Friday, July 28, 2006

Stockholm Challenge Award- Operation Village Health

Stockholm Challenge Award - Operation Village Health : "Through leveraging of an expanding Internet infrastructure, this cross-cultural program provides email-based physician support to Cambodian health workers in two remote sites, allowing Harvard-affiliated specialists to share their knowledge and collaborate with underserved communities on the other side of the globe. "
This is how and why the web can be so powerful in improving healthcare delivery in India !

Thursday, July 27, 2006

The BetaBase

The BetaBase: "This site collects beta scores from pregnancies and makes the information available as a public service."
Beta HCG ( beta) is a key pregnancy hormone ; and its levels are serially mesaured to confirm the pregnancy is progressing well.
I am impressed with this site ! This is a great example of how infertile women are using technology to empower themselves with information !

You are not a helpless pawn !

Many infertile patients have low self-esteem because they cannot have a baby. They are socially stigmatised and isolated and often have an inferiority complex. This is why they are emotionally very vulnerable, and many do not seem to be able to make the right medical decisions for themselves. Many doctors exploit this helplessness, and misguide patients.
It's important that you stop thinking of yourself as a pawn. You are the Queen of your life, and are very capable of charting your own life's course. The best way of regaining control is by arming yourself with the information you need; and exploring all the options, so that you have peace of mind you did your best !

Surrogacy in India - the real picture

Surrogacy is a hot topic in the Indian media right now - and newspapers, magazines and TVs are full of talk-shows and reports as to how India is poised to become the next surrogacy outsourcing capital of the world. Not only does India have a number of successful IVF clinics; there are a lot of women who are willing to be surrogates , so that surrogacy costs a fraction of what it would in the West. While a surrogacy treatment cycle would be about US $ 50000 in the US, it is about one half to one fifth the price in India - a bargain by any standards ! And in this day and age of globalisation and market-driven economies, there is considerable demand for this service !

The amount of media attention which surrogacy attracts is huge, but it is completely disproportionate to its utility in real life. Surrogacy stories are full of human interest, which is why they are so popular, but what I find very disappointing is the fact that the media does not provide the right perspective while covering this topic. I feel the failing is because of innumeracy - of not realising how uncommonly this particular treatment is needed in the first place !

We need to remember that surrogacy is useful for only a very small group of women. For example, a busy IVF clinic which performs about 300 IVF cycles every year will see only about 3 patients who medically need surrogacy. Medically, the indications for surrogacy are few and far between, and most infertile patients can be helped with much simpler and easier treatment options. The commonest reason is a woman who has no uterus. The uterus may be absent from birth (Mullerian agenesis, MRKH syndrome); or may have been removed surgically (hysterectomy for life-saving reasons, such as excessive bleeding during a caesarean). Other women who may wish to explore surrogacy include those whose uterus is irreparably damaged because of uterine tuberculosis or Ashermann's s syndrome.

However, in real-life, when we we analyse the medical histories of women who opt for surrogacy, we find that the vast majority of the time it is usually infertile couples who either :

1. have had multiple miscarriages; or
2. who have failed repeated IVF attempts for unexplained reasons.

While these can be reasonable indications for surrogacy, the fact is that it is often done because the patient is fed up and frustrated with repeated IVF treatment failures or miscarriages; and is looking for alternative options. In a market economy, supply rises to meet demand, and there are many clinics who are happy to oblige these desperate couples - for the right price, of course !

However, the fact is that many of these couples do not need surrogacy at all ! They have a perfectly normal uterus; and would be better of opting for donor eggs or donor embryos, rather than surrogacy. Unfortunately, they fail to realise this, partly because these options are not adequately highlighted in the media; and because some doctors prefer "pushing" the more lucrative surrogacy treatment option ( as this means more bucks for them !)

Unfortunately, it's hard for patients to think straight when they are desperate, which often means they opt for surrogacy rather than egg donation - a choice which is much more complex , because of all the legal, emotional and social issues involved - and also needlessly expensive .

Let's look at the real-life problems involved in surrogacy. Firstly, finding a surrogate can be extremely difficult ! If you have a friend or relative who agrees to be your surrogate, then your best option is altruistic surrogacy. Not only is this much less expensive, the risk of this going sour is much less. Commercial surrogacy is much trickier, because you then need to take extensive steps to protect your interests, and ensure that the surrogate will hand over the child to you after birth. Finding a reliable clinic, an honest surrogate and a good lawyer can be hard work - it is also very expensive !

If the surrogate is anonymous and confidential, then you need to trust the clinic 100% - and this can be a big mistake . When there is so much money at stake, many doctors are tempted to cut corners , partly because it's so easy to do so - and it's so hard to check their actions ! It's easy to fool vulnerable patients . For example, clinics or agencies may take an advance fee and promise to find a suitable surrogate - who then backs out at the last minute because of a faked "personal or medical emergency". Some clinics take the money ; claim to perform the treatment ; and inform the patient that the surrogate is pregnant. They then add to the lie by saying that the surrogate unfortunately miscarried, with the result that all the money has been poured down the drain ( or into the clinic's coffers). Since there is no way of verifying any of this, the patient is completely at the doctor's mercy - and woe betide the patient who falls into the hands of an unscrupulous doctor ! Since many surrogates who act as surrogates for purely financial considerations are poor and malnourished, the babies they give birth too are often low-birth weight as well.

Many patients also have unrealistic expectations of surrogacy treatment. They think that it is a 100% sure-shot affair , while in reality the pregnancy rate is still only 50% per cycle.

Of course, the major problems with surrogacy arise after birth. However, desperate patients refuse to think so far ahead, and plan to "cross the bridge" when they get to it - without thinking clearly through the real-life hurdles they will encounter at this time.

Let's look at this closely and assume the treatment has been successful; the pregnancy has been uneventful; and the child is now born in an Indian clinic. Whose name is going to appear on the birth certificate ? How will the infertile couple claim parenthood ? How will they take the child back with them to their home country after the birth ? And what happens if the surrogate ( or her husband) changes her mind and refuses to hand over the baby ? Or blackmails you for custody ?

While many clinics talk about the " Indian Council of Medical Research ( ICMR ) guidelines for surrogacy"; and about how they make the surrogate sign an agreement to protect the infertile couple, what they do not tell the patient is that the guidelines are just a piece of paper which have no legal validity whatsoever !

The Indian legal system today only recognises the birth mother. There is no concept of DNA testing for establishing paternity as far as the Indian legal system goes, which means that the name on the child's birth certificate has to be that of the birth mother and her husband ! Many couples naively plan to adopt the child and then take it back with them. What they fail to realise is that adoption in India is a long and convoluted process which can only be performed by a recognized adoption agency - and you cannot select a particular child for adoption !

Hopefully, the Indian parliament will soon pass a law which regulates IVF and related assisted reproductive technologies which may provide some legal protection for infertile couples when they go in for surrogacy treatment. However, no matter what laws are passed and what contracts are signed, remember that real-life can be very messy; and if the surrogate chooses to dispute the contract after birth, then the infertile couple is likely to find themselves embroiled in a legal quagmire - and knowing the way the Indian judiciary work, the child will be about 10 years old before the problem is solved ! King Solomon's wisdom is hard to come by in this day and age !

In my opinion, the real danger with surrogacy in India today is that it is being overused and misused today. Without a safe legal framework to operate in, patients are being misled and misguided.

The biggest tragedy is that it is being used for women who do not need it in the first place - women who can be successfully treated with much simpler ( and less expensive) treatment options ! These are women who have had repeated IVF failures; or recurrent miscarriages. They feel that their uterus is defective, because it is "rejecting" the fetus, which is why they opt to go in for surrogacy. They feel that if they use a healthy woman's uterus to grow the embryo, their problems will be solved.

Actually, this is a misconception. The commonest reason for recurrent unexplained miscarriages or repeated IVF failures is NOT a defective uterus - it is usually poor quality eggs. Extensive research has shown that embryos fail to implant ( and miscarriages occur ) because of a genetic problem in the embryos . It has been documented that these problems become commoner as the eggs age, because older eggs have a higher chance of being genetically abnormal. The
solution to this problem is not surrogacy, because replacing a normal uterus with another woman's normal uterus does not correct the underlying problem !

