A provision in the new Medicare bill slows the growth of specialty hospitals by restricting
physician investments in them. Physician
investment in imaging centers to which they then refer patients also raises
ethical concerns, and a reporter suggests that patients now need to become
familiar not just with scanner technologies, so they can shop for the best
scans, but also with their physician’s stake in and experience with the scanners
the physician recommends. The necessity of caveat emptor, which
disappeared in medicine along with snake-oil, appears to be making a
comeback.

Other items of policy interest:

• Brazilian owners of a Caribbean online pharmacy empower a Missouri doctor to
  prescribe from
  Pennsylvania to patients anywhere. Get it?
• A commentator suggests that a legal but regulated market is need to avert
  the ills of a growing black market in
  transplant organs.
• The UN General Assembly has declined to impose the total ban on therapeutic and reproductive
  cloning sought by the Bush administration and a number of mainly Catholic
  countries.

A Kaiser Family Foundation study has found that almost 50 percent of
non-elderly American adults with permanent disabilities may go without enabling
equipment, while more than a third may postpone care, skip doses, or split pills
because of cost. A third appear to spend less on food and heat than they spend
on healthcare.

Reference: Sherman, Mark (2003). “Health
Care Costs Hurt Disabled Americans.” Associated Press/Washington Post,
December 12.

Rationing and IT

Technology could help reduce the rationing of healthcare that goes on in US
hospitals today, reports Laura Landro in the Wall Street Journal.
Eliminating unnecessary paperwork alone could save $125 billion, eliminating
medical errors would save $37.6 billion, reducing the overuse of just three
antibiotics would save $1 billion. The “most promising ideas” are to install
information systems, use them to practice evidence-based medicine and for
disease management, peg reimbursements to quality and efficiency, and involve
patients in their own care management decisions.

Reference: Landro, Laura (2003). “Six
Prescriptions To Ease Rationing In U.S. Health Care.” Wall Street Journal,
December 22.

Economic Impacts of Technology

Recent indicators that the US economy is surging prompted Fortune‘s
David Kirkpartrick to wonder whether the accumulated investment in technology is
finally paying off, and — if so — who are the ultimate beneficiaries. He
points to the prevalence of enterprise resource planning software in
manufacturing, linked to supply chain and financial systems providing instant
feedback, as pioneered by Wal-Mart, as evidence that technology is indeed paying
off. But he finds it worth noting that in the last two years US manufacturers
have eliminated about two million jobs, and that “One unfortunate side effect of
techno-efficiency is that it reduces the need for people to do things machines
can do,” not to mention that globalization and networked outsourcing has added
to the labor pool several billion foreigners willing to work hard for much less
than the typical American. “I’m not sure,” he concludes, that “we have entered a
new sustainable economic boom.” If it is not sustainable (and we agree with him
that seems unlikely) then there is major trouble ahead.

Reference: Kirkpatrick, David (2003). “The
real boom.” Fortune, December 4.

Long Term Employment in Healthcare

Few industries offer better prospects for long-term job security than
healthcare, says Kim Norris in the Detroit Free Press, citing as reasons
the growing market of ailing boomers, increasing longevity, current and
projected nursing shortages, and the relative insecurity of jobs in other
industries as globalization sends US jobs overseas.

“The hot jobs are the ones that are resistant to outsourcing,” and those tend
to be the service-oriented jobs such as salespeople, financial planners,
information technology consultants, pharmacists, nurses, accountants, . . . and
physicians. The physician shortage in the US will continue to get worse for a
decade, until efforts barely begun by the medical school establishment to
increase the number of physicians start to work, she suggests. However, this
prediction fails to take into account the vulnerability of all service jobs to
accelerating developments in globalization (e.g., offshore accounting and tax
preparation/filing) and technology (e.g., robot nurses), or both (e.g., robot
nurses monitored by real physicians in India.)

