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Singapore medical tourism diaries

by David Williams

I finally completed my diary from my medical tourism research trip to Singapore. Now I’m working on posts about some of the individual hospitals I visited. If you’d like to read the entries on MedTripInfo, see:

Follow-up to “Red Package Health Care in China”

by Nick Jacobs

 This could have been a comment to Fred Fortin’s last blog post, but, since it’s so long, I decided to blog it.

This comment came from a wonderful, Chinese physician friend:  “I have practiced in a half dozen different hospitals in China and can tell you definitively that the Red Package is absolutely true in China.”  His very clear description of the life of a physician in China is that it is a very high risk profession.  The majority of hospitals have no malpractice insurance.  If the patient has a problem with the physician, there have been numerous cases where physicians are beaten, kidnapped and sometimes even killed.  Most of the time, he explained that hospitals choose to take no action, and the police usually assume the same position.

Physicians in China earn just a little more than the average salary.  The income does not match their education, requirements and talent, and according to my physician friend, respect for physicians is not very high.

Solutions?  Well, because it is a third world, developing country, there are numerous challenges.  A health insurance system for the people of China, support from the media, and, generally, protection for them provided by hospitals and law enforcement organizations would go a long way.

So, when the Red Package is discussed, it brings back memories of a conversation that I had with an accountant once said to me, “If you want to make an honest man dishonest, pay him too little and put him in a position where he is exposed to cash on a daily basis.”  Red Package is a way of life in most developing countries.

While speaking at a World Health Organization conference in Africa, I noted that what we would give as a tip after service in the United States is given as encouragement to receive that service in Aftrica.  Bribes by any other name may be considered TIPS, and, if it takes a TIP to save your mother-in-law, I’m sure you won’t think twice to do that!

Not too many years ago, in the United States, we had physicians taking vacation cruises paid for by pharmaceutical companies. These gifts were intended to encourage the use of their product.  Was this payola or advertising?  Bribes or Tips?  Red Packages are actual income enhancements for service to be rendered in a society that does not recognize the true value of the medical profession.  Ethical or unethical?  Yes, it is.

Wiki Media, Expert Systems, Free Culture and Health Care: Imagining the Convergence Horizon in Developing Countries.

by Fred Fortin

The title of this post is a mouthful, I know. But I’m hoping that the murky possibilities embedded in this elongated title will stimulate finer minds than mine to think about the connections that could exist between these various fields of endeavors. I’m often drawn into these explorations by a long standing drive to find the edges where intractable problems (say, in health care) and the emerging (and often peripheral and below-the-radar) stew pot of new thinking bump up against each other –I must add doing so most when you’re not paying attention of course.

One of the exercises I like to do is to peak into radically different areas of culture, work, and intellectual thought with the objective of eventually asking the question of how the tropes, metaphors, and ideas that naturally float out of these circles of social activity can be applied to health care. An so, in delving into areas such as ‘new media’, I am continually asking the question of how could we use these cultural, artistic and technological thought streams to address health care needs in rural China, for example.

In article in this latest issue of Health Affairs (see my previous posts here and here on this issue of Health Affairs), Gardner et al. talks about technological and social innovation as a unifying new paradigm for global health. The authors explain that innovation takes three forms: the technological, the social and the adaptive. And they argue, “a strong capacity for both technological and social innovation in developing countries represents the only true sustainable means of improving the effectiveness of health systems.”

In a previous post, I wrote about how a number of people were pursuing a wiki approach as a device to building an early warning notification system for pandemics. But as I try to think this through, I see that effort as only the tip of a very beneficial iceberg.

So, here is one way to speak of the challenge that I see confronting us:

How can we combine the community values, social networking, and collective intelligence and information gathering of the wiki enterprise, with the critical science, professional competence and amplifying effect of expert systems, (take a deep breath) with the bold attempts to break down archaic or self-serving legal and political barriers to information the public needs — as symbolized possibly by the ‘Free Culture’ movement — in order to bring health care to the poor and rural populations in Asia or anywhere else for that matter?