Not only is egg donation much easier and less expensive; it also bypasses all the social and legal problems associated with surrogacy. Once the donor donates her eggs, she relinquishes all rights to them; and since it's the infertile woman who gives birth to the baby, it's her name which appears on the birth certificate, thus preventing any problems in the future. It's also much more satisfying for women, because she is the one who experiences the pregnancy; can bond prenatally to her baby; and gives birth to her baby !

However, unless patients become better informed, many of them will continue to opt for surrogacy, when in fact the right answer to their problem would be using donor eggs !

Institute for Healthcare Improvement: Going Lean in Health Care

Institute for Healthcare Improvement: Going Lean in Health Care: "Lean management principles have been used effectively in manufacturing companies for decades, particularly in Japan. IHI believes that lean principles can be — indeed, already are being — successfully applied to the delivery of health care.Lean thinking begins with driving out waste so that all work adds value and serves the customer's needs. Identifying value-added and non-value-added steps in every process is the beginning of the journey toward lean operations. Although health care differs in many ways from manufacturing, there are also surprising similarities: Whether building a car or providing health care for a patient, workers must rely on multiple, complex processes to accomplish their tasks and provide value to the customer or patient. Waste — of money, time, supplies, or good will — decreases value."
Applied commonsense !

Institute for Healthcare Improvement: Shortening Waiting Times: Six Principles for Improved Access

Institute for Healthcare Improvement: Shortening Waiting Times: Six Principles for Improved Access: " Thinking about delivering health care like UPS delivers boxes might make some people uneasy. But Mark Murray, MD, MPA, says health care providers can learn a lot from the successful companies that track packages, assemble cars, and serve food quickly. Adding a bit of understanding of economic supply and demand theory can’t hurt either. The work that corporations have put into streamlining processes should be harnessed by health care to reduce the bane of many health systems’ existences: waiting times, everything from the extra hour in a doctor’s office to an extra six months waiting for a procedure that is in limited supply. Murray points to six principles for improving access: understanding the balance between supply and demand, recalibrating the system, applying queuing theory, creating contingency plans, influencing the demand, and managing the constraints."
Clever article, which every clinic manager and doctor should read.

Wednesday, July 26, 2006

Lessons from developing nations on improving health care -

Lessons from developing nations on improving health care : " Notwithstanding the barriers, nothing in my two decades of work on healthcare improvement has inspired and amazed me quite so much as these early days of systemic improvement in the developing world. Time after time, in setting after setting, I find exactly the combination of intensity, cleverness, hard work, and optimism that we all need for this tough job of change to go well. Here are a few of the lessons I am starting to learn from the people whose form of wealth is so different from mine.

Simplify everything—The core of improvement need not be complex. Set aims, track results, find great ideas, and change something every day to find the better ways. Involve everyone you can, and do not assume that the rules of today must be the rules of tomorrow. I find elegance in the simplicity of approach that people who have little to waste have a knack for. Complexity is waste.

Take teams seriously—Improvement is about cooperation, and no one should trump the team. Uncooperativeness is waste.

Be pragmatic about measurement—Information technology is nice but not the point at all. Use the least measuring that helps, not the most that you can think of. Too much counting is waste.

Strip the support system for improvement to a minimum—Flatten the organisation. Consultants should make it their job to become unnecessary as fast as they can. Dependency is a form of waste.

Manage the political interface wisely—It is wiser to use it than to change it. Naivety is waste.

Help patients become advocates for change—Their stake is the highest, and their voices count the most. Keeping patients silent is waste.

Go quickly. Start now—Delay is waste.

Make spread a system—Find the latent structures, the channels along which change can flow, and use them from the start. Go, as Tver, from 5 to 50 to all, then to the neighbours, and then to their neighbours. Isolation is waste.

And finally, don't complain—I have visited settings in Rwanda, Mozambique, Peru, and Palestine where every person I met had 100 times more reasons to complain than I do. And none did. Complaint is waste."

This is an inspiring paper - please read it !

Institute for Healthcare Improvement: Innovations in Planned Care

Institute for Healthcare Improvement: Innovations in Planned Care: "The Institute for Healthcare Improvement (IHI), along with partners across the country, is championing a comprehensive effort to improve care in clinics and office practices by encouraging organizations to create a reliable and lean system of planned care for all patients. Building on significant knowledge and experience, IHI is developing and testing a new design for the delivery of primary care for all patients, which reaches high levels of effectiveness, efficiency, and patient-centeredness. The design is based on the idea that in order to ensure reliable care delivery, every patient should have a plan for his or her care. This calls for changes in four key elements of the service delivery system:
* The care team
* Patient activation
* Clinical information system
* Leadership"

Partnering with Patients and Family

Partnering with Patients and Family “Fixing” the problems that plague health care in the United States, most experts now agree, demands system-wide solutions. The health care system must be redesigned, and that enormous task must be undertaken collaboratively by all key stakeholders—health care professionals, administrators, planners and policy makers, and payers, as well as by patients and their families. Such partnerships must begin with a shared understanding of the problems, and a shared commitment to work together to solve them. Only then can an action plan for redesigning the health care system be developed and implemented. This paper provides background information to facilitate the development of an action plan to ensure that sustained, meaningful partnerships with patients and families are in place in hospitals and health systems; in community clinics and other ambulatory settings; in schools educating the next generation of health care professionals; in national associations; in federal, state, and community agencies; in foundations and advocacy organizations; and among payers.

Welcome to My Healthy Living!

Welcome to My Healthy Living! Simple interactive website to help you lead a healthier life.

The Chronic Care Model: The Patient Level

The Chronic Care Model: The Patient Level: "'Productive interactions' between providers and patients need not be restricted to face-to-face visits, nor necessarily to one-on-one encounters. Self-management support using group visits and telephone follow-up are evidence-based examples of how a system might find new methods of making communication between patients and providers both more efficient and more useful to the patient."
I personally prefer email as everything is in writing and is documented. It also saves me time - and my patients prefer it too, because it allows them to get better organised and ask intelligent questions.

Patient-Centered Collaborative Healthcare

Patient-Centered Collaborative Healthcare "Patient-centered, collaborative care” is healthcare jargon. But underlying the jargon is the principle that a patient who receives such care strongly agrees that “I receive exactly the healthcare I want and need exactly when and how I want and need it.”Currently only about 1 in 4 Americans who have adequate financial resources can make this claim. Think of a pyramid. At the apex is the highest level of “patient-centered, collaborative care.”At the base are measures about “what’s the matter” (from the clinical perspective) and “what matters” (from the patient perspective). As patients and clinicians act collaboratively on these measures, they climb closer to the apex of the pyramid."
Happy patients also make happy doctors !

Transforming Medical Care: Case Study of an Exemplary, Small Medical Group -

Transforming Medical Care: Case Study of an Exemplary, Small Medical Group " Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality. These were the principal attributes they founds.
1. Strong visionary leadership
2. Patient centered
3. Strong support for physician-patient relationship
4. Strong group, team, and standardization orientation
5. Extensive involvement and engagement of all physicians and staff
6. Highly organized change management
7. Focused
8. Strong change and improvement orientation
9. Broad physician sense of ownership and responsibility
10. Market driven
11. Data-based, transparent, and accountable
12. Pride and joy"
Excellent model - and it's possible to replicate it. However, I don't think it's one which it's possible to scale up. I believe medical care is a very personal service, which is best provided in the setting of a small medical practise.

Promoting Informed Choice: Transforming Health Care To Dispense Knowledge for Decision Making -

Promoting Informed Choice: Transforming Health Care To Dispense Knowledge for Decision Making : "Perhaps nothing is changing more dramatically in health care than the increased volume and influence of information. Patients face a growing need for assistance in knowledge management and for access to professionals who are qualified for this task. As the volume of information and the complexity of choices increase, this need will only grow more urgent.The health care system as a whole faces its own difficulties in implementing informed decision making because it is not well designed for this task. Health care has been slow to respond to society's appetite for communication and has not reorganized itself to provide high-quality information about options and outcomes. The system is not equipped to inform patients in a manner that is timely, easily understood, and jargon-free, nor does it encourage people to consider consequences, to ask questions, to clarify values, and to express preferences."
What a great business opportunity for whoever can provide a clever solution to this problem !