Illustrative of the myopia is the reaction of a state nurses’ association
official to a trial of a roving robot equipped with a screen showing the face of
the nurse controlling it and cameras to navigate the wards and see patients.
“The robots will just enable nurses to do what they to do in a different way
[and] don’t eliminate the need for humans,’ she told a reporter. We would
respectfully point out that this is not necessarily, nor even probably, true of
the next generation of nurse robots, which are likely to be more autonomous and
require less human control. In any event, since the robot is as easily connected
over a broadband Internet connection to a nurse in India as to a nurse down the
hall, telemedicine plus even the limited first generation of service robots may
eliminate the need for relatively costly* American nurses.

Pediatric cardiology teams in Northern Ireland have already begun using
telemedicine to monitor patients in their homes throughout the province, Anthony
Quinn reports. The teams, each of three consultants and one research fellow, can
check visible symptoms via a video camera and biometric readings through devices
connected to the broadband network. The patients do better in their home
environments and they and their families are saved the expense and inconvenience
of making trips to the hospital for routine checkups.

We predict that telemedical monitoring will grow, and that the next
inevitable (and not so distant) advance will be robotic medical devices in the
home — at first controlled remotely by the physicians, later acquiring more
autonomy — to deliver care. In the Robotics section of this issue, we
report that the Toyota car company is developing a humanoid robot for both
factory and — specifically — for nursing work.

In an area of such importance to government policy, organizational strategy,
and individual well-being as healthcare staffing, we urge a broad, deep, and
urgent study of the impacts of telemedicine, robotics, and indeed all
technologies likely to impact healthcare. What if the US goes on a physician and
nurse training binge for the next decade, only to find that just as these
expensively trained people start to look for work, the work has disappeared
through cures for cancer, heart disease, and diabetes; intelligent robotic
nurses; and an inexpensive global caregiver pool accessible through automatic
language interpreters? Some or all or none of these things could happen in two
or five or ten or 20 years. The point is that the people making the decisions
appear not only not to know when these things might happen; they appear
to be unaware that they are happening at all.

* Nurses earn and deserve their salaries, but the
global free market, unencumbered by human values, is unmoved by those implied by
“earn” and “deserve.”

Reference: Norris, Kim (2003). “Health care jobs are
safe.” Detroit Free Press, December 29.

Reference: Manning, Joe (2003). “Doctor shortage looms
as threat, professor warns; Medical schools must expand, he says.” Milwaukee
Journal Sentinel, December 9.

Reference: Curet, Monica (2003). “Robot
gets job as nurse.” Mobile Register, December 9.

Reference: Quinn, Anthony (2003).”Telemedicine lets
children go home.” ENN, December 9.

Deceleration in Specialty Hospitals

A single paragraph in the 678-page Medicare bill signed into law last week
forbids physicians from making new investments in specialty hospitals for at
least the next 18 months, while federal officials study their impact. These
facilities specialize on a single branch of medicine — mainly surgery, cardiac
services, orthopedics, or specialty care for women; and most are formed by
physician-investors. Proponents say they provide more efficient, higher-quality
care at lower cost than traditional hospitals. Opponents say they siphon
profitable patients away from traditional hospitals while leaving them with the
burden of treating the indigent.

Reference: Goldstein, Amy (2003). “Medicare
Law Stunts Hospital Rival: Growth of Specialty Care Centers Slowed While Impact
Studied.” Washington Post, December 16.

Ethics & Cost of Digital Imaging

A study confirms that the surging use of diagnostic imaging is due to rising
consumer demand and the introduction of more sophisticated, less-invasive
imaging systems. It seems the newer systems are not replacing older ones, which
tend to remain in use also. The study concluded that growth in the use of both
old and new systems suggests that duplicative and unnecessary tests are being
ordered to cover the costs of the newer equipment and to mitigate the threat of
malpractice litigation by practicing defensive medicine, rather than to produce
higher quality care.

Legislation has existed for a decade that prohibits physicians from referring
Medicare and Medicaid patients — but not patients with private health insurance
— to imaging centers in which they invest. The American Medical Association’s
code of ethics generally frowns upon the practice but neither monitors nor
enforces compliance with its own code, saying state physician licensing agencies
are responsible — which, if true, makes at least some state licensing agencies
appear irresponsible, judging by Gil Gideon’s article in the
Courier-Journal.

“Ethicists and radiologists,” he writes, “say they are concerned that
physicians who invest in diagnostic centers may order unnecessary scans, or
direct patients to their facility, even if others are of higher quality.” The
article suggests that patients should not only familiarize themselves with
scanner specifications, so they can ask the right questions about the facilities
to which physicians refer them,* but they should also ask whether the physician
has an ownership stake in the particular facility, and whether the facility uses
trained radiologists or just physicians who’ve read the scanner manual over the
weekend — and then draw their own conclusions.

Entrepreneurs and equipment vendors are urging the physicians on with
co-investments and low-interest loans, putting million-dollar imaging and other
machines within reach. “Most obstetricians,” says Gideon, “now have their own
ultrasound, mammography and bone density machines. It’s faster and more
convenient for patients to have tests done in the doctor’s office.”

Missing from the reference articles is recognition of the likelihood that
imaging technology (such as the handheld ultrasound) will become ubiquitous and
cheap, and that their built-in intelligence will mean very little user training
is required. When that happens (and it is already well in hand) the ethics and
cost issues go away.

* See Med-Tech-Savvy
Patients” in the December 2003 issue.

Reference: Barry, Tom (2003). “Impact
of imaging: Diagnostic tools drive up cost.” Atlanta Business Chronicle,
November 28.

Reference: Gil, Gideon (2003). “Medical
ethics, dollars clash in diagnostics: Doctors’ stakes in MRI testing risk
referral conflicts.” Courier-Journal, December 1.

Internationalized Medicine

To date, 13 states including his own have revoked or suspended a Missouri
pathologist’s license for online prescribing. Yet he continues to write
prescriptions — 5,000 for Viagra alone this year. Although he may review
patients’ medical questionnaires via the Internet in Missouri, he claims he is
practicing medicine in Pennsylvania, where he still holds a valid license,
because that is where his website server is located. One of the website
company’s owners is in Brazil, and it is incorporated “somewhere down in the
Caribbean.”

Proposed federal legislation may eventually put him out of business, but in
the meantime he and the drug companies are doing rather well out of the
arrangement.

Reference: Gaul, Gilbert M. (2003). “Crossing
Lines to Prescribe Online: Internet Pathologist Outmaneuvers State Medical
Boards.” Washington Post, December 18.

Organ Market

A black market in human organs for transplant has emerged to meet demand in
the face of shortages. The development of better anti-rejection drugs and more
doctors trained in transplant procedures will likely spur organ demand further,
says Ronald Bailey in ReasonOnline. The eventual success of xenotransplantation,
stem cell therapies, and artificial organs will eventually eliminate the
black market, but in the meantime several people in the medical community are
suggesting that a legal, regulated market allowing healthy people to sell their
organs (a kidney, for example) would be less unethical than tolerating the
growth of the black market and its attendant ills.

Reference: Bailey, Ronald (2003). “Is Organ Bootlegging Inevitable?
Only markets and science will prevent it.” ReasonOnline, December 17.

UN Reprieve for Stem Cell Therapy/Research

The United Nations General Assembly has again declined to impose a ban on all
human cloning (therapeutic and reproductive), reportedly in the belief that
imminent advances in stem-cell therapies will overcome the arguments against
human cloning for therapeutic purposes. A genetics authority told Wired‘s
Kristen Philipkoski: “There will be scientific breakthroughs in medical research
that will probably derail any hope of banning therapeutic cloning on a permanent
basis.” It appears that in seeking the extreme of a ban on all cloning, the
anti-abortion lobby and various religious groups in the countries — including
the US — that sought a total ban have thrown the baby out with the bath water,
losing the chance of a UN ban on reproductive cloning.

Reference: Philipkoski, Kristen (2003). “U.N. Balks at
Cloning Ban.” Wired News, December 9.