It is a question, I believe, worth pursuing despite all of its complex interpretive, trans-disciplinary and trans-national complications.

Will We All Become “Drug Addicts”?

by Scott MacStravic

With the clear worldwide “obesity epidemic” a major concern for practically everybody, and a major contributor to increased diseases of many kinds and increased sickness care costs, it is understandable that it has also become a major market opportunity for many entrepreneurs.  Weight loss products and services have sprung up all over the U.S. for example, and charges that many of they are over-hyped, with only short-term effects soon “reversed” by relapses into old bad habits are rife.

Perhaps the biggest market opportunity exists for pharmaceutical manufacturers.  What could be better, from a money-making perspective, than coming out with an expensive drug that would be taken by the majority of the population for their entire lives?  And there are a number of weight-control drugs already available, working on the body’s processing of fat, on appetite suppressing, energy expenditures, or almost anything that affects body weight and mass.

All will undoubtedly cause side effects, such as the gastro-intestinal problems and occasional embarrassments associated with GlaxoSMithKline’s Alli, and headaches, nausea, insomnia, anxiety and dry mouth effects of Orexigen Therapeutic’s experimental Empatic. [T. Somers “Obesity Drug Shows Promise in Testing” SignOnSanDiego.com July 25, 2007] But given consumers’ almost universal presence for a pill over personal effort to control their weight, all will probably sell well.

When obesity is added to the host of diseases and risks that people will want to avoid, reduce, or eliminate from their lives, including a variety of “disorders” (eating, sleeping, emotional, etc.), “dysfunctions” (erectile, for example), “syndromes” (restless leg, metabolic, etc.), there is almost no limit to the market potential.  And this threatens to create the kind of world envisioned in the novel “Brave New World”, where everyone is forever “on drugs”, with all the social and economic consequences thereof.

In the worst case scenario, it may turn out that employers and insurers will be willing to pay enough to make such lasting and widespread “addiction” affordable, once they learn whether they are better off in terms of labor and sickness care cost reductions to pay for such addiction, while consumers decide they are also sufficiently better off in terms of health, appearance, out-of-pocket sickness care costs, etc.  I may be a good case example, taking over twenty pills a day for a variety of digestive, physiological, and health protection reasons, though, fortunately, only one is a prescription drug, and it costs only $11 for a 90-day supply.

It may be odd and ironic that we will become dependent on a host of drugs, some OTC and others prescription, some inexpensive and some really challenging to pay for, in pursuit of independence from health problems, particularly in later life.  We can hope that the drugs on which we come to depend will be affordable for us as individuals and for payers who help, and will not create so many side effects as to make life unbearable.  But we can also choose to make lifestyle change an alternative to addiction in the first place.

There are already programs available to help us make “permanent” lifestyle changes that reverse diseases such as diabetes and heart disease, and may even work with prostate cancer, in the sense of not only controlling the disease, but doing so independently of pharmaceutical dependence.  And most of the health risk conditions and behaviors can be reduced or avoided through lifestyle/behavior changes, without using drugs to help, even though there are drugs available to help in most cases.

It may become a personal balancing act that most of us will have to address on our own – how much we are willing to spend on drug dependence to address risks, disorders, dysfunctions, syndromes and diseases.  It will certainly require tough decisions on how much we are willing to depend on outside dependence compared to the time and effort costs of do-it-yourself personal health management.

There have often been indications that pharmaceutical drug manufacturers, despite the long use of the term “ethical drug industry” to describe them, have been somewhat unethical, or at least mostly entrepreneurial in promoting use of their products.  Examples have included paying other manufacturers not to come out with generic competing products, “bribing” physicians to prescribe them, “medicalizing” problems, questionable advertising to consumers, questionable support of research to support their own or raise questions about competing options, withholding information about side effects, etc.