Perils, Pitfalls, and Possibilities in Talking About Medical Risk,

Perils, Pitfalls, and Possibilities in Talking About Medical Risk : " Virtually every course of medical action is associated with some adverse risk to the patient. Discussing these risks with patients is a fundamental duty of physicians both to fulfill a role as trusted adviser and to promote the ethical principle of autonomy. Discussing medical risk is a difficult task to accomplish appropriately."
This article is a great guide for doctors, to help them discuss the risks of medical treatment with their patients.
He discusses the 5 key dimensions of risk.
1. What Are the Unwanted Outcomes ( risks) ?
2. How Permanent Is the Unwanted Outcome? ( risk) ?
3. When Will the Unwanted Outcome Occur?
4. How Likely Is the Unwanted Outcome?
5. How Much Does the Unwanted Outcome Matter to the Patient?

Tuesday, July 25, 2006

Of Mice and Ecomomics and medical decision making

Of Mice and Ecomomics and medical decision making: "'No proposition in economics is more firmly established in economics than the supreme irrelevance of sunk costs.'"
This is especially true for infertile couples who are paralysed into inactivity when past treatments have failed. Because they have invested so much time, money and energy in their current doctor, they are very reluctant to consider switching. This can be a major mistake - and since getting a second opinion from an expert has become so easy, I just cannot understand why more patients don't do this routinely. It's important to start with a clean slate - and move on !

The McKinsey Way for making medical decisions

The McKinsey Way for making medical decisions : "The hallmark of problem-solving at McKinsey is that every analysis is decomposed such that the issues are:
* Mutually Exclusive (each idea is distinct and separate; overlap represents muddled thinking) and
* Collectively Exhaustive (you've covered all the possibilities; you've thought of everything."
McKinsey is one of the world's leading consultant firms, and you can apply their MECE technique when you need to make a decision about a medical problem.
For example, for patients who are infertile, the MECE list would include:
1. child-free living
2. adoption
3. medical treatment

Of course, you would then need to learn more about each of these options by researching them, till you find the one that's right for you !

Monday, July 24, 2006

Home-centered health care

Home-centered health care: "What is needed is a completely new paradigm of health, one that places a much stronger emphasis on prevention and wellness over intervention. We can refer to this new paradigm as 'home-centered health care' – built on a system in which health management begins at home, connects to physicians and care teams, and circles back to home."
This makes so much sense ! Actually, hospitals are a relatively new invention - just about 100 years old. The home is the best place to get healthcare !

Sunday, July 23, 2006

Checking on your doctor

I believe in patient empowerment, which is why I offer a free second opinion service on our website at www.drmalpani.com. I learn a lot from the questions patients ask me !

Firstly, it allows me me to peek into the mind of an infertile couple ( because they share their worries and concerns with me, and email allows them to unburden
themselves ) . This allows me to be more empathetic and considerate with my real-life patients ( who usually have the same doubts but maybe hesitant about voicing them) !

Secondly, it allows me to track what services other doctors offer their patients. For example , I got an email from a lawyer today, who was advised to have a " laparoscopy, endoscopy and hysteroscopy " performed by a high-profile leading doctor in New Delhi; who had told her it would cost 2 Lakh. " Not only was this doctor taking her patient for a ride by advising surgery which the patient did not need - she was also charging her at least 4 times the standard rate , just because she was well off ! This was a valuable learning lesson for me, because I now know ( from first-hand experience in one sense), how this doctor treats her patients. I am never going to refer a patient to her again !

Thirdly, it makes me feel good about the service I offer. Not only have I saved this patient a large sum of money; I have also saved her unnecessary surgery - and this did not cost either my patient or me any money !

I feel health insurance companies can use the power of the internet to offer such a service to their clients. Not only will this prevent unnecessary surgery; it will help to keep doctors honest; and also help to reduce the claim payouts of health insurance plans and save them money ! Maybe retired doctors ( who have no axe to grind and have a lot of experience) can offer this service - all they would need is a computer to do so !

Saturday, July 22, 2006

Gesundheit - a new model for healthcare

Gesundheit - a new model for healthcare: "To bring fun, friendship, and the joy of service back into health care. The Gesundheit! Institute is dedicated to upholding a radical socio-political vision replacing greed and competition with generosity, compassion and interdependence.
As a stimulant to broaden the health care delivery dialogue, Gesundheit! Institute's mission is to build a hospital/healing community and provide care based on these priciples:
* All the healing arts are welcome
* All patients are treated as friends
* There is no charge for health services
* No third party reimbursement is accepted
* The health care experience is infused with fun
* No malpractice insurance is carried by the Institute
* The health of the staff is valued equally with the health of the patients
* The health of an individual is nested in the health of family, community, society and the natural environment"
Wow ! This is a big, original audacious dream - hats off to them !

Friday, July 21, 2006

WellPoint to package records online

WellPoint to package records online : "One of the key features of 360 Health is the 'personal health record,' which can be accessed by the member over the Internet. The record will include claims, lab results and pharmacy information tracked by WellPoint, as well as some information from the member, such as blood-pressure readings if that member has been instructed by a doctor to track their blood pressure.
The goal, WellPoint said, is to arm people with information about their own health histories. For instance, a man seeing a cardiologist for the first time could share his personal record with that doctor so the physician would have a more complete picture of that patient's medications and medical history.
In another example, a pregnant woman could use 360 Health to research information on proper nutrition during pregnancy. Or that mom-to-be could look up names of doctors and hospitals that specialize in high-risk pregnancies or register to have a dedicated nurse to have phone consultations with throughout the pregnancy.
WellPoint said much of 360 Health is packaging together information and services already available to its members. But some experts said the personalized health record stood out to them as an innovative approach to better using health information.
'I think it is an important step to make an effort to use their data to put it at the fingertips of patients and doctors where they can access it day or night,' said Dr. Brad Doebbeling, a professor of internal medicine at Indiana University and director of IU's Center for Health Services and Outcomes Research at the Regenstrief Institute.
The concept for 360 Health was developed by New York-based insurer WellChoice, which WellPoint acquired last year. WellPoint said nearly $100 million has gone into developing the program."
This is a win-win situation and I am sure lots of other health plans will provide the same services to their customers soon.

Hospitals Implement Technology To Attract Patients

Hospitals Implement Technology To Attract Patients : " Some hospitals in California are implementing technology aimed at improving comfort in an effort to attract more patients, the San Fernando Valley Business Journal reports. For example, Henry Mayo Newhall Memorial Hospital in Valencia, three years ago implemented the Pyxis PatientStation, a touch-screen bedside computer system that provides patients with access to medical charts and discharge instructions as well as the Internet, e-mail and on-demand movies, radio and video games. Patients also can use the system's medical encyclopedia feature to research a specific condition. Physicians can use the system to view lab results, charts and X-rays. Physicians also can use the system to track and verify prescriptions by scanning a patient's wristband, the prescription and the nurse's thumbprint. "

Thursday, July 20, 2006

Where There is No Doctor - now available online !

Where There is No Doctor - now available online ! : "We are proud to announce that our classic manual, Where There Is No Doctor, is now available online!. Click here to access the complete, newly updated 2006 edition. This manual provides practical, easily understood information on how to diagnose, treat, and prevent common diseases. Special attention is focused on nutrition, infection and disease prevention, as well as the use of diagnostic techniques as primary ways to prevent and treat health problems. With over 90 translations and adaptations of the book available worldwide, and millions of copies in print, the book is an essential health resource for individuals and communities around the world." This book is a health classic - even though most doctors are sadly unaware it exists ! It's designed to empower patients to manage their own healthcare - and they place great emphasis on the "real-life" political problems people enconter when trying to improve their own healthcare, as they clash with vested interests, bureaucrats and politicians.

Basic Nursing Skills - Where Women Have No Doctor

Basic Nursing Skills - Where Women Have No Doctor " Certain skills that can help a person give the best care to someone who is ill. These skills include preventing infection, giving an exam and getting information about a person’s body, giving life-saving fluids, and giving injections. This section gives more complete information about these skills. You may think of these as ‘doctor’s’ or ‘nurse’s’ skills, but they are all skills that anyone can learn with time and practice. Some skills, like giving an exam or an injection, are best learned by having a skilled person show you how. Once learned, all of these skills can make a careful person better able to help other safely."
This will help to demystify a lot of what doctors and nurses do. Valuable skills to add to your armamentarium - all presented in a very simplified format - a bit like the Dummy's Guide to Home Nursing.

