In February 2007, William Winkenwerder Jr. announced he was stepping down from his post as assistant secretary of defense for health affairs following a press conference in which he downplayed the Walter Reed scandal as a mere "quality-of-life experience." In the months that followed, it seemed clear that Winkenwerder’s negligence may have been partly to blame for the deplorable conditions at the military hospital.

Now, more than a year and half after his departure, Winkenwerder’s legacy lives on in a multibillion-dollar Defense Department electronic medical-records (EMR) system that many military doctors believe is fatally flawed. One military physician, speaking anonymously, calls it "another Walter Reed-type scandal."

And now, as I noted in a piece that Mother Jones magazine posted this morning, it turns out that the Defense Department’s foray into the world of healthcare IT, a system dubbed AHLTA, is going to cost taxpayers somewhere in the realm of $20 billion—four times what the government had originally budgeted.

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Over the past few months I’ve twice posted about AHLTA, the poorly-designed, unreliable, and costly EMR system that the Department of Defense introduced in November 2005.  In my first post on the issue in June, I noted that one fundamental problem with AHLTA is that it shouldn’t exist: in contracting with an IT firm called Integic to develop the AHLTA software, the Defense Department has actively ignored the Veterans Administration’s successful VistA system as a promising option for building up the military’s EMR capacity.

Last month, my second post focused on the unhappy military clinicians who are forced to use AHLTA  to manage their patient records. Over the summer, the DoD held an online town hall to collect the comments and thoughts of military doctors on AHLTA, and the response was overwhelmingly negative. Participants said that they were “completely disappointed” with AHLTA, and that the system is “a debacle,” too slow and unreliable to be anything besides an “impediment to…seeing patients in an expeditious manner.” The message of the town hall was crystal clear: the Defense Department had spent over $5 billion in taxpayer money to develop an EMR system that its own doctors don’t want to use. 

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If there are such things as universal truths, then one of them is almost certainly this: nobody likes to be in pain (okay, maybe masochists). This simple assumption is the key principle behind palliative care, which focuses on reducing the severity of pain and managing symptoms of patients with advanced illness—instead of relentlessly concentrating on trying to cure a condition. As many have put it before, palliative care is about caring, not curing—helping patients feel better, sometimes through medication and sometimes through communication and personal support.

Palliative care seems like a practice that would be somewhat at odds with American-style medicine, which centers on maxing out detection efforts and treatment interventions. The reasons for this tendency are two-fold: in our warped reimbursement system, doctors get paid more to do more procedures, and our medical culture is very much focused on ‘beating’ sickness instead of treating people.

Yet palliative care has been on the upswing in American medicine over the past few years. According to the American Hospital Association, as of 2005, 30 percent of U.S. hospitals and 70 percent of hospitals with more than 250 beds had a palliative care program—an increase of 96 percent from 2000. What’s behind this surge?

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A few days ago over at The Health Care Blog, Robert Laszewski posted a list of Sarah Palin’s health care priorities while serving  as governor of Alaska. Number one on her list was the repeal of certificate of need (CON) laws in the state. Such laws give state planning agencies the final say in approving the construction and development of a new hospital, nursing home, or medical service center. Simply put, in the 36 states currently regulated under CON laws, nobody can build a hospital or introduce a new hi-tech device such as magnetic resonance imaging (MRI) scanners without first getting government approval.

This approval is based on “need” and “quality assurance.” Basically, the planning board asks whether a given community could benefit from a service or facility and if those services can be delivered effectively over time. In theory, the main goal of such a vetting of facilities is to reduce health care costs: by regulating the supply of health care in a given region, CON regulations are meant to limit the proliferation of expensive, medically unnecessary services. 

On paper, CON regulations sound exactly like the sort of policy that we at Health Beat have been advocating for a while now: one that realizes an all-you-can-eat buffet of health care options drives up costs without improving quality. Yet CON regulations haven’t been as successful as supporters hoped—not just by the ideological standards of free-marketeers, but also in terms of empirical impact. Why is this so?

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Over at “Home of the Brave,” Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:

“But even as Linda Scheinbaum — Morton’s wife of 24 years — was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.

