This Is a Brainstorm

There is no such thing as a blank check — particularly in this economic climate. Resources are not endless; parameters exist. But the Pioneer Portfolio is dedicated to powering ideas that have the ability to truly transform health and health care and — to do so — we need to encourage people to THINK BIG.

From October 27-30, members of the Pioneer team will be in San Diego to participate in TEDMED2009. While we are there, we will ask other participants — if someone was to hand them a blank check — what they would do to transform the future of health and health care? What kind of problems do they see as being “stuck” and that, if solved, could bring about significant improvements 5, 10, 15 or more years down the road?  Where are the breakthrough opportunities?

But we don’t want to limit the conversation to the group at TEDMED; we want to take the conversation to Twitter and ask a broader audience for their ideas. Like you.
 
There is no blank check.
 
This is not a call for proposals.
 
This is a brainstorm.
 
We want to hear your ideas because they inspire us and because we hope you might inspire each other.
 
If you would like to participate in the conversation and let us know how you would transform the future of health and health care, please tag your “tweets” with the #blankcheck hashtag. We’ll “retweet” them to share with those who follow Pioneer on Twitter and we’ll share them with everyone at TED MED through a live feed we’ll have playing throughout the event. If you don’t want to share your own ideas, but want to see what other people are thinking, you can follow the conversation here. And please consider telling others about the #blankcheck conversation.

Comments

[Sabitha Rajan]

Well Clinics - free, primary care clinics for everyone, regardless of insurance or immigration status. Basic care: Immunization, Htn, DM, excercise classes, stress mgmt classes, parenting classes, Prenatal care, Mammograms, PAP's, c-scopes, well child care, TB in high risk areas. Basic care everyone should get which takes care of not only the individual but the 'public' we all live in. Plus it is only humane.

"Centers of Excellence" in psychiatry (as opposed to the usual heme/onc, ortho, heart which are only picked b/c they earn income - which is ok ("NO Margin, NO Mission") but Psych is what most people really need and those with psychiatric problems contribute the most to Health care costs anyway.

[bert singleton]

To often we get caught up in designing "pie in the sky" proposals that have no hope of being accepted due to their high costs. How about a brainstorming effort based on:

If you had absolute power to make any changes you wanted that did not involve spending more money - how would you transform the future of health care?

[jeffrey]

I come from a family of medical doctors'

Healthcare reform is simple

Doctors and patients need to act like the old days one on one and get the insurance industry out of dictating medical treatments ridicious costs etc

I have many ideas and suggestions on how this can be accomplished

[Charles Beauchamp MD, PhD]

Here is what I am doing to change the future of health care at the age of 63. I am taking a Critical Access Hospital position as the only internal medicine physician in a rural poor county of 40,000. I will be covering primary care, inpatient care, nursing home care, intermediate care and emergency care at the hospital AND interacting with Early College High School students to motivate them to consider becoming a primary care health professional by incorporating "Public Health Biology", a "Principle of Duty" to know how to be a community health worker and a goal of being certified as a Medical Assistant / Health Educator upon graduation from High School. We (I and my fellow community hospital workers) will motivate these high school students to "work in the field" while pursing higher education as a nurse, nurse practitioner, physician assistant or primary care physician if one of these professions is reasonable personal goal. The design here is to motivate more young people to go into primary care professions even if they come from very poor socioeconomic circumstances by having a feasible means of "tracking" in that direction. There will be a heavy emphasis on their ability to contribute to changing access to quality care by participating while in high school in rural free clinics by, for example, having expertise in wound care, blood pressure self-monitoring, determination of impaired glucose tolerance, patient self-care education....and the documentation of events in the patients' lives that preceeded their presentation to the free clinic. They will be challenged by the dictum that "Every Person is a Community Health Worker" and achieving that initial goal can begin in the 9th grade.

[Dale Keshishian]

I would develop a third point of care to support the medical home & the hospital. This third care center would be staffed with medical coaches to work with physician recommendation to coach patients one on one for both chronic disease management and to provide coaching for behavior modification to avoid chronic diseases such as diabetes and heart disease. The program would be incentivized for patient participation, and tailored with goals and benchmarks. I would make these sites available in public libraries as accessible conveners for information and area resources.Interaction would be made part of the electronic medical record. Additionally,they would serve the public as resources to identify area aid agencies that provide services, particularly those needed with an aging population, such as transportation and opportunities for engagement. By centrally locating this information, each community could develop additional aid as the need is identified. This could help keep seniors in their homes, lowering the cost of institutional care and adding quality of life, as well as supporting the needs of local residents.