Tuesday, July 18, 2006

Filling the information gap in modern health care with the PHR

Filling in the information gap in modern health care with the PHR Information is the currency of modern health care. Knowing an individual’s family
background, history of diagnoses and procedures, test results and medications, and diet and
exercise habits is essential to managing health, assessing problems, and preventing medical
error. Today medical information is scattered among the many health care providers people
see throughout their lives. It is stored in individual memories, on scraps of paper and in
spreadsheets on personal computers. Some doctors and hospitals keep computerized
medical records, but most personal health information is stored in thick paper files that line
office walls. There is no coordinated system, no standardized, private and secure way to
integrate an individual’s health information in one place. A visit to a new doctor means new
forms to complete, new tests to run and new conversations reviewing your personal medical
history -- conversations that depend almost entirely on memory alone. People need effective tools to help them manage their health and their healthcare.

NoMoreClipboard.com—How it works

NoMoreClipboard.com—How it works: "It’s frustrating trying to remember all of the information needed for “clipboard forms” at the doctor’s office. But with NoMoreClipboard.com, you can relax. NoMoreClipboard.com is an online service you can use anytime, anywhere. It’s a secure Web site where you can consolidate all of your personal health information and then send it to your healthcare provider before you visit the doctor’s office. Say goodbye to the days of balancing the clipboard on your lap and struggling to remember details about injuries, medications, hereditary medical conditions, and more. You can make sure your doctor has all of that information ahead of time by sending it to him or her using NoMoreClipboard.com. Plus, you’ll find NoMoreClipboard.com can help you keep all of your family’s medical information better organized and quickly accessible in the case of an emergency."
Here's a clever solution to a common problem !

Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs

Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs : "We considered two kinds of interventions intended to keep people healthy (or healthier): disease prevention measures and chronic disease management. These interventions are key to understanding HIT’s potential. First, they would exploit important features and capabilities of EMR systems: communication, coordination, measurement, and decision support. Second, they are potentially high-leverage areas for improving health care. Physicians deliver recommended care only about half of the time, and care for patients with chronic illnesses absorbs more than 75 percent of the nation’s health care dollars. Third, evidence from regional health information network (RHIN) demonstrations suggests that these are key applications of HIT."
A one-word summary of the article would be - Yes !

Health insurance in India

Health insurance in India: "But why are insurers jostling for space in the health segment? The potential premium in the Indian health insurance sector is estimated to be Rs 1,000 billion. 'Health insurance is hot and happening,' says Elizabeth M. Keim, former president of American Society for Quality, who is working with the Federation of Indian Chambers of Commerce and Industry in insurance. Public sector general insurers—New India Assurance, National Insurance Company, Oriental Insurance Company and United India Insurance Company—command about 80 per cent of the health insurance market. But they do not offer cashless settlement of hospital bills or tie-ups with health care providers. About 76 per cent of the population pays for medical expenses from its own pocket, often wiping out family savings at one stroke. Only 20 per cent of the population is covered by health insurance.
In 2004-2005, health insurance premium collections amounted to Rs 2,000 crore which, in comparison with the total health care spend at around Rs 60,000 crore, pales into insignificance. Health cover premiums, however, account for less than 1 per cent of total premiums for life insurers and 10 per cent for general insurers of total premiums but it is an idea whose time seems to have come. Per capita health care spend in India is just $32 as against $5,365 in the US and $3,036 in the UK in 2004."
Someone is going to be making a lot of money by tapping this segment - let's hope they provide good value for money !

Bad bedside manners

Bad bedside manners : "We invest our docs with so much power that it feels awkward or downright impossible to tell them when we think they've treated us badly or provided inadequate care. And, because our health or our very lives may depend on them, we don't want to anger them. But doctors and sometimes their superiors need to know. Many problems are merely a matter of communication and can be resolved directly with the doctor or a patient advocate. But if the issue is serious, higher officials need to know."
How will doctors ever improve if you don't given them feedback ?

Baby or Bust | Mission

Baby or Bust | Mission: "Our goal for this site is two-fold:
1. To earn $20,000 so that we can become parents. And if we earn more than that, and all of our medical expenses have been covered, then we'll donate the additional money to another couple.
2. We hope it will serve as a positive, and personal window, into the IVF process- this includes keeping you updated on our experiences, a running total of money earned, a detailed breakdown of every penny spent and resources we've found useful in educating ourselves- giving another couple in our position a first-hand account of the process and better prepare them for their journey."
I am glad to see this website from this clever infertile couple who are taking matters into their own hands !

Sunday, July 16, 2006

How many embryos should I transfer ?

As an IVF specialist, the commonest question patients ask me is - How many embryos should I transfer ? While IVF technology today is very good at making embryos in the IVF lab, we still cannot control the process of embryo implantation. This means that most of the embryos we transfer do not become babies - which is why the success rate of most IVF treatment cycles is still about 40% per cycle.
I tell patients that if the technology was perfect, we would transfer 2 embryos for every patient ( most infertile couples are very happy to have twins so they can complete their family at one stroke); or just 1 for the minority who wanted to have only one baby. However, because the technology is still not perfect, deciding how many embryos to transfer is always a heart-wrenching decision.
As is usual with most of life's decisions, there is a price you pay for every decision you make - and every couple needs to weigh the risks and benefits of this tough choice. ( In countries which allow doctors to transfer only 2 embryos by law, the decision is much simpler, because there is no choice available !)
We know that the chances of pregnancy are proportional to the number of embryos we transfer - the more the number of embryos transferred, the greater the chances. However, just as the chances of success rise, so does the risk of multiple pregnancy. High order multiple births can be a major complication, because of the risks of prematurity, so we would like to select the optimal number of embryos to transfer , which would ensure a pregnancy, without risking a high-order multiple birth.
Since the chances of implantation depend upon a number of biological variables which are hard to quanitfy, we use the following guidelines to help our patients make this difficult decision.
The variables we need to consider include:
1. Age of the woman and ovarian reserve
2. Quality of the embryos ( Grade)
3. Day of transfer ( Day 2, 3 or 5)
4. Number of failed IVF attempts
5. Fertility history
6. Endometrial receptivity
7. Financial and real-life constraints
8. Patient preference
9. Use of donor eggs/ donor embryos
10. Quality of the clinic ( overall success rate)

Such a large list of variables ( many of which are "soft" and subjective")explains why this is such a difficult decision.

This is how we approach this problem in our clinic.

For young patients ( less than 30) , who are doing their first IVF cycle, we suggest they transfer 2 embryos if these are Grade A embryos on Day 3. If the patient is between 30-38, we add one more, so we transfer 3. For patients more than 38, we suggest 4, as the risk of a multiple pregnancy decreases as a woman gets older. For women more than 40, we are happy to transfer as many embryos as they get.( Of course, if they are using donor eggs or donor embryos , then we need to re-do the calculations). If the embryo quality is poor ( Grade C or less) , we add one more. If the endometrium is poor, we add one more embryo ( as the chances of implantation go down if the uterine lining is poor). For patients who have failed IVF cycles elsewhere, we transfer one more embryo. If the patient opts for a Day 5 ( blastocyst ) transfer, we reduce the number by one. This algorithm gives us a rough rule of thumb as to how may embryos to transfer, which tries to factor in all the key variable which can affect embryo implantation. What I like about it is that it allows us to choose a number which is individually tailored for each patient,
However, we always let the patient make the final decision. For example, if a patient says that it's her last IVF cycle, because of financial constraints, and she wants to transfer more embryos, we will do this.
In the final analysis, we feel that the patient should make their own decision, since they suffer the consequences of whatever decision they make. I suggest to patients that they take what I call the "path of least regret". It's often a question of choosing between the lesser of two evils : not getting pregnant; or having a high order multiple. Many patients prefer transferring more embryos, and are willing to consider the option of selective fetal reduction in case they have a high order multiple. In this sense, a high order pregnancy is a "manageable complication" . Others would start a fresh cycle rather than countenance a reduction. Since this is such a personal decision, it's best if couples make it for themselves, so that they have peace of mind they did their best.
Most of the time, this system works well and we have a high pregnancy rate and many satisfied patients. However, whenever a patient does not get pregnant, we always wonder - Maybe if I had transferred one more embryo, she might have conceived ? And conversely, when she has a triplet pregnancy, we kick ourselves for transferring too many embryos ! Being an IVF specialist can be stressful !