“‘I’ll give you all the information later!” Linda Scheinbaum yelled at the clerk.

“It would be Scheinbaum’s tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait — even though a delay of just minutes can make the difference between life and death during a heart attack…

“The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.

“And that’s where he died, his admission paperwork completed.”

There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger—and just as depressing—picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (EDs) in the United States.

Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun’s less-than-probing characterization: “Is the ‘nurse’ cited an unlicensed admission clerk?” asks Annie. “A secretary?…or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital’s accreditation agency standards?”

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Back in October, Maggie touched on America’s shortage of nurses, as well as the different factors behind the crisis—namely, hectic working conditions, insufficient academic resources for nurse training, and a hospital building boom that has outstripped the nursing workforce. Thanks to the convergence of these forces, the government predicts that the nursing shortfall will grow to more than 1 million nurses over the next 12 years.

What can be done to nip this problem in the bud? According to a new white paper, our priorities should lie with expanding the capacity of nursing schools and doing more to make sure that existing nurses work under better conditions.

First, the nursing schools: “there is widespread agreement that the primary bottleneck at this point in time is the faculty shortage,” say Jennifer Joynt and Bobbi Kimball, authors of “Blowing Open the Bottleneck,” published jointly by the AARP, the U.S. Department of Labor, and the Robert Woods Johnston Foundation. According to the authors, “a 2007 survey of baccalaureate nursing schools found that 71.4 percent of schools indicated faculty shortages as a reason for not accepting all qualified applicants.” Turning away potential nurses is a bigger problem than you might think: according to a companion write-up in JAMA, more than 42,000 qualified applicants were turned away from nursing programs in the U.S.

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The Massachusetts experiment in health care reform is all about expanding access.  But it doesn’t try to control costs.  This, in a nutshell, is why it’s running into trouble.

The plan didn’t reform health care delivery, just coverage. Granted, in terms of bringing more people in under the tent, it’s been a success: Since the plan went into effect in 2006, 439,000 people have signed up for insurance—a number that represents more than two-thirds of the estimated 600,000 people uninsured in the state two years ago. This surge in coverage has reduced use of emergency rooms for routine care by 37 percent, which has saved the state about $68 million. (Going to the ER for routine care drives up health care costs by creating longer wait times and tying up resources that can be used to help patients who are critically ill).

But even with these savings, Massachusetts is having trouble funding its plan. Earlier this month the Boston Globe reported that the governor’s office is planning to shift more responsibility for funding to employers. Currently, the Mass. Health care law requires most employers with more than 10 full-time employees to offer health coverage or to pay an annual ‘fair share’ penalty of $295 per worker:  this is called ‘pay or play’, an employer either provides coverage or pays a fee toward the system for not doing so).

To “play” rather than “pay,” employers must show either that they are paying at least 33 percent of their full-time workers’ premiums within the first 90 days of employment, Or that they are making sure that at least 25 percent of their full-time workers are covered on the company’s plan. (In other words, they must be paying a large enough share of the premiums so that 25 percent of their employees can afford the plan they offer.)   

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This post was written by Niko Karvounis and Maggie Mahar

It’s no secret that the wars in Iraq and Afghanistan have stretched the military thin. Indeed, the past few years have seen a steady flow of news stories depicting just how desperate our armed forces are for warm bodies—including reports that the military is “at its breaking point” and has considered non-citizens for service; that states are seeing their largest mobilization of reservists since World War II; and that the army has abandoned the 24-month limit on time that reservists must serve.

Meanwhile, in November, Stars and Stripes reported that the Pentagon was quietly looking for ways to make it easier for people with “minor” criminal records to join the military. In 2007, the share of Army recruits needing waivers for infractions that included stealing, carrying weapons on schools grounds, and fighting rose to 18 percent –up from 15 percent a year earlier.

There’s no shortage of political objections one can level against the military’s never-ending need for manpower, but there are also some profoundly personal issues to consider when reflecting on just how dangerous it is for our military to deploy—and redeploy—so many soldiers. More than 100,000 American veterans have been sent back to Afghanistan and Iraq despite finishing the terms of their enlistment. Imagine what it means to think that you have fulfilled  your duty—and then to find yourself on the way back to hell.

