Yesterday I commented on the intriguing health care 'value chain', shown above, that Verna Allee's
group has constructed, seen from the perspective of Big Pharma. This
perspective assumes that 'the patient' is basically helpless, passive,
ignorant and uninterested in taking an active role in the management of
his/her own health. That's a very patronizing perspective, though I
admit I know many patients who give it credence.
I would argue, however, that this is changing, and changing quickly. What is precipitating this change is:
- The
growing, glaringly obvious dysfunction of the health care system in
most countries (expensive, bureaucratic, two-tier, motivated by profit
not well-being, distorted by wealthy corporate lobbyists'
self-interests, oriented to treatment not prevention, under-resourced
etc.)
- The availability of information on the Internet that
allows people to start to take charge of their own health management
(prevention, self-diagnosis, self-treatment)
- Increasing awareness that preventing disease makes more sense than waiting for it to occur and then treating the symptoms
- A
growing epidemic of chronic, diet-, lifestyle- and
environmentally-related diseases that the traditional health care
system seems unable to cope with and uninterested in resolving (since
more repeat customers is good for business)
- Growing skepticism of the motives and effectiveness of Big Pharma's 'synthetic drugs for every disease' approach to health care
- Growing fear that public systems are incapable of handling future disease pandemics, so self-preparedness is essential
- A
willingness by more enlightened health practitioners to involve the
patient/customer more in resolving health issues, as they realize (a)
patients know more about their body, health and symptoms than the
practitioner can ever hope to know and (b) by all measures this is a
more effective approach
- In the US and other countries lacking
universal health care, an increasing number of people can no longer
qualify for or afford public health care services, so they have no
other choice than to look for alternative approaches (both good and bad
-- many quacks are exploiting this situation to sellphony, even dangerous 'alternative cures' to ignorant, desperately ill people).
Last week I contrasted, a bit simplistically, the traditional approach and the emerging 'Edge' approach to being healthy:
- Traditional approach:
Relying completely on doctors & synthetic drug-makers (Advantages:
you get fast results; it's easier, requiring little time or energy
investment; and it's cheaper, if you're insured)
- Emerging approach:
Self-directed, largely self-diagnosed and self-treated,
prevention-focused, natural holistic health care (Advantages: you're
sick less often; you're more self-sufficient; you get better diagnosis
& treatment; and if you're not insured, it's your only option)
This emerging approach is entirely consistent with the recommendations of the US National Institute
of Medicine's 2001 Crossing the Quality Chasm report which laid out these ten 'rules' to govern effective health care:
- Care based on continuous healing relationships.
Patients should receive care whenever they need it and in many forms,
not just face-to-face visits. This rule implies that the health care
system should be responsive at all times (24 hours a day, every day)
and that access to care should be provided over the Internet, by
telephone, and by other means in addition to face-to-face visits.
- Customization based on patient needs and values.
The system of care should be designed to meet the most common types of
needs, but have the capability to respond to individual patient choices
and preferences.
- The patient as the source of control.
Patients should be given the necessary information and the opportunity
to exercise the degree of control they choose over health care
decisions that affect them. The health system should be able to
accommodate differences in patient preferences and encourage shared
decision making.
- Shared knowledge and the free flow of information.
Patients should have unfettered access to their own medical information
and to clinical knowledge. Clinicians and patients should communicate
effectively and share information.
- Evidence-based decision making.
Patients should receive care based on the best available scientific
knowledge. Care should not vary illogically from clinician to clinician
or from place to place.
- Safety as a system property.
Patients should be safe from injury caused by the care system. Reducing
risk and ensuring safety require greater attention to systems that help
prevent and mitigate errors.
- The need for transparency.
The health care system should make information available to patients
and their families that allows them to make informed decisions when
selecting a health plan, hospital, or clinical practice, or choosing
among alternative treatments. This should include information
describing the system’s performance on safety, evidence-based practice,
and patient satisfaction.
- Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
- Continuous decrease in waste. The health system should not waste resources or patient time.
- Cooperation among clinicians.
Clinicians and institutions should actively collaborate and communicate
to ensure an appropriate exchange of information and coordination of
care.