Why can't I get pregnant even though all my tests are normal ?

I just received this email from a very upset patient. " All my tests are normal, and yet I can't get pregnant. My doctor says my infertility is "unexplained" ! What does this mean ? The very fact that I cannot conceive means there must be something wrong somewhere ! "

This was my reply.
" Yes, you are right. Unexplained infertility is simply a confession of our ignorance, and means that our technology is not good enough to be able to identify the problem. For example, a semen analysis can show that your sperm count is normal. However, it tells us nothing about the functional competence of the sperm - whether they are able to fertilise the egg or not ! In any case, I feel the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! Fortunately, our technology for solving problems ( by bypassing them in the IVF lab !) is much better than our technology for identifying them - and perhaps this is just as well ! This means that rather than waste time trying to pinpoint the problem, we can just bypass it altogether ! "

Advocacy Letters

Advocacy Letters:" The majority of insurance companies don't provide health insurance for fertility treatments. Here are some sample letters to help you and your healthcare provider advocate for coverage."
This is a clever idea, and will help infertile couples to fight for their rights !

Lessons in Life that Infertility Teaches

Lessons in Life that Infertility Teaches : "A very useful book I read recently was the “ Infertility Survival Handbook - Everything you never thought you’d need to know “ , by Elizabeth Falker , a lawyer who has “been there, done that”. She has three extremely clever rules which I think are well worth repeating . Rule One is the Clean Slate Rule which states, Start with a clean slate , whenever possible . Infertility treatment is a process - and it can be a very long process . It’s a war, not just a battle, which means every new attempt is a fresh attempt, and a new chance at success. The good news is that failed attempts do not harm you – except for the damage they cause to your psyche and your wallet ! They can actually make you even stronger and better prepared. This means that every time you start a new cycle, it’s best to wipe the slate clean and pretend you’re starting from scratch. As Scarlett O’Hara said in Gone With the Wind, “Tomorrow is another day “ ! "

Friday, July 14, 2006

India's first standalone health insurance company

India's first standalone health insurance company: "Why a standalone health insurance company when so many others are debating the viability of Rs 100 crore capital investment? I feel there is tremendous potential in the health insurance business. Currently, the health business is pegged at about Rs 1,700 crore a year, whereas I see the potential at about Rs 15,000 crore and, this is set to grow phenomenally once the tariff regime goes off from 1 January 2007. The regulator has been very supportive of our venture and, as you can see, our starting capital is Rs 105 crore and we have a group of committed investors including Oman Insurance Company that has a 10 per cent stake, besides few other businessmen from the Gulf. Moreover, one must realise that all other forms of non-life insurance business is linked to the economy, whereas health is a category by itself. I feel a specialist health insurer is the need of the hour. And we have the first mover advantage."
The Indian health insurance market is hotting up ! Health insurance plans can serve as important catalysts in improving healthcare services for the population.

Take medical history to the doctor's office

Take medical history to the doctor's office: "How many times have you shown up for a doctor's appointment and been handed a stack of multicolored double-sided forms to fill out?
You scan the information and realize that you don't remember when you had your tonsils out or the name of the medicine that caused you to break out in hives five years ago. You soldier on, filling in the blanks as best you can, hoping that your memory lapses won't come back to haunt you. Having complete and accurate records for everyone in your family isn't just a nice thing to have, it's essential."
This is why a web-based PHR ( personal health record) makes so much sense ! ( And if your family members have their own PHRs, then it's that much easier to complete your own family medical history reliably.)

JAMA says it was misled by researchers

JAMA says it was misled by researchers : "For the second time in two months, the Journal of the American Medical Association says it was misled by researchers who failed to reveal financial ties to drug companies. The studies' validity — and the prestigious journal's reputation — are at stake, and JAMA is tightening its policies for researchers as a result.
'This is costing us,' said Dr. Catherine DeAngelis, JAMA's editor-in-chief. 'It's costing us really good articles and God knows what it's costing us in ads.'"
I find it fascinating that the editor of USA's leading medical journal is worried about the impact of her policies on her revenue ! Things have come to a sad pass when academic journals need to worry about keeping their advertisers happy ! I guess it's a sad reflection of our times that editors have to worry more about their ad revenue, than about their reader; or their product's reliability and integrity. However, once they lose this, then who will want to read their journal - forget about advertising in it !

Improve care by building better relationships with your doctors - Nashville, Tennessee - Tuesday, 07/11/06 - Tennessean.com

Improve care by building better relationships with your doctors : "In his book, 'Building Patient/Doctor Trust,' Boehm compiled a series of columns he's written over the years that explain to patients how doctors see their jobs and to instruct doctors how to put themselves in their patients' shoes.'Trust is the glue that holds us together,' Boehm said. 'Doctors need to see that we are losing people's faith and trust in our profession.'In the end, communication is the key. 'Doctors need to know more about their patients than what hurts,' Boehm said. 'The more you learn about somebody, the more you can trust them.'"
As with any two-way street, good doctors are skilled at getting patients to open up !

Thursday, July 13, 2006

Patient Cost Sharing: How Much is Too Much?

Patient Cost Sharing: How Much is Too Much?:" Responding to successive years of double-digit health insurance premium increases, employers continue to restructure health benefits to slow the rise in company costs by increasing patients' financial stake in their care. A new Center for Studying Health System Change (HSC) study examines how increased patient cost sharing through higher deductibles, copayments and coinsurance raises patients' out-of-pocket costs. Increased patient cost sharing creates more financial burdens for seriously ill and low-income workers. Concerns about financial hardships for seriously ill and low-income workers may limit employers' ability to slow rising premiums through increased patient cost sharing."
In USA, it's all about money ! Unfortunately, healthcare does not respond to bottom-line concerns, and we need to think of cleverer ( and more humane) ways of providing better medical care.

Wednesday, July 12, 2006

wellness � Executive summary

wellness � Executive summary: "Creating a better future requires understanding why things are the way they are, having a vision of a better tomorrow, and having a strategy for realizing that vision. When it comes to something as complex as healthcare, making sense of all this is no easy task. This wiki, therefore, focuses on presenting the main issues in a clear and organized manner to stimulate productive dialogue about ways to solve the healthcare crisis.
First, we define the problem: Healthcare expenditures in America continue to escalate out of control as quality (safety, effectiveness, efficiency, affordability, timeliness, and availability) suffers.
Second, we examine proposed solutions: Debates now focus on what models should replace the failed financial strategies of the past.
Third, we propose a unique and sensible model to solve our country’s healthcare problems."
This is an extremely comprehensive and optimistic view of how we can use existing technology to heal a sick healthcare system.

VC Ratings: Google preparing health portal; pitching WebMD and Intuit as partners

VC Ratings: Google preparing health portal; pitching WebMD and Intuit as partners: "Google is planning a product that it hopes will overhaul the way patients, doctors, vendors and pharmaceutical companies manage their medical information online. Dubbed the Google Health Scrapbook, the product is in developmental stages now and there is no certainty that it will be launched."
If Google is setting up a health portal, this confirms that this is a "hot" area and there is money to be made. Anyone who customises a portal for Indian health consumers will do very well. The chase is afoot, Dr Watson !

Being Your Own Patient Advocate, Not a Pest

Being Your Own Patient Advocate, Not a Pest: "You know advocating for yourself with your physician is a worthy goal, one that could affect your satisfaction, treatment and outcome. But how can you influence your treatment effectively without making a nuisance of yourself? Here's how to tell the difference."
( Of course, one doctor's advocate could be another doctor's pest :)

Who's in Charge?

Who's in Charge?: "Whatever the source of a patient's information, a physician is most effective when he or she isn't defensive, but acts as an interpreter of information and guide of treatment, leaving the ultimate control to the patient.
For the ideal combination, mix an informed patient with an inquiring physician. Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania, likes to cite a quote attributed to the ancient Greek physician Galen: "The best physician is something of a philosopher." Such a physician does more than "pose questions," says Caplan. He "isn't afraid to have them asked. The process of questioning can lead to understanding and patient satisfaction."
And doctor satisfaction as well. It's much more fun ( and intellectually stimulating) to treat a well-informed patient who does his homework and asks questions ! Smart patients can teach their doctor a lot !