If we hold with Milton Friedman that the sole duty of publicly held corporations is to deliver returns for their shareholders, we can hardly expect any other pattern of behavior but doing whatever can be gotten away with to promote sales and profits.  But the prospect of a nation of drug-dependent consumers, even if they are “healthier” as a result, may be something.  And the only preventative for this threat may be consumers taking charge of their own health and health behaviors to prevent being “suckered” into such dependence to make a small number of shareholders richer.

In any case, we will likely all be challenged to balance the total benefits vs. total costs of opting for medication “solutions” to the wide range of problems that we face relative to our health and longevity.  There will surely be pharmaceutical and medical solutions available, but there are no medical problems, only problems to which there are medical solutions, among others in most cases.  Both preventing and solving such problems will almost always be possible at least partly through our own efforts, in addition to the option of drug dependence.  And payers, as well as consumers, themselves, may prefer lower-cost self-management options to lasting dependency.

Red Package Health Care in China

by Fred Fortin

A few years ago I was talking to a Shanghai businessman about China’s health care system and his experience with it. He told me of his own personal encounter, which gave a certain insight into the delivery of health care. One evening his mother-in-law suffered a medical emergency. While she was being transported to the hospital, his first action was to call his friends and tell them to bring all of the cash they had on hand to him. When he went to the hospital he had about 5000 yuan (US$660) in his pocket. It took 3000 yuan to finally persuade the specialist just to come in to see her. His mother-in-law was seen and treated. The businessman considered himself very lucky.

In the latest issue of Health Affairs, Maureen Lewis has written an article on “informal payments” and health care in developing countries. These informal payments are under-the-table, mostly illegal payments, bribery, or gifts that patients give to health care workers for variety of purposes. They are a significant form corruption and symptomatic of bad management according to Lewis. They are widespread, largely unreported, and typically indicative of under-funding and the absence of accountability.

In China, these informal payments and gifts are know as “red packages or envelopes” usually containing cash.

Why there is little systematic data, I’d like to highlight a few points made by Lewis, as well as those cited in an excellent review of the research over the last several years into this area by Bloom et al. ( referenced by Lewis) on the situation in China.

  • Selected studies in China of “red packages” paid to providers report that payments average 140–320 yuan per hospital visit (US$16–US$36), with referral hospitals averaging 400 yuan (US$44), roughly 90 percent of half-monthly income.
  • Red packages have always been around but have become more common in China’s new market economy. One study reported that health workers in 190 hospitals recently turned 3.5 million yuan in such payments over to local government. Another found that over 50 percent of inpatients in Shengyang had paid a red package averaging 260 yuan. Yet another found that 74 percent of inpatients had made informal payments. Most studies focus on urban health facilities, however, one reported that health workers in rural Jiangxi also receive red packages.
  • Patients give red packages to doctors or other health care workers to allow them to jump the queue or obtain special services such as shortened admission time for surgery or for longer lengths-of-stay in hospitals. Patients pay to receive more-attentive and “higher-quality” care, as they perceive it. Longer lengths-of-stay do not necessarily mean better clinical care, but patients tend to value shorter waits, longer hospital stays, and attentive treatment by medical staff. Quality as perceived by patients increased with the amount paid informally.
  • Health workers have ambivalent attitudes towards red packages. One study reported that 21 percent of doctors said they accepted them to compensate for unrealistically low pay, 59 percent refused them on ethical grounds and 15 percent turned them down for fear of punishment. Another survey found that 31 percent of recent medical school graduates thought that red packages were normal.
  • The government has become increasingly concerned. The government treats red packages as unethical and unprofessional. They punish offenders with fines, loss of bonuses, termination of employment, postponement of promotion, demotion and/or loss of the right to prescribe drugs. A recent strategy has been to ask patients and doctors to sign an agreement not to pay or receive a red package.
  • Few strategies exist to control informal payment. Raising official fees as a substitute for under-the-table payments showed positive effects as does transparent official fee policy, indeed greater transparency in all fiduciary functions. Civil-service reform and increasing the accountability of public workers often play a key role in improving governance and relinquishing reliance on informal payments.