[Charles Beauchamp MD, PhD]

Public Health Biology concepts:
1) Portal of Entry --> serious infection. Importance of the person with predisposition to diabetes mellitus to practice self care of their feet and to immediately treat "portals of entry" in their feet to prevent amputation. The treatment for sterilization of the portal of entry right after it occurs - chlorhexidene - can also be used by sports team members to immediately treat outbreaks of MRSA. The importance of hand washing and skin sterilization by health care workers as they go from patient to patient.
2) Redox potential change --> oxidative stress --> endothelial dysfunction --> microvascular dysfunction --> regional blood flow dysfunction --> "downstream pathologies" Look up "endothelial dysfunction AND pathology AND outcome in pubmed to derive an understanding of the importance of this cascade
3) Bioenergetic production deficit --> Mitochondrial dysfunction --> fatigue and failure of functions. Role of oxidative stress in Mitochondrial Dysfunction. Role of "ischemic pre-conditioning" in positive modulation of cardiovascular outcomes. Study in India (yes there are countries that do health care research) that demonstrated an NNT of 4 for rx with co-enzyme Q10 (a "supplement") post MI to prevent death at one year. What is a randomized controlled trial? What is evidence? What is a cohort? What is an intervention?
4) Mental and Physical united via endothelial dysfunction. Depression & Anxiety Endothelial Dysfunction Cardiovascular and Diabetes Mellitus related outcomes
5) Hyperimmune response in "well young" --> Induction of ARDS like pathology in young infected with H1N1.
6) What is increasing in incidence and why? Diabetes Mellitus & complications thereof, Autism Spectrum Disorders, Sleep Apnea, Gastroparesis, Restless Legs Syndrome, premature births / low birthweight for dates..... One potential answer: increase in endothelial dysfunction. Importance of hypothesis generation and listening to the patient who will give one thoughts about why something is happening. Example: patients with diabetes mellitus reporting that benfotiamine (a fat soluble derivative of thiamine) not only reduces their peripheral neuropathy pain; it also "cured" their restless legs problem.
7) Cutural Stress (The Lone Mother) Endothelial Dysfunction Increased incidence of adverse cardiovascular outcomes. Microvascular angina and females with normal coronary arteries.

[Winifred Carson-Smith]

Nurse Practitioners have the ability to practice independently, but are impeded by barriers to competition and tradition. As independent practititioners they expand accessibility and availability to health care for consumers. While I cannot address all barriers to practice at this time, I will discuss those which I feel presently impede effective independent practice.

Medicare reimburses NPs at 85% of the physician fee schedule. As the physician fee schedule does not adequately address costs associated with the service and it is unfair to not pay all providers equally for the same service, I would change the reimbursement regulation to allow nurse practitioners and other advanced practice nurses who provide Medicare services to obtain 100% reimbursement.

Nurse practitioners and clinical nurse specialists who practice independently and obtain reimbursement from Medicare are disproportionately audited by Medicare. Although they serve as independent primary care providers or specialty service providers, they are compared to nurses who are employees of other practices. The audit process is overwhelming and serves as an disincentive for some nurses to set up practices. Medicare audits independent practice NPs because they include NPs who practice independently into the same category as NPs who work collaboratively or who are employed by MDs, so their billing seems out-of-kilter with the norm for their category of practitioners. To obtain equity and incent more independent practices, I would set up a new category of nonphysician providers -- the independent clinician -- for billing comparison and audit purposes.

I would change pharmacy software to adequately document nurse practitioner (and other nurse prescribers) prescribing patterns. Nurse practitioners who work in collaborative practices or those who are in supervised practices can prescribe independently, but their prescriptions are often attributed to their collaborating or prescribing physician, thus altering the physicians prescribing numbers, but more importantly, the attribution does not give an accurate perception of how nurse practitioners prescribe. I would alter the software to make accurate attribution to assist in the understanding of how nurses practice.

Finally, I would change state corporate practice laws to allow nurse practitioners and others to set up professional corporations. While some states have changed their professional corporation laws to address this problem, others have not and nurse practitioners have to work around the problem to set up practices in their state. For example, nurse practitioners may be employed by retail clinics, but in some states cannot set up independent retail clinics. Many nurse practitioners opt for nonprofit corporation licensure as an alternative, but again, this impedes nurses from developing profit-making practices. Nurses should have the option of setting up professional corporations and availing themselves to the benefits afforded these corporations within the state, to include access to business loans and other business support systems.

We need more health providers especially as we move to provide health care to all Americans; and artificial barriers to practice should removed to ensure that all have the value of utilizing nurses as primary care providers.