Tuesday, July 11, 2006

New retail health clinic coming to area

New retail health clinic coming to area: "The new health delivery model, in the long-run however, could have a 'profound effect' on the conventional doctor's office model, said Brian Klepper, president of the Center for Practical Health Reform. 'Doctors may find themselves feeling the necessity to reexamine their pricing ... they may need to look at their hours,' he said. 'This will create greater market pressure for physicians in a lot of ways.' As employers shift more of the financial cost of health care onto workers through increased premiums and deductibles, cost-conscious patients are turning to these models, which offer inexpensive and up-front pricing for medical services. The retail clinic model is gaining traction as many Americans find themselves priced out of commercial health insurance coverage, Klepper said. People, he said, are 'showing up at these places and getting care when they need it.'"
Just like ATMs revolutionised the banking industry, maybe this model will change the face of healthcare delivery by making it more easily available and affordable. Instead of patients having to come to doctor, what's wrong with doctors going to where the patients are ?

Employer Healthcare Costs and Global Market Competition

Employer Healthcare Costs and Global Market Competition"The second solution, one that runs counter to employers’ abandoning employee health insurance, is actually increasing their investments, but in proactive health collaboration (PHC), rather than more sickness care expenditures. Instead of waiting and paying for employees (dependents and retirees) who get sick, thousands of employers are investing in making or keeping them healthy. In effect, if other countries are more competitive at least partly because their workers are healthier, we need to have healthier employees ourselves to compete. For even if employers manage to shift sickness care costs to somebody else, they will still suffer the consequences of their employees’ unhealthy lifestyles."
This makes so much more sense, and is a great win-win solution ! However, few corporates are willing to invest in even something so simple as a health education program for their employees. While they are happy to pay lip-service to the slogan - "Our people are our most valuable assets", few put their money where their mouth is !

Too Many Doctors in the House - New York Times

Too Many Doctors in the House - New York Times: "How can it be that more spending and greater physician effort does not lead to better health or to improvements in patient satisfaction? One explanation may be that when more doctors are around, patients spend more time in hospitals, and hospitals are risky places. More than 100,000 deaths a year are estimated to be caused by medical mishaps."
Doctors are sickness specialists - not wellness specialists ! While I won't say that more doctors = more illness, it is true that more doctors does not mean more health !

Saturday, July 08, 2006

Stepping Stones to Better Health

Stepping Stones to Better Health:" At some time in our lives, most of us have been confronted with health information that we could not interpret or understand. Where do people turn when they need reliable assistance to help them learn more about health, wellness, and medical topics? That is where a patient education resource center can help. The name 'Small Stones' is derived from a Chinese proverb, 'Those who remove mountains begin by carrying away small stones.' 'We think it's appropriate because if you start with small pieces of information, you will begin to get a better idea of the big picture. By advancing one step at a time, you can meet a challenge,' Steele said."
Every clinical facility should have a patient education recource center. This could be as simple as a computer with an internet connection - but it should be easily accessible and freely available !

Preventing Medical Mistakes

Preventing Medical Mistakes : "The patient may well be the one who can do the most to prevent many types of medical mistakes. As a patient, you have the time (and motivation) to double-check your diagnosis and medications, whereas the hurried medical staff do not have hours to spend on your case. Education can allow you to double-check your diagnosis, examine all possible treatments, check your medications for possible adverse events, and so on. Although you can't always prevent the slip of the scalpel in surgery or fully avoid a hospital-caused infection, you can at least be informed about the risks, and research the past record of your doctor and your hospital."
I like the emphasis placed on the importance of the patient's active participation in minimising medical mistakes.

Misdiagnosis

Misdiagnosis : "Misdiagnosis can and does occur and is reasonably common with error rates ranging from 1.4% in cancer biopsies to a high 20-40% misdiagnosis rate in emergency or ICU care. Surveys of patients also indicate the chance of experiencing a misdiagnosis to range from 8% to 40%. This makes misdiagnosis one of the most common types of medical mistakes.There are various reasons as to why a misdiagnosis can occur including errors by doctors, specialists, and laboratory tests. The patient can also contribute to an error in various ways. There are various types of misdiagnosis ranging from a totally wrong diagnosis to a partial misdiagnosis as to the wrong subtype, underlying condition, medication causes, related conditions, or complications. Conditions for which a person never seeks medical advice are also a common type of misdiagnosis.
Misdiagnosis does not occur equally for all conditions but follows certain patterns. Some conditions are inherently more difficult to diagnose, whereas common familiar conditions are less commonly misdiagnosed. Some diseases are over-diagnosed whereas other conditions are more commonly under-diagnosed or overlooked."
A misdisgnosis can be a doctor's nightmare - and a patient's as well. This is a very well-written review on the common causes for misdiagnosis; and what you can do to protect yourself !

Role of Vegetarian Diet in Health and Disease- Doctor's views

Role of Vegetarian Diet in Health and Disease- Doctor's views : "'You are what you eat' is an age old adage—and it is a fact that it is food that maketh a man. The food we eat, its quality, quantity, its timing and combinations is proven time and again to be of utmost importance in Health as well as in Disease.
At the Bombay Hospital we have been serving vegetarian food from the inception of this institution and now we feel that the time has come to offer scientific justification for this. Not only on religious or moral grounds is this justifiable, but also on scientific grounds vegetarian food seems the more suitable diet for human beings. More scientific work has been done on vegetarianism in the last two decades than in the entire previous history of the world. Therefore, we felt that we should take the lead and bring to the fore all that there is to know on vegetarianism from the scientific angle and thereby justity the use of vegetarianism in health and in disease."
Excellent scientific review by leading doctors as to why vegetarian food is good for you !

See you in health court?

See you in health court?: "Analysis: See you in health court? Bankruptcy cases are referred to bankruptcy court. Labor disputes are settled before a special labor court. Now, a growing chorus of voices is calling for the establishment of a health court with jurisdiction over medical malpractice cases. Proponents of such a plan say it will ease doctors' concerns about lawsuits and help patients get fair compensation in a timely way. They also say that judges with expertise could set clear medical procedural guidelines that could improve the practice of medicine."
Makes sense. Specialised courts for specialised problems, so patients don't have to wait forever and ever to get a fair hearing and redressal.

Thursday, July 06, 2006

Evidence Based Medicine

Evidence Based Medicine: "
This process of looking at the state of the evidence before making a decision is called evidence-based medicine or evidence-based health care. It means based on scientific evidence or supported by proof. It means not relying only on the views of experts, but on the most objective knowledge as well. The goal is to help patients get the most appropriate treatment for them. After considering the evidence and the person's own values and judgment about their options, a patient and experienced doctor can come to a better decision. The best health care is not necessarily where 'everything” is done for the patient, but rather, the most appropriate. This can protect people from harmful and useless treatments. What's more, it is only when we know what the limits of knowledge are, that we can know what needs to be done in the future to fill the gaps in what is known."
Evidence-based medicine ( EBM) is one of medicine's current buzzwords. This is a very useful guide, which explains what EBM Means in clear English .

Teaching medicine - see one, do one, teach one

Medicine ( especially the surgical branches) are the ultimate "hands-on" profession ! How do we teach medical students and residents how to perform medical procedures and operations ? The aphorism is - "See one; Do one; Teach one". Of course, in real life, it's more like, " See ten; do ten; botch one; teach one". Before you can teach one, you usually need to "botch one " - and every good teacher would agree that you learn more from your mistakes than from the straightorward, "uneventful" procedures.
Is this fair on the patients ? Not always, but this is the occupation hazard of being a patient in a teaching hospital. Fortunately, the "errors" are often easily corrected, and don't result in any lasting harm.

Understanding Your Laboratory Tests

Understanding Your Laboratory Tests: "Reference Ranges and What They Mean. Test results are usually interpreted based on their relation to a reference range. This article will help to explain what a reference range is, what it isn't, and why test results and references ranges should not be interpreted together in a vacuum."
Excellent primer on medical laboratory testing ! Every well-informed patient needs to know these basics. Check this before you go for your next test.