China’s health care reform advocates will have to confront these issues as they begin to modernize the country’s health care system.These informal payments are health care’s dark side and ripe for the picking by China’s anti-corruption forces. But a careful hand has to be played here. Root cause analysis and systemic approaches need to be considered. Just lopping of the heads of doctors will certainly not fix the problem.

Evaluating Health Management Results: Therapeutic Specificity?

by Scott MacStravic

When evaluating results of any “medical” intervention, including proactive health management (PHM) efforts involving medical care providers, the question must always be asked: which “results” can logically be attributed to the effort, as contrasted to any number of confounding factors at work?  In the past, both vendors and customers of PHM interventions have tended to ascribe everything good that happens after the intervention to their efforts, where at least some such results may be totally unrelated.

Once the PHM evaluation has avoided or controlled for the most common causes of overestimating results, namely “regression to the mean” with before/after comparisons, and self-selection bias with side-by-side comparisons, a third control is often recommended: “therapeutic specificity”.  This involves making sure that the changes in valuable metrics discovered can logically be attributed to, i.e. have some known connection with the intervention.

The origin of this demand for therapeutic specificity was curative medicine, where rigorous clinical control studies are needed to evaluate new drugs and medical procedures.  Unless the physiological effects of such treatments are known to produce specific consequences, any other consequences discovered in patients so treated should not be considered to result from such treatment.  For example, if asthma patients are found to improve their IQ scores after treatment with a particular drug, this improvement should not be attributed to the drug unless there is an established connection between it and mental performance effects.

In evaluating diabetes management, for example, one proponent of therapeutic specificity made a strong case for not counting among the effects of such a disease management effort any reductions in hospital admissions or other sickness care use and expense not directly linked to diabetes.  Specifically: “It should not be assumed that an intervention targeting one disease will impact another”. [A. Linden “What Will It Take for DM to Demonstrate an ROI?”, Disease Management Colloquium May 2006 (www.ehcca.com)]

When considering the cost savings from diabetes DM, evaluations may focus solely on sickness care use/expense reductions where diabetes was the sole cause, include it plus known co-morbidities, or at least conditions known to be directly related thereto.  But “therapeutic specificity applies to the “therapy” used, not to the disease targeted alone.  For example, diabetes is not merely a disease, but a known risk factor for a host of other disease, of the eyes, hands and feet, kidneys and heart.  For this reason, diabetes DM often includes explicit attention to blood pressure and cholesterol, in addition to blood glucose control.

Moreover, since diabetes is known to be “reversible” through lifestyle changes alone, nor merely medications, diabetes DM often includes lifestyle modification efforts.  If these are successful, patients are often able to control this chronic condition without relying on medications anymore, saving themselves and third-party payors significant prescription drug costs.  The same has been shown to be true for heart disease, and may be true even for prostate cancer. [D. Ornish, et al. “Can Lifestyle Changes Reverse Prostate Cancer?” Preventive Medicine Research Institute April 2002 (www.pmri.org)]

The “rule” of therapeutic specificity is clearly intended to apply to the therapy, not necessarily the disease involved, particularly with diabetes, since it is also a risk factor for so many other diseases.  The focus in evaluation should be ensuring that the DM or other PHM intervention is logically related to any results claimed to be due to it, even when the results are not directly related to the disease specifically targeted.

Moreover, medications often have unexpected, even unintended consequences, that can either be negative “side effects” to watch out for, or “serendipitous” added benefits that add to their value.  For example, many of the statin drugs used in reducing cholesterol levels have been linked to reductions in cancer risk.  Recent research in the UK has indicated that controlling people’s heart disease reduces older people’s cognitive function declines. [A. Harding “Heart Disease Tied to Mental Decline” ReutersHealth.com July 27, 2007]

The rule of therapeutic specificity only argues that no connection between an intervention and a result should be assumed, not that none should be credited to a disease-specific or risk-specific intervention.  Fortunately, there are many good “side effects” of both medical and lifestyle interventions, and both should be counted in both benefits and costs of DM and PHM interventions.  While care is needed to avoid “over-attribution” of positive effects to such interventions, equal care is needed to be sure of avoiding “under-attribution” as well.

