone in buying off doctors. This time it is a criminal investigation into ortho docs who have been paid handsomely by device manufacturers to use their implants. No one is accusing these docs of compromising patient safety, but it is illegal to accept kickback payments AND be a Medicare provider.

This reminds me of a recent conversation I had with an orthopaedic resident (I am summarizing the conversation for obvious purposes):

ME: “How many of these surgeries do you plan to do?”

RES: “Well we’ve not been doing too many, but my attending is good friends with the sales rep from company B, so we will probably stop using company A and do more surgeries with B’s implant.”

ME: “Oh, he’s friends with the guy?”

RES: “Yeah, they go fishing, and my attending stays at his cabin. They go on trips
all the time.”

ME: “I didn’t realize that implant had FDA approval yet!”

RES: “It doesn’t, but I think we’re kind of holding 0ff on surgeries
using company A while we wait for company B’s implant to get it.”


Today's Review of Health Policy Folly

Last week the New York Times had two related articles about small business and health insurance. The gist of both articles was that insurance companies are free to charge as the wish, and the ability of self-employed and small businesses to purchase health insurance is declining.

One article discussed how, after one employee suffered a serious illness and subsequently passed away, the business became burdened with inordinate rate hikes.

The other article talks about some of the struggles self-employed individuals face as they confront high premiums and denials of coverage.

Another article, from the Salt Lake Tribune, describes a study published in this month’s Pediatrics journal. It breaks down the cost to the community when a child has no health insurance coverage. This study found that it costs a government more to not provide insurance that do provide it.

But, even as our health policy troubles mount, notoriously unpopular insurance providers are still a good buy.