Wednesday, July 05, 2006

Strengthening Micro Health Insurance Units for the Poor in India

Strengthening Micro Health Insurance Units for the Poor in India: "Microinsurance is a form of health, life or property insurance, which offers limited protection at a low contribution (hence “micro”). It is aimed at poor sections of the population and designed to help them cover themselves collectively against risks (hence “insurance”). Normally, microinsurance schemes are linked to associations (besides non-governmental organizations for instance trade unions, religious congregations and hospitals), whose main area of work puts them in direct contact with the target groups. They may, but must not necessarily, act as the insurance provider: in many cases, they have transferred the risks of the insurance business to a professional insurer."
We need to also address the needs of the 200 million middle class Indian citizens who can pay for health insurance - but who are not being adequately served at present.

Social Health Insurance in India

Social_Health_Insurance_an2.pdf (application/pdf Object) " Around 24% of all people hospitalized in India in a single year fall below the poverty line due to hospitalization (World Bank, 2002). An analysis of financing of hospitalization shows that large proportion of people; especially those in the bottom fourincome quintiles borrow money or sell assets to pay for hospitalization (World Bank, 2002) . This situation exists in a scenario where health care is financed through general tax revenue, community financing, out of pocket payment and social and private health insurance schemes. India spends about 4.9% of GDP on Regional Overview in South-East Asia health (WHR, 2002). The per capita total expenditure on health in India is US$ 23, of which the per capita Government expenditure on health is US$ 4. Hence, it is seen that the total health expenditure is around 5% of GDP, with
breakdown of public expenditure (0.9%); private expenditure (4.0%). The private expenditure can be further classified as out-of-pocket (OOP) expenditure (3.6%) and employees/community financing (0.4%). It is thus evident that public health investment has been comparatively low. In fact as a percentage of GDP it has declined from 1.3% in 1990 to 0.9% as at present.
Furthermore, the central budgetary allocation for health (as a percentage of the total Central budget) has been stagnant at 1.3% while in the states it has
declined from 7.0% to 5.5%."
This actually represents a huge business opportunity. Anyone who taps this underserved market intelligently will do very well - as well as doing a lot of good !

Monday, July 03, 2006

Inspiring lecture of Dr Paul Farmer's work

Inspiring lecture of Dr Paul Farmer's work :"In his book Mountains Beyond Mountains, Tracy Kidder chronicles the work of Dr. Paul Farmer, a renowned infectious-disease specialist whose life's calling is to bring the lifesaving tools of modern medicine to those who need them most. Guided by the Haitian Creole saying 'Tout Moun Se Moun' (we're all human beings), Farmer demonstrated that radical change could be fostered in situations that seem insurmountable."
Reading this great book can inspire you - listen to this lecture to get an idea of what an unusual man Dr Farmer is !

Physician Portals Fill the Gap

Physician Portals Fill the Gap : " Physician portals, once low-value Web sites used as bulletin boards by medical societies or for back-door e-detailing by marketers, are now positioned to become a vital link in the national health information value chain. The convergence of two trends — the growing patient and physician comfort with accessing health information via the Web and the development of physician/patient online exchanges — have created an opportunity for physician portals to connect patient information with physician practice patterns. Integrated physician/patient data can dramatically increase the information value added by providers, payors, and manufacturers."
Are they making a comeback ? Is this a new business opportunity ?

Sunday, July 02, 2006

OpenCourseWare at the Johns Hopkins Bloomberg School of Public Health

OpenCourseWare at the Johns Hopkins Bloomberg School of Public Health: "The Johns Hopkins Bloomberg School of Public Health's OPENCOURSEWARE project provides access to content of the School's most popular courses. As challenges to the world's health escalate daily, the School feels a moral imperative to provide equal and open access to information and knowledge about the obstacles to the public's health and their potential solutions."
Great site ! Unfortunately, you won't get an Master of Public Health degree ( MPH ) by studying this course online - but you will learn a lot !

The Price of Motherhood - Ready to have a baby? You'll earn 10 percent more if you wait a year.

The Price of Motherhood - Ready to have a baby? You'll earn 10 percent more if you wait a year.: "Women agonize over the trade-offs between family and career. Now, thanks to Amalia Miller, a young economist at the University of Virginia, there is a new and particularly vivid way to think about those trade-offs.

On average, Miller has found in a new paper, a woman in her 20s will increase her lifetime earnings by 10 percent if she delays the birth of her first child by a year. Part of that is because she'll earn higher wages—about 3 percent higher—for the rest of her life; the rest is because she'll work longer hours. For college-educated women, the effects are even bigger. For professional women, the effects are bigger yet—for these women, the wage hike is not 3 percent, but 4.7 percent.

So, if you have your first child at 24 instead of 25, you're giving up 10 percent of your lifetime earnings. The wage hit comes in two pieces. There's an immediate drop, followed by a slower rate of growth—right up to the day you retire. So, a 34-year-old woman with a 10-year-old child will (again on average) get smaller percentage raises on a smaller base salary than an otherwise identical woman with a 9-year-old. Each year of delayed childbirth compounds these benefits, at least for women in their 20s."

No wonder women ( and their husbands) agonise over when to start their family. Career versus Baby ?

Human Rights and Human Enhancement: Is genetic modification of people moral?

Human Rights and Human Enhancement: Is genetic modification of people moral?: "They argue that future genetically enhanced children will not have given their consent to be enhanced. Is this a showstopper? After all, obtaining the informed consent of patients before they receive treatments is a bedrock principle of bioethics and clearly future children cannot give their consent to enhancement because they do not yet exist. First, keep firmly in mind that none of us gave our consent to be born, much less to be born with the specific complement of randomly conferred genes (both good and bad) that we bear. In that moral respect, future genetically enhanced children are no different than non-genetically engineered children today."
If I had a choice, I would have liked to be born with genes which allowed me to be more athletic and more intelligent !

Hello Nurse! Is the U.S. stealing health care workers from abroad?

Hello Nurse! Is the U.S. stealing health care workers from abroad?: "But it's not for well-meaning Westerners to decide where a health care worker would be 'better off' anyway. Workers are not the property of countries that train them, and any policy that seeks to limit their options will prove cruelly restrictive. After all, stemming the flow of skilled labor doesn't just mean locking workers out of wealthy nations. It means locking them into poor ones."
This is why "brain drain" is NOT a bad thing and should be encouraged. Think of it as exporting skilled manpower to the USA !

How one physician escaped the panic over prescription drugs

How one physician escaped the panic over prescription drugs: "Dozens of doctors have been prosecuted for "overprescribing" painkillers. The Justice Department and the DEA have pushed this aggressive new campaign in the war on drugs. First, prosecutors blitz local media with reports of out-of-control prescription drug abuse problems and discuss the problem of "pill mills." Then, they swoop in with a SWAT team and arrest any doctor brave enough to actually treat chronic pain with doses of opioid medication large enough to work. They call him a "drug dealer" and "pusher with a pen. Usually, the media buy the tale of evil substances and vile physician-pushers. But Reynolds offered a more compelling alternative narrative. She brought the suffering patients into the media eye. Rather than telling the tale of an evil drug-dealing doctor who brings down the poor addict, she and the patients provided another version of the story, in which the wonderful healer allows his grateful patients to function—until the cops drag him away."
I am glad for once someone focussed on the fact that the doctor was providing a useful service to his patients ! Unfortunately, it's easy to paint doctors as villains and bash them up - and unfortunately, when they are down and out, no one comes to their aid !

A Few Good Doctors - Don't look for them on a magazine top-10 list

A Few Good Doctors - Don't look for them on a magazine top-10 list: "The doctor-patient relationship is just that, a relationship, full of all the nonsense and idiosyncrasy that defines the genre. It's why good doctoring has a magic quality, like a good friendship. The intricacy of this symbiosis also is why a 'best doctor' can't be determined by asking a bunch of professors whom they might send their brother-in-law to.

Which is not to say the search for a solid doctor is hopeless—just that the guidebook approach has made the task more complicated than it needs to be. Below is my simple one-two-three approach. It's even in glossy-magazine format.

1) Trust your instincts: There are lots of rotten doctors, really really lousy ones, wretched souls you wouldn't want to know as people, much less trust with your health. But they aren't any harder to suss out than the schmucks you meet in everyday life. If your gut says run, then run.