So
what would a health-care system 'value network' look like that honoured
these rules? Certainly not like the one above. Here are two charts that
show, first, how I think an increasing number of (cynical) patients see
the 'value network' operating today, and then, below it, what a
reformed health-care system 'value network' would/could/should look
like:
The significant new 'ingredient' in the bottom chart, the Health Info ClearingHouse, is an example of what I have called a peer-to-peer information exchange.
The ClearingHouse would be largely Internet-based (though also
accessible through other media), not-for-profit, and not owned or
controlled by anyone. It would aggregate and objectively assess health
information provided by everyone
in the system -- customers (patients), doctors and other health-care
providers, pharma companies, regulators and other government bodies
etc. It would allow us to second-guess the hype we're getting from
for-profit providers and bureaucracies, get second opinions, and form
support groups and share information and resources with other customers
dealing with the same ailments.
Under this system, as in most
countries today other than the US, Big Pharma would no longer be able
to 'push' its drugs through the mass media ("despite these 147
side-effects, ask your doctor if new overpriced toxic XanthamPlus is
right for you!") nor would it be able to bribe doctors with
'incentives' to prescribe its brands.
The other big change would
be in the relationship between doctors and other health-care providers
and their customers (mere 'patients' no longer). The new relationship
would be a continuous one, with factual information (data about
customers' health, analysis reports, new medical reports, etc.) being
transmitted continuously between the customer and the health-care
provider (perhaps even, as in some places in Japan now, automatically
and electronically). The three-way information flows between customers,
health-care providers and the ClearingHouse would enable the
establishment of a co-developed
ongoing personal program for every individual that would include (a)
activities to prevent illnesses from occurring, (b) activities to
self-diagnose illnesses in their very early stages, and (c) activities
to treat illnesses when they occur. These would be joint activities with the customer actively engaged in the process.
Such
a system is almost a no-brainer: it would generally result in a
healthier populace and much lower costs to the system. But its
evolution has been, and will continue to be, blocked by the special
interests who would lose out in such a system: Big Pharma would find
less need and market for its products, and its influence in the system
would be drastically reduced. The HMOs, of course, would be out of
business. Many of the lawyers who make their living on both sides of
patient-health-care-provider litigation would also be out of business,
since along with greater control over their own health, customers would
also have to accept more responsibility, and not be able to hide behind
ignorance and helplessness when suing doctors and drug companies.
Doctors with God-complexes would not handle such a system well.
Predatory snake-oil and wonder-therapy 'alternative' health-care
providers would find themselves exposed by the ClearingHouse.
As
you can see, then, there are plenty of reasons why the current
dysfunctional system continues to squander our money and our health.
And this is another complex
system, that cannot be fixed by government fiat or by any group acting
alone. We need to get to the system in the bottom chart above by
evolutionary means. That evolution needs to start with bottom-up
awareness, organization and information exchange, probably beginning
with both (a) an insistence, when dealing with health-care providers,
on complete two-way information exchange, total honesty and active
customer involvement in all assessments and decisions, and (b) the
establishment of the beginnings of what will eventually be the Health
Information ClearingHouse. Instead of opting out of the system in
favour of alternative medicine, we need to demand a greater role in our
own health management from practitioners, and refuse to take no for an
answer. My guess is that many practitioners will welcome rather than
resist this change.
In other words, we need to become our own
holistic 'general practitioner'. We cannot expect doctors to know what
is happening, and what we are doing, in alternative health-care and in
our own lives, unless we tell
them. We need to tell everyone we involve in our health what everyone
else we involve is doing and saying and prescribing, and what we are
doing about it. That means that what our doctor, our physical and/or
psychotherapist, our herbalist, our pharmacist, our personal trainer,
our dietitian knows, they all should know, and we should know not only
what they have told us to do, but why, and what else they considered
and ruled out.
And there, of course, is the rub. This requires
more candour than a lot of us are willing to exhibit, and an investment
in time and energy and learning that is more than many of us are
prepared to make.
But until we do, the system will remain dysfunctional and insolvent. And we'll keep getting needlessly ill. |
5:21:52 PM 
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