Imagine being told that you will have a year at home before going back to Iraq—and then being ordered back, as the 4th Infantry Division from Fort Hood, Texas  was after a break of only seven months. “It just plays with your head," says one soldier. “The people in Washington think that this is a board game."

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Did you know that three-quarters of the 40 million sightless people in the world don’t have to be blind? According to ORBIS International, a global nonprofit organization, most of the world’s blind population owes its lack of sight to a lack of access to care.

ORBIS’ mission is to eliminate avoidable blindness by "strengthening the capacity of local eye health partners in their efforts to prevent and treat blindness." Through a process that ORBIS calls capacity building, local partners gain "self-sufficiency in eye health care and residents enjoy quality eye health services that are affordable, accessible and sustainable."

As part of ORBIS’s broad-based capacity building program, the organization works with carefully selected local partners on projects typically lasting at least three years. ORBIS has about 100 of these active partners, which include hospitals, health centers, universities and training centers, local non-governmental organizations (NGOs), eye banks and government health departments.

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You’ve probably heard about “medical tourism,” the traveling of patients to foreign countries in order to receive care. But what you may not know is just how popular medical tourism has become: according to Deloitte LLP, an international consulting firm, an estimated 750,000 Americans traveled abroad for medical care in 2007. Aggressive projections put this number somewhere around 6 million by 2010.

As interest in medical tourism increases it’s important to understand the nuts and bolts behind its allure, and the risks that it poses—both for patients and health care systems at home and abroad.

Saving Money

Over the past few years insurers and employers have warmed up to medical tourism as a way to save money: its cheaper for insurance plans to help fund patients’ trips to foreign doctors who charge much less for procedures than their U.S. counterparts.

The price differentials  are stunning. According to a recent Deloitte report, Thailand, the world’s leading medical tourism hub, saw 1.2 million medical tourists from around the world in 2006. On average, medical procedures in Thailand cost a mere 30 percent of American prices. India, another destination that sees more than 400,000 medical tourists each year, charges just an average of just 20 percent as much as the U.S. Thousands of Americans also flock to Mexico and South America every year for cosmetic and dental surgery, where procedures cost anywhere from 75 to 50 percent less than they do in the U.S.

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In a 2006 New York Times article, Dr. Amit Shah, a physician at Johns Hopkins, recalled how other doctors looked down on him during his residency because of his chosen field. “The most memorable discouragement came during his residency, from a pulmonologist,” notes the Times. ‘When I passed him in the hall, [the pulmonologist] would shake his head and mutter, ‘waste of a mind,’” Shah said.

Dr. Shah’s sin? He had chosen to become a geriatrician.

You’d think that Shah would be applauded by his colleagues for choosing geriatrics, given that the U.S. is in the throes of a major geriatrician shortage: Since 2000, the number of geriatricians in the U.S. has fallen by a whopping 22 percent to a mere 7,100. According to a May Institutes of Medicine report, the outlook for the future isn’t much better: by 2030, there will be just 8,000 geriatricians, despite the fact that the U.S. will need about 36,000 to cover the workload as the number of Americans 65 years and older mushrooms.

Clearly, the U.S. needs more geriatricians. Yet the reason we don’t have more stems from the mindset of the pulmonolgist that scoffed at Dr. Shah: both our health care system and our medical schools devalue the kind of care that geriatricians provide.

Geriatricians are family or internal medicine physicians who have taken extra training in the area of aging and the special needs of seniors. In the words of Cheryl Phillips MD, a Sacramento geriatrician, “the particular focus of geriatrics training is the care of frail elders—where understanding how to assess and determine the individual’s ability to function is oftentimes every bit as important as understanding their diseases.” Thus geriatrics deals with coordinating long-term care for chronic conditions or helping seniors to manage their day-to-day life. Geriatricians tackle issues like confusion, dementia, incontinence, falls, depression, and the special effects that medications can have on the elderly. As the New York Times explains, “caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.”

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