2) Don't trust your instincts if a scalpel is involved: Subjective impression is meaningless when selecting a surgeon. Craft should trump your desire to like them; in fact, it's OK to hate your surgeon. You simply need him to cut and sew very intelligently. So always select the surgeon who has already done the most iterations of whatever procedure you need. Stated in Zagat-ian terms: Which restaurant do you want to go to—the one with the line or the one that sits empty?

3) Shop around: Diagnosticians, sensitive (and craftless) souls that we are, succeed only if we connect. A doctor who is beloved by one person can be a disaster for the next. Think of who ended up marrying whom—there simply is no accounting for taste. So look before you buy. Yes, it takes time, it takes money, it is humiliating and ridiculous and maybe just a sinister plot to give doctors more business. Do it anyway, and do it when you are well."

Excellent advise from a doctor who appears on a Top-10 list. You can use it for everything - including looking for a wife; or a college !

Consultation with an IVF specialist - a video preview

A consultation with an IVF specialist can be stressful , because you are worried and anxious. In order to help you prepare, here's a short peek at what a real-life consultation with an IVF specialist would be like. The pretty doctor in the video is Dr Anjali Malpani.

Saturday, July 01, 2006

Why is health insurance in India so untapped ?

Why is health insurance in India so untapped ?: "Health insurance is a segment, which is grossly untapped? How are you trying to take advantage of this opportunity?

One of the biggest challenges to the General Insurance Company’s in India has been the penetration of individual health insurance product. Figures quoted by various sources reveal that only 2-5% of the population buys a health insurance product. The figure is incongruent in today’s context where concerns regarding health care are dominant across various segments of the population. There is a growing distress among all sets of individuals regarding rising health care costs.
Inspite of this concern, health insurance has failed to penetrate in India. We have done a consumer research through Quantum Market Research, India’s leading qualitative Market Research agency on this issue. The research revealed that consumers are reluctant to accept health insurance because of the complex procedures that need to be followed for buying a health insurance product. The premium to be paid for health insurance for the entire family is also perceived to be very high especially when the consumer is buying something, which he believes could be unlikely, or an unforeseen situation.

The issue is further compounded by the fact that the insurance agent does not find it lucrative enough to sell health Insurance as the commission amount does not commensurate with the effort that it takes to convince a potential customer to go through a complex procedure and buy a health insurance product.

Aiming to address the above concerns, we intend to bring in quite a few initiatives in our individual health product portfolio. Direct marketing to the vast untapped middle income groups is one of our priorities. We would be giving various price point options for the customer to choose and offer premium payment options through installments to eliminate the entry barriers."

The other reason is that health insurance in India was a monopoly, and health insurance cover was provided only by government insurance agencies. This was seen to be a social service; and this segment always incurred major losses, which is why it was neglected. Once health insurance gets de-tariffed, many more private players will enter; and along with competition will come a lot more innovative efforts to provide cost-effective health insurance cover.

Need to detariff insurance industry says IRDA Chairman

'Need to detariff insurance industry says IRDA Chairman: "I think health insurance is an area that is riddled with problems. There is no denying of that. The basic problem is that we do not have individual health profiles. In the West, from the time the child is born records are maintained. This is not there in our country. In the absence of such record maintenance, the insurance companies find it difficult to assess the eligibility of an individual for health insurance. The second thing is that they (the health insurance companies) also have difficulty in fixing an appropriate premium for various kinds of diseases in the absence of information. So, lack of information is one of the major problems we have today, which is preventing the spread of health insurance. We are trying to address that particular problem. We are now trying to build up data by compiling whatever data is available at different places. We have constituted a Working Group, which has already met twice and created one more sub-group to look at only the data currently available and analyse them."
I feel the entry of private health insurance companies into India will mark a dramatic change in the way healthcare is delivered. Their entry will be a major catalyst towards the adoption of EMRs ( electronic medical records) and PHRs
( personal health records), which make a lot of business sense !

Healthcare insurance in India is a Rs. 25,000 crore industry

Healthcare insurance in India is a Rs. 25,000 crore industry : "According to a recent study by PHD Chamber of Commerce and Industry (PHDCCI), healthcare insurance is likely to become a Rs. 25,000 crore industry by 2010. The PHDCCI estimates that the percentage of the elderly in the total population will increase to 8.9% and total number of senior citizens will increase by 107% to 113 million by 2016, providing immense scope for growth. Most importantly, health spending in India at 6% of GDP, is among the highest estimated for developing countries. In per capita terms, that is higher than that in China, Indonesia and most African countries. With the insured population expected to hit 250 million the next five years and each person paying an average premium of Rs. 1,000 per year, the health insurance industry would be worth Rs.25,000 crore.

Diseases such as cancer and cardiac conditions are likely to account for nearly 30% of ailments and HIV infections are also expected to rise significantly during this period.

Meanwhile, the four public sector insurers and the country's largest private insurer ICICI Lombard have submitted their bids for a number of State Government-sponsored health insurance schemes. The State Government's plans are part of the Central Government's initiative to increase public spending on health to 2% of the GDP by 2009 and provide health insurance to people below the poverty line."

Times of India celebrates Doctor's Day

Times of India celebrates Doctor's Day Reflects Dr Aniruddha Malpani, infertility specialist and Medical Director, Health Education Library for People (HELP), “Information Therapy is the best way of improving the doctor-patient relationship. A wellinformed patient has realistic expectations of medical therapy and is able to get better care from his doctor, because he participates actively in his own care, and helps the doctor to help him.”
To mark the day, HELP is providing the book ‘Successful Medical Practice - Winning Strategies for Doctors’ at a subsidised price of Rs 100 (regular price Rs 250) to all doctors who come to the library. The message of this book is simple - ‘Love your patients. Doctors who take good care of their patients will have a flourishing practice!’
Doctor’s day makes you aware of the role of doctors in your lives so that you can express your gratitude for their compassion and commitment towards health care and wellness of the society. Says Dr Kapoor, “This day is an opportunity for patients to express their gratitude to their doctors for the medical assistance and solace they may have received in their time of emergency.”
Panacea Biotec has come up with a novel idea wherein, the company will deliver a bouquet to the doorsteps of the doctors of the first 1,000 people who log on to their website. The campaign aims at encouraging every person to thank their doctor for the latter’s invaluable services.
“It’s a pleasure to encounter a thoughtful patient who just takes the time to say ‘Thank you!’ This patient makes the doctor’s day. The best gift a doctor can receive is the referral of another patient - an ultimate accolade any professional can be awarded,” concludes Dr Malpani.

As We See It: Dietary Supplements Attacked By The Media

As We See It: Dietary Supplements Attacked By The Media: "What most people don’t realize, however, is that it is not the obligation of the media to provide accurate reporting. The media is responsible for generating profits for its shareholders, which means they have to grab the public’s attention with sensational headlines that sell newspapers and TV viewing time."
I find his basic message is worth emphasising - you can no longer trust what you read in the press. Unfortunately, the media has got so good at "dumbing down" all of us, that with our reduced attention spans and constant need for stimulating "sound bites", we have become so addicted to "sweet, short and simple" messages, that we find it hard to think critically; or separate the wheat from the chaff. Let the reader beware !

The Medical Profession's Culture of Corruption - and how to protect yourself

The Medical Profession's Culture of Corruption - and how to protect yourself: "Doctors make decisions based on information. If doctors' sources of information are dominated by the drug industry, then doctors' decisions will typically focus on drugs. The drug industry invests billions to accomplish this. Carefully selected information is provided to doctors at drug company-subsidized seminars, via advertising in medical journals, and via 90,000 drug reps who leave samples and studies at doctors' offices every day. Drug companies write the package inserts included with all medications, and they design and conduct or underwrite studies that are published in medical journals. Such studies are usually more favorable toward their medications that independent studies. "
What this means is that you really can't trust your doctor to prescribe what's best for you ! Even if he is honest, he may have been brainwashed by the pharmaceutical industry's propaganda into prescribing drugs which may not be very good for you.
Many people are so fed up of Big Medicine, that they prefer using alternative medicine as their treatment of first choice. However, the field of alternative medicine is even murkier. While the misinformation in Big Medicine is systematised and cleverly oiled, quackery flourishes in the arena of alternative medicine, because there is no regulation or supervision. Your best weapon is information - but you have to be very careful where you source your information from. There's too much information out there - and lots of it is unreliable or biased.
This is why information produced by independent organisations such as Healthwise is worth its weight in gold !
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