Loyd E. Eskildson
Halvorson's book is an excellent background source for anyone looking for an overview of health care economics. The book clearly benefits from his years of experience as a health care administrator - now CEO of Kaiser Permanente. Halvorson begins by pointing out that acute (non-chronic) health conditions often get the most public attention because each case can be very dramatic and made visible by the media. However, the most frequent uses of acute care (cancer, maternity, trauma, infectious diseases) are relatively minor cost contributors - eg. cancer and maternity care respectively contribute only 4% and 5% to total health spending. Five types of chronic care (diabetes, congestive heart failure, coronary artery disease, asthma, and depression) generate the overwhelming costs (75%). Each tends to be progressive, and those getting the most expensive care usually have two or more of the five, or at least an added acute problem. (Additional chronic problems are usually referred to as 'comorbidities.') Hypertension is also an important health care problem because it is the underlying condition that leads to heart failure and exacerbates the complications of diabetes.
Diabetes is the chronic condition that receives the most attention from Halvorson, and he makes a good case for doing so. About 32% of Medicare costs go to treating diabetes, kidney failure in the U.S. is most often a complication of late-stage diabetes, and it also is the #1 cause of new blindness, foot/leg amputations, and is strongly linked to heart failure as well. Despite these potentially serious outcomes, diabetics only receive proper treatment 8% of the time per expert-determined care protocols, the rate of U.S. obesity has nearly tripled since 1980, and it is now 2.5X that of the OECD average. Halvorson also cites a source indicating that with appropriate and consistent care supported by patient behavioral change, the number of diabetic-related kidney failures could be cut by at least one-third. Another indication of the potential for improvement - Pima Indians over age 65 on the U.S.side of the border with Mexico have over 5X the rate of diabetes of their relatives on the Mexican side with the same genetic makeup. The difference is attributed to greater activity, and better diet by the Mexican Pimas.
The latter portion of "Health Care Reform Now" is taken up with several proposals for how to restructure health care to improve preventive care. The first problem is that health care is built around 9,000 billing codes associated with treatments and procedures, with none for 'cure' or 'prevention.' A second is that most physicians are paid accordingly - for providing services, not prevention. A third is that various physicians involved in treating chronic patients with comorbidities have no incentive or easy mechanism to share information, and most don't - duplicating tests, providing conflicting care and drugs that interact. Halvorson is convinced that electronic medical records (EMRs) are a must - ideally, providing not just treatment records but test, scan, etc. results, and millions of data records for analysis as well. (Taiwan, spending slightly more than one-third that of the U.S., uses a small credit-card sized device that patients carry around with them.) Side benefits of detailed EMRs are that computers could then also feed physicians appropriate findings from recent (30,000/year) published clinical trials to assist care while they are with patients.
Unfortunately, probably due to recency, Halvorson does not provide information on Kaiser's new EMR system. Business Week 4/7/09 tells readers that less than 2% of acute-care hospitals have a comprehensive EMR in place (Kaiser and the V.A. are major examples), with a similarly low proportion of physician offices as well. ((Less than 4% of U.S. physicians work in practices with at least 50 physicians, making strategic analysis or major investment, about $75,000/physician for a small office, in EMRs impractical.) Kaiser's efforts began 40 years ago, and include a $400 million joint project with IBM that was scrapped in 2003. Kaiser has invested over $4 billion to date. Within the first 18 months of the recent installation of EMRs within Kaiser, physician office and E.R. visits dropped by 7%. Patients can also make appointments on-line and correspond with physicians using e-mail. Patients can also take their records with them on a small flash-drive. (Information included on the drive includes medical problem lists, medications, allergies, immunization records, lab results from the past year, most recent EKGs and chest scans - both images and readings.)
Halvorson also says little about the Archimedes computer simulation program (aka SimHealth) it uses to analyze treatments for and the status of diabetic patients and others. Funded by Kaiser, though developed independently by Dr. David Eddy beginning in the 1990s (also a PhD mathematician), the system required only 30 minutes to simulate the results of a thirty-year trial regimen that in practice reduced heart attacks and strokes by 60-80%, while saving $350/patient/year. Other diseases covered by Archimedes include coronary artery disease, hypertension, colon cancer, congestive heart failure, stroke, obesity, asthma, breast cancer, lung cancer, dyslipidemia (high cholesterol and triglycerides), and metabolic syndrome (risk factors that occur together and increase the risk of diabetes, stroke, coronary heart disease).
Bottom-Line: Thoughtful readers of "Health Care Reform Now" and related materials will find it difficult NOT to get excited over the enormous potential for improving patient outcomes, without spending more money. His thinking is well-organized and focused - making a big dollar and health improvement impact through focused improved prevention and early alleviation efforts that include patient responsibility.