If there are effects from treating diseases or risk conditions that go beyond the specific disease being addressed, these can justify counting at least the risk-reduction effects of DM and PHM interventions.  This can easily be expressed as a probable percentage reduction in sickness care costs, absences, productivity and performance impairment related to the calculated risk reduction effects.  While a deliberately myopic insistence on limited effects may prevent over-attribution and over-investment in DM/PHM, a more realistic and open-minded approach can prevent both under-attribution and under-measurement, and thereby under-investment.

Grand Rounds 3:45

by David Williams

Grand Rounds, the best of the week’s medical blogging, is hosted today at the Health Business Blog. You’ll find intriguing posts including:

  • A critique of the NEJM article on the spread of obesity through social networks
  • Examination of Charlie Weis’s malpractice case
  • A defense of New Orleans doctor Anna Pou, who’d been accused of murder
  • A story about possibly poisonous candies


Are We Approaching “Critical Mass” in Managing Health?

by Scott MacStravic

I have heard and read reports with a wide range of conclusions regarding the future of managing health, in contrast to and competition with treating sickness.  Some have suggested that the consistently unenthusiastic evaluations of disease management, the most widespread example of managing health, portend the demise of at least this narrow range of “solutions”.  Others have predicted that the “wellness” or “healthy living” market will reach the $1 trillion a year level within the next few years or decade.

Just as the original “health maintenance” and “managed care” organizations ended up focusing almost entirely on managing costs, so managing health has a major focus on reducing costs, though with a far broader range of “costs” than either HMOs or MCOs.  It includes the costs to patients in terms of health and life quality as well as longevity of life, for example.  And it includes the costs to employers and the overall economy of the absences, reduced performance at work, turnover, shortened work life, and other effects caused by “unhealth” in general.

While the “healthcare system”, and hospitals, in particular, are fond of describing the value they represent to their communities in terms of jobs and total economic impact on local economies, which naturally add up to the total costs of the system, over $2 trillion each year.  But the illegal drug industry could as easily brag about its economic impact as well, if only the money involved were used to measure it.  The real point is that the healthcare system has done extraordinarily little to promote the health, prevent and reduce disease risks, and manage patients with chronic diseases so as to reduce the crises, complications, and worsening thereof.

But there are signs that the larger health system, which includes the entire population and its health, all providers, all payers, and all other stakeholders that are affected by and affect the health of the population, are approaching a “critical mass” or “tipping point” level in terms of a far different balance of health management vs. sickness treatment.  Developments in essentially all stakeholder categories are moving in that direction, at least.

For example, “Revolution Health” has most recently partnered with Medco Health Solutions to empower consumers with a personal health record to better manage their own health and healthcare expenditures.  This adds to its investments in health spas, the RediClinic chain of retail clinics, which is the one I know of with a significant focus on “Stay Well” as well as “Get Well” services, and its own online health information memberships. [“Revolution Health and Medco to Partner on New Portal” E-Health Trend Watch July 26, 2007 (www.healthleadersmedia.com)]

Disney has joined in the effort to reduce the promotion of unhealthy behaviors by banning depictions of smoking in its movies. [“Disney Films to Ban Depiction of Smoking” MSNBC.com July 25, 2007 (www.msnbc.msn.com)]  Google and Microsoft are both competing for the e-health market, with Google focusing mainly on consumers, and Microsoft on patient/physician interaction and information therapy. [“Google vs. Microsoft e-Health in Medical Search War for Big Profits” DirectTraffic.org July 26, 2007

Positions on controlling chronic disease costs through disease management and preventing current epidemics in new cases are being taken by both liberals and conservatives.  And most of the daily increasing number of presidential candidates seem to have a position in favor of health promotion and disease prevention, as well as disease management as essential to the solution of the “healthcare cost crisis”. [T. Pugh “Curbing Chronic Diseases New Issue in Health Care Politics” KansasCity.com July 26, 2007]

Canada is taking essentially the same position, with British Columbia complaining how far it has fallen behind other provinces in its investments toward preventing, rather than waiting to treat and pay for sickness. [“An Ounce of Prevention” Straight.com (Vancouver, BC) July 26, 2007]  Employers are shifting toward “value-based approaches to employee benefit design, health plan purchases, which promotes by reducing financial barriers to employees obtaining prevention, early detection and disease management services.

