• What Can the U.S. Health System Learn From Singapore?

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    Singapore’s health care system is sometimes held up as an example of excellence, and as a possible model for what could come next in the United States.

    When we published the results of an Upshot tournament on which country had the world’s best health system, Singapore was eliminated in the first round, largely because most of the experts had a hard time believing much of what the nation seems to achieve.

    It does achieve a lot. Americans have spent the last decade arguing loudly about whether and how to provide insurance to a relatively small percentage of people who don’t have it. Singapore is way past that. It’s perfecting how to deliver care to people, focusing on quality, efficiency and cost.

    Americans may be able to learn a thing or two from Singaporeans, as I discovered in a recent visit to study the health system, although there are also reasons that comparisons between the nations aren’t apt.

    Singapore is an island city-state of around 5.8 millionAt 279 square miles, it’s smaller than Indianapolis, the city where I live, and is without rural or remote areas. Everyone lives close to doctors and hospitals.

    Another big difference between Singapore and the United States lies in social determinants of health. Citizens there have much less poverty than one might see in other developed countries.

    The tax system is progressive. The bottom 20 percent of Singaporeans in income pay less than 10 percent of all taxes and receive more than a quarter of all benefits. The richest 20 percent pay more than half of all taxes and receive only 12 percent of the benefits.

    Everyone lives in comparable school systems, and the government heavily subsidizes housing. Rates of smoking, alcoholism and drug abuse are relatively low. So are rates of obesity.

    All of this predisposes the country to better health and accompanying lower health spending. Achieving comparable goals in the United States would probably require large investments in social programs, and there doesn’t appear to be much of an appetite for that.

    There’s also a big caveat to Singapore’s success. It has a significant and officially recognized guest worker program of noncitizens. About 1.4 million foreigners work in Singapore, most in low-skilled, low-paying jobs. Such jobs come with some protections, and are often better than what might be available in workers’ home countries, but these workers are also vulnerable to abuse.

    Guest workers are not eligible for the same benefits (including access to the public health system beyond emergency services) that citizens or permanent residents are, and they aren’t counted in any metrics of success or health. Clearly this saves money and also clouds the ability to use data to evaluate outcomes.

    The government’s health care philosophy is laid out clearly in five objectives.

    In the United States, conservatives may be pleased that one objective stresses personal responsibility and cautions against reliance on either welfare or medical insurance. Another notes the importance of the private market and competition to improve services and increase efficiency.

    Liberal-leaning Americans might be impressed that one objective is universal basic care and that another goal is cost containment by the government, especially when the market fails to keep costs low enough.

    Singapore appreciates the relative strengths and limits of the public and private sectors in health. Often in the United States, we think that one or the other can do it all. That’s not necessarily the case.

    Dr. Jeremy Lim, a partner in Oliver Wyman’s Asia health care consulting practice based in Singapore and the author of one of the seminal books on its health care system, said, “Singaporeans recognize that resources are finite and that not every medicine or device can be funded out of the public purse.”

    He added that a high trust in the government “enables acceptance that the government has worked the sums and determined that some medicines and devices are not cost-effective and hence not available to citizens at subsidized prices.”

    In the end, the government holds the cards. It decides where and when the private sector can operate. In the United States, the opposite often seems true. The private sector is the default system, and the public sector comes into play only when the private sector doesn’t want to.

    In Singapore, the government strictly regulates what technology is available in the country and where. It makes decisions as to what drugs and devices are covered in public facilities. It sets the prices and determines what subsidies are available.

    “There is careful scrutiny of the ‘latest and greatest’ technologies and a healthy skepticism of manufacturer claims,” Dr. Lim said. “It may be at the forefront of medical science in many areas, but the diffusion of the advancements to the entire population may take a while.”

    Government control also applies to public health initiatives. Officials began to worry about diabetes, so they acted. School lunches have been improved. Regulations have been passed to make meals on government properties and at government events healthier.

    In the United States, the American Academy of Pediatrics and the American Heart Association recently called on policymakers to impose taxes and advertising limits on the soda industry. But that’s merely guidance; there’s no power behind it.

    In Singapore, campaigns have encouraged drinking water, and healthier food choice labels have been mandated. The country, with control over its food importation, even got beverage manufacturers to agree to reduce sugar content in drinks to a maximum of 12 percent by 2020.

    Should beverage companies fail to comply, officials might not just tax the drinks — they could ban them.

    Singapore gets a lot of attention because of the way it pays for its health care system. What’s less noticed is its delivery system.

    Primary care, which is mostly at low cost, is provided mostly by the private sector. About 80 percent of Singaporeans get such care from about 1,700 general practitioners. The rest use a system of 18 polyclinics run by the government.

    As care becomes more complicated — and therefore more expensive — more people turn to the polyclinics. About 45 percent of those who have chronic conditions use polyclinics, for example.

    The polyclinics are a marvel of efficiency. They have been designed to process as many patients as quickly as possible. The government encourages citizens to use their online app to schedule appointments, see wait times and pay their bills.

    Even so, a major complaint is the wait time. Doctors carry a heavy workload, seeing upward of 60 patients a day. There’s also a lack of continuity. Patients at polyclinics don’t get to choose their physicians. They see whoever is working that day.

