Saving Lives and Saving Money by Newt Gingrich with Dana Pavey and Anne Woodbury.

I was expecting great things from this book and was very disappointed. While offering the promise of the transformation of health care we got mostly vagaries that don’t help us get started now and where he offered specific remedies they were for vitamins and exercise. At the end of my reading I was reminded of that elderly woman from the old TV add saying, “Where’s the beef?” The book leaves the reader without answers or even direction.

Transformation
The author promises transformation of health and health care. We get a look at what might be transformational breakthroughs in medical science but these are years if not a decade or more away for the average doctor’s office. We are offered little in the way of transformational thinking that we can use now, when we need it, to get our health care system on its way to health. We are told that “third-party-payer system doesn’t work” and yet are offered no alternatives. In fact we see several times that part of the solution for our health care woes is for everyone to be “insured” by these third parties. We are told that we should restructure Medicaid and Medicare and that is not transformational either. Perhaps we need to start over with new systems rather than re-tool the existing ones.

Best Practices
In medicine, like industry, we strive to find the best way to do things. When we do we label it a best practice and share it with others so that they may use it and improve their care of patients. The problem with best practices is that they are not always obvious and they are not always best. There have been many instances when we have found a best practice only later to discover that it really wasn’t the best or that is was worse than average or it was actually harmful to our patients. Medicine in general is chastised in the book for taking too long, 17 years, to incorporate improvements into every day practice. While 17 years is a very long time and too long when truly life changing modalities are discovered it is not long enough when we choose poorly and our therapy or testing hurts instead of helps. There is no tolerance for injuring patients and there is no large industry or corporation that absorbs the fallout when patients are injured or die. This isn’t like making cars or toys. The failures are very personal so we like to make sure that the best practices really are best and that takes some time, maybe not 17 years but some time.

In industry you can improve quality and usually reduce cost by refining the manufacturing process. There is incentive there in greater profits for the manufacturer. The same dynamic may not hold true in medicine as higher quality and better care may cost more not less. In comparing medicine to industry, specifically Alcoa, the author made the statement “…focusing on quality will inherently decrease costs”. This may be true at Alcoa manufacturing and it may not be true for your heart disease or cancer. Americans don’t want the least expensive good treatment we want the best available treatment at any price.

Taking care of patients with their individual illnesses, physiology and psychology is not the same as making cars or aluminum. In every interaction between doctor and patient we like to think that it is unique and that the doctor is looking at us as an individual, not as a disease or a number.

EMR
Electronic medical records are held out by many to be a panacea for cost and quality control in medicine. I have used one for over 12 years and while it is a useful and powerful tool they are not the be-all and end -all that some think they are. The EMRs that I have seen are just barely ready for prime time and in very limited ways. There is no standard format for data exchange between EMRs or between EMRs and laboratories so data exchange is often laborious and many times paper-based. Because of this lack of standardization my medical record may not ‘fit’ into your EMR and the labs that I had done at hospital Q don’t show up in the EMR either.

For an EMR to be useful it has to be reliable. Just the other day while caring for a patient I was reminded by the EMR that he was due for immunizations. It even told me which ones. This is a tremendous feature, if only it was correct. In actuality 2 of the three recommendations for my patient were wrong. In this instance the EMR slowed me down (I had to verify its correctness), my nurse had to take extra time to verify the information in the EMR and I almost provided incorrect care. Until the systems are much more reliable they are just another tool and create many problems as well as solving some. As for cost containment I am not yet convinced. Maybe when we have computers as quick and competent as the ones depicted on Star Trek we will have an EMR that delivers on the promises.

Medical Training
Medical training needs transformation almost as much as the care delivery system does. Mr. Gingrich points out that what doctors need to know now is vastly different and is much larger in quantity than it was in the past. The approach to health and health care needs to be fundamentally remade. Changes in health education need to start in grade school (or better yet at home before that). Changes in health care training for doctors need to start in medical school.

There also needs to be transformation in medical education funding so that doctors can afford to choose primary care and to encourage medical school enrollment in general. Medical school applications are down and fewer and fewer who graduate are going in to primary care. As our population grows older we face critical shortages in the number of primary care physicians. We need to change the way we pay for medical education in this country. While most medical students go in to medicine to help and care for people and with an interest in primary care they quickly learn that they have to have an extraordinary income to pay off their school debts (often about $200,000, as much as many mortgages) and live in a decent home, drive a decent car and raise a family.

Rationing Care
He only alludes to rationing as a fix. He never confronts it directly and never mentions it by name. Continuing the “insurance” focused system will ensure continued rationing of care albeit in a clandistine and dishonest manner.

Self Serving
I was surprised and disappointed by the number of self references in the book and the “I love me” group of pictures. How do these help us move forward? How do they help us address the need for transformation in health and health care? We need a forward vision to fix the problems in our health care system. The references to “when I was speaker…” and all the pictures with other famous individuals did nothing but distract me from the real reason for reading the book, to learn where we need to go to fix our system.

Health Transformation
Mr. Gingrich is absolutely right when he talks about the need for Americans to take responsibility for their own health and self help books can be effective in helping some people change. We need to get off the couch and get moving. That alone will make a huge difference in our health and subsequently in our health care costs. We need recipes for better nutrition and there is a little of this in the book too. I was surprised to see this book try to be that kind of book. It was interesting to see this kind of detail in this section when this level of detail was lacking in the rest of the book.

My Summary
Overall I found the book dissapointing. There were a whole lot of words and some pictures on the 324 pages and yet not a whole lot was said. Can we expect more from the soon promised publication from the Center for Health Transformation?

Dr. Fogoros goes where few other authors on health care reform/transformation can go. He does an extraordinary job taking us inside the health care system and exposes many frightening truths:

• We ration care, we just don’t call it that
• Doctors have been strong armed into putting the interests of employers, insurance companies and the government ahead of patient interests
• Money talks and when your insurer is a for-profit company they are obligated to make the highest profits possible and they put their profits ahead of your health
• Private insurers intimidate doctors to ration care and increase corporate profits
• Money talks and when your government is trying to save money they put their budget ahead of your health
• The government intimidates doctors to ration care and decrease spending
• Scientific studies are manipulated to support rationing of care
• Doctors have been complicit, through action and inaction, in destroying the patient-doctor relationship and consequently supported covert rationing of care

Dr. Fogoros shows us how who pays for your care and who decides what care you can and can’t have determines the quality of the system we have and the care we receive.   He shows us how insurers and our government programs, Medicare and Medicaid, ration care without our knowledge and consent, sometimes hiding behind suspect science.    

And he shows us how we will have to ration care because we just can’t pay for everything for everybody.  Americans have a “no limits” mentality when it comes to the care we want.  Unfortunately we do have a limited budget and will need to learn to ration care openly and with compassion.        

Besides the powerful insight he gives us into the real workings of medicine he gives us a blueprint for getting out of the mess and his solution starts where it should, with the patient and the patient-doctor relationship.  Patients and doctors need to get back to the root of excellent care in our country and that is the relationship that they have.   

“Who Killed Health Care” by Regina Herzlinger.  The book is divided into three parts.  The first two parts assess our present health care system and the reasons it is so expensive, 2 TRILLION dollars and ineficient at covering our people.  These are worth reading for anyone trying to understand the successes and failures, well mostly failures, of this system.  The author does a great job showing us how things were cobbled together to get us into the mess we are in, from greed to government interference and bungling.  It is easy to see how money is power and how it influences health policy.  Our policies have been shaped more by special interest with money than sound medical science or even concern for patient well being.  

In the third part of the book she tries to explain to us about the solution for our out of control system and that is Consumer Driven Health Care and she falls short.  She uses limited examples of success that I don’t think apply to the health system in general.  Can we care for chronic disease in the same way that a surgeon repairs a hernia?  She compares public consumption of consumer goods like cars to how we use and ought to use health care.  Are the two markets comparable?  You will see the term “focused factory” a lot, and how using these factories to treat chronic disease will improve care and save money.  Factories may be fine when you are building hundreds or thousands of identical products.  They are not so fine when you are trying to craft an individual item that is unique the way each of us and our medical needs are unique.  Sure the diseases we have are similar but each of us is not and our health care needs to be individualized for us.  It is also easier to control cost and quality when thinking about a factory where the point of interaction is well defined,  the environment controlled and you are producing trinkets or cars.  In actuality medical care is crafted for the individual one visit at a time.  

The last chapter, on laws and their legislators, summarizes things pretty well.  

All in all a great read, very good on history and perspective, weak on the solution.  It is useful to put what I have learned from this book together with other books and ideas on the topic.  So far no magic bullet for the problem,

“The Healthcare Fix” – Laurence Kotlikoff.  The book is clear and concise, an easy read. Mr. Kotlikoff very plainly explains the mess that our health care system is in and gives us detailed plans for starting our way out of that mess. Think that we don’t have universal health care coverage? Of course we do it just isn’t pretty or fair and it is very expensive and inefficient. Think that he government isn’t very involved in our health care? Of course they are to the tune of covering 100 million people in some way with Medicare and Medicaid (that is one out of every three people). In addition to covering their care our government spends another 200 billion dollars supporting the system that covers the rest of the population. Are you of the opinion that the government has no business providing or ensuring such a thing as medical coverage for the people? Is that thought too “paternalistic”? Then what about our already paternalistic activities that I bet you don’t mind? He is talking about our government assurances and provision for protecting private property, providing a basic education, supporting housing (and that includes tax subsidies for every property owner in the country), providing for legal representation, ensuring a safe and healthy environment, providing for equal opportunity in education and employment and already providing health in the form of mandatory immunizations for children and emergency medical treatment (just call 911 and you will not only get care you will even get a ride to the hospital)?