Intel, Inc.’s Digital Health Group is focusing R&D efforts on finding better ways to use computer and communications technologies to enable consumers to protect and enhance their own health over a “health lifetime” as a way to promote both physical and financial independence. [S. Love “Intel in Health Care” Intel.com July 2007]  Cell phones will soon be able to store individual’s medical history for access by providers in both sickness care and health management. [“New Cellphone Projects to Save Lives with Medical History Information” World e-Report/Disease Management Alliance July 12, 2007 (www.dmalliance.org)]  Physicians are poised to join health management vendors and health insurers as providers of proactive health management services, based on the “medical home” model agreed to by primary physicians’ associations. [V. Kuraitis “Disease Management and the Medical Home Model” Disease Management & Health Outcomes 15:3 2007 135-140]

And these are but a few of the literally hundreds of examples of just about every stakeholder in the “system” poised to or already heavily involved in attacking the healthcare crisis proactively.  Some focus just on short-term gains from disease management, while others look longer term at health promotion, risk prevention and reduction.  But all are persuaded that proactive interventions that will reduce the incidence and prevalence of disease and injury, along with the crises, complications and worsening of existing chronic diseases are clearly an essential component of any serious and potentially effective solution to the crisis.  And instead of merely calling for such interventions by others, almost all stakeholders are implementing their own.

Global Health Care Standards and China

by Fred Fortin

In a recent article in the MIT Sloan Management Review, authors Seung Ho Park and Wilfried R. Vonhonacker argue that

“To succeed in China, multinational corporations must turn the aphorism ‘think global, but act local’ on its head. Although they have to master the art of local operation, their behavior must match their global standards, as expected by the Chinese. . . Beijing has been looking to (multinational corporations) to set global standards in China — a particularly important contribution at this stage in the development of the country’s economy.”

While the authors were not talking about health care per say, I found the message being conveyed clearly something to be considered by those involved in China’s health care reform efforts: specifically, by those from the international community now trying to help China address some of its most pressing health care problems. What the Review authors suggest is that, while compromises may have to be made, the expectations of the Chinese people are not simply to make do. There are growing public aspirations that China’s time has come for its people to have full access to the benefits of the modern world. For better or for worse, foreign helpers carry the burden of representing that world to a struggling population desperately seeking entry.

And these aspirations certainly include health care.The public frustration in China with health care is palpable and its temperament volatile as demonstrated by continued outbursts of violence and threats against medical workers. For foreign companies or health-related NGOs, difficult issues arise around what people do when the situation on the ground is drastically different than the standards of health care patients believe they deserve or, in the case foreign health care organizations, what they may be accustomed to in their home country.

The Review authors believe foreign companies should be responsive to local sensibilities, but act according to global standards. In health care, that is a very difficult, but very necessary, challenge. Global health standards are often mired in cultural, political and scientific controversy despite many serious and well-intentioned international collaborations.

Foreign companies and NGOs in China may also increasingly find themselves in their own Catch 22 as the local expectations surrounding their efforts pale in juxtaposition to media-dramatized health scandals and the intrinsically slow nature of social change. As foreign health care organizations become more deeply involved in direct activities related to health care reform in China, they also become more vulnerable to the political dark side as well and the unsettling tendency at times to vilify international assistance when things go wrong to satisfy domestic politics.

So the course is set, and the travel is known to be dangerous. But there is a tremendous opportunity for discovery on the horizon. Yet, how well we navigate the treacherous currents in between still remains to be seen.

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