Thursday, August 9, 2012

ISM/FoSiM: "Inversion" - Putting the Cart before the Horse in Healthcare Reform

One of the amazing arrogances and Blindspots of the fanatics and zealots of ISM and their "mini-me", FoSiM, is they've got the Healthcare Reform debate turned around completely. Colloquially, they've put the cart before the horse.

The FoSiM "Vision Statement" in their recruiting letter was:
"To reverse the current trend which sees government-funded tertiary institutions offering health care ‘science’ courses not based on scientific principles nor supported by scientific evidence”.
And from the ISM Policy paper on Regulation and Licensing all Healthcare Practitioners and Training:
As a consequence of these practitioners being legitimized through political rather than scientific means, the health of people worldwide has been put at significant risk.
Not hard to spot that both these statements aren't backed by any Evidence, any Theory but only Absolutist Assertion: it shows from the start that this is only Ideological based, not based in fact or need, nor indeed arrived at by any valid, credible process.

The "Inversion" of ISM/FoSiM is who they put at the centre of their Healthcare Reform proposal in their call for more "Science in Medicine", ignoring their one-eyed bias where they never examine the Practice or Science of their own, Medical Care.

ISM/FoSiM put "Science" at the centre of their Reform proposal and agenda.
Specifically, 'Science' applies to:
  • Practitioners,
  • Specialities,
  • Organisations,
  • Research, Academic or Commercial,
  • Professional Bodies,
  • Professions, and
  • Governance bodies and processes, such as defined by Government Agencies.
What's completely missing is The Patient. This is the Inversion. It's Practitioner- and Profession-centric, not Patient-centric.

This is the Big Lie, the massive horn-swoggle that ISM/FoSiM are attempting to pull off:
The Patient, their Outcomes, the Quality of their Care and their Safety under Medical Care is completely absent. And most importantly, Patient Accessibility and Affordability are missing.
ISM/FoSiM want to "Fix All Ills of Healthcare and its Systems" through More Science, amusingly without evidence that this can or will help. The evidence of the last sixty years of "More Science" in Medical Care is that costs rise astronomically (5% to 18% of GDP in the USA), while more people are untreated and Public Health outcomes do not seem commensurate change.

The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:
Better Healthcare!
Which is admirable in its intent.

Only, like all their efforts, it's vague, incomplete and unfocussed. It's posturing not a useful addition to the debate.

They are advocating for Better Healthcare:
  • For Whom?
  • Where?
  • How Measured?
  • Within what Cost and Resource envelope?
  • But mainly, How can their Reforms be delivered and Implmentation executed when the current Medical Care system is grossly understaffed, inefficient and already too expensive for ordinary folk?
More "Science" won't deliver Better Medical Care, it can only deliver more expensive, less accessible and less effective care, and further stress already over-worked and failing individuals and organisations.

"More Science" does involve more money for research, more expensive devices, drugs, equipment and services and, for the very few that can afford it, much more expensive interventions ("Rescue Care") for extreme conditions. It's a Bonanza for everyone making money out of the process, the Companies, Practitioners and Researchers, and a FAIL for everyone else: the Patients, the Healthcare workers and the Governments funding it.

The only group of Patients, the only reason this field of work exists at all, who might benefit aren't just the "Top 1%", but probably the "Top 0.1%".

This is a proposal that will cost a whole bunch of money, mostly Public (ISM/FoSiM are universally silent on Cost and Efficiency Improvement) and the two groups to benefit are: themselves and their rich mates.

That's a really interesting proposal for spending piles of Public Money with no sense of Accountability and where the only evidence available is "It won't help, but will cost a whole lot more."

How does "More Science" equate to "Better Healthcare"?
Not in the Real World and not at all for Ordinary People who'll be paying for it... 
This is a scheme dreamed up by the privileged, for the privileged, of the the privileged.

If you'd like to know what Better Healthcare looks like, here's the definitive guide, with actual research references:
"Managing Clinical Processes: Doing Good by Doing Well" by Dr Brent James.
What do we get for all that money? [slide 16]
  1. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
  2. Rapid response -- the Rule of Rescue
Three classes of outcomes: [slide 65]
  • Physical outcomes
    • medical outcomes: complications and therapeutic goals
    • includes functional status measures (patient perceptions of medical outcomes)
  • Service outcomes
    • satisfaction: patients and families, communities, professionals, purchasers, and employees
    • includes access issues (e.g., waiting times)
  • Cost outcomes
    • just another outcome of a clinical process
    • includes the cost of the burden of disease
Medical outcomes are of four types: [slide 66]
  • appropriateness
    • (referral and procedure indications)
  • complications
    • (process failures / defects)
  • therapeutic goals / biologic function
    • (when stated in the negative, merges with defects)
  • the patient's ability to function
    • (functional status, as reported by the patient)
  • are process specific
    •  (different clinical conditions have different complications, different therapeutic goals, functional status measures)
  • Medical outcomes relate directly to health care costs
Service outcomes are of two types: [slide 67]
  • the clinician-patient relationship
    • (bedside manner: a "caring and concerned" clinician)
  • access issues: convenience vs. hassle
    • (scheduling, travel times, registration, physical comfort, wait times, etc.)
  • operate by a separate, general process that is independent of medical outcomes
  • Service outcomes directly affect market share, community perceptions and relations (that is, prestige and social status), and
  •  rates of malpractice law suits
Health care consumers seek value [slide 69]
  • Value = (Medical outcomes + Service outcomes) ÷ Cost outcomes
  • The goal is the best possible medical outcomes at the lowest necessary cost
It'd be interesting if ISM/FoSiM ever apply their considerable talent and resource to addressing just how their call for "More Science" will deliver better Healthcare outcomes in the structure given by DR James.

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