    Care is cheap, however. A visit for a citizen costs 8 Singapore dollars for the clinic fees, a little under $6 U.S. Seeing a private physician can cost three times as much (still cheap in American terms).

    For hospitalizations, the public vs. private share is flipped. Only about 20 percent of people choose a private hospital for care. The other 80 percent choose to use public hospitals, which are — again — heavily subsidized. People can choose levels of service there (from A to C, as described in an earlier Upshot article), and most choose a “B” level.

    About half of all care provided in private hospitals is to noncitizens of Singapore. Even for citizens who choose private hospitals, as care gets more expensive, they move to the public system when they can.

    So Singapore isn’t really a more “private” system. It’s just privately funded. In effect, it’s the opposite of what we have in the United States. We have a largely publicly financed private delivery system. Singapore has a largely privately financed public delivery system.

    There’s also more granular control of the delivery system. In 1997, there were about 60,000 ambulance calls, but about half of those were not for actual emergencies. What did Singapore do? It declared that while ambulance services for emergencies would remain free, those who called for nonemergencies would be charged the equivalent of $185.

    Of course, this might cause the public to be afraid to call for real emergencies. But the policy was introduced with intensive public education and messaging. And Singaporeans have identifier numbers that are consistent across health centers and types of care.

    “The electronic health records are all connected, and data are shared between them,” said Dr. Marcus Ong, the emergency medical services director. “When patients are attended to for an emergency, records can be quickly accessed, and many nonemergencies can be then cleared with accurate information.

    “By 2010, there were more than 120,000 calls for emergency services, and very few were for nonemergencies.”

    Singapore made big early health leaps, relatively inexpensively, in infant mortality and increased life expectancy. It did so in part through “better vaccinations, better sanitation, good public schools, public campaigns against tobacco” and good prenatal care, said Dr. Wong Tien Hua, the immediate past president of the Singapore Medical Association.

    But in recent years, as in the United States, costs have started to rise much more quickly with greater use of modern technological medicine. The population is also aging rapidly. It’s unlikely that the country’s spending on health care will approach that of the United States (18 percent of G.D.P.), but the days of spending significantly less than the global average of 10 percent are probably numbered.

    Medical officials are also worried that the problems of the rest of the world are catching up to them. They’re worried that diabetes is on the rise. They’re worried that fee-for-service payments are unsustainable. They’re worried hospitals are learning how to game the system to make more money.

    But they’re also aware of the possible endgame. One told me, “Nobody wants to go down the United States route.”

    Perhaps most important, the health care system in Singapore seems more geared toward raising up all its citizens than on achieving excellence in a few high-profile areas.

    Without major commitments to spending, we in the United States aren’t likely to see major changes to social determinants of health or housing. We also aren’t going to shrink the size of our system or get everyone to move to big cities.

    It turns out that Singapore’s system really is quite remarkable. It also turns out that it’s most likely not reproducible. That may be our loss.


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  • Preparation

    Almost 8 years ago I posted a quote from Toshiro Kageyama (1926-1990), a professional Go player. It speaks to what it means to be (what is required to be) a professional. I return to that post often and encourage you to read it. I want to focus on a part of it here and add a new interpretation.

    [To be a professional], the fundamentals have to be handled subconsciously. For example, if you watch the way a star infielder moves in baseball, you will observe that no matter how difficult the bounce or how hard the line drive, he meets it frontally, faithfully following the fundamentals.

    In fact, if you watch how an infielder moves in baseball, some of it is before the ball is struck by the batter or even thrown by the pitcher. Moreover, it’s not random movement. It’s specific, routine movement. This is important preparation, and it happens even before the play has begun. It’s not part of the game, but it’s what helps the players play the game at a high level. It’s part of the canon of fundamentals.

    There’s the thing and there’s what you do to best prepare to do the thing to your fullest ability.

    Trumpet playing is like this too. As with any instrument, there’s a lot of preparation involved to reach any level of proficiency, whether amateur or professional grade. These include things one should do in the seconds before one plays, akin to an infielder’s preparation before the pitch. I don’t need to describe them. Suffice it to say that until recently I wasn’t consistently doing them, as was pointed out to me at a lesson. I wasn’t doing them even though I knew I should do them. At times I was deliberately not doing them.

    To eschew the fundamentals is self-limiting. Why do that?

    Certainly there are lots of reasons one fails to prepare, even if one knows how. One of them is a lack of seriousness. This may stem from a feeling that our modest abilities are not worthy of preparation. Maybe we worry we’d look like we’re putting on airs to do all that professional-looking preparation just to make an amateur sound or to field a baseball like a novice.

    (In truth, these are relatively subtle movements, not grand gestures. There’s no rational, objective reason to be embarrassed about them. Moreover, just because we do them doesn’t mean anyone thinks we think we’re professionals. To feel that way is to be overcome by a warped sense of vanity.)

    There’s a disrespect in an attitude that leads to deliberate avoidance of preparatory fundamentals. We’re not respecting the thing we’re trying to do. And, we’re disrespecting others in our presence with whom we are trying (or should be trying) to achieve the best performance (like a rehearsal or lesson).

    These insights cannot possibly be unique to the trumpet, or to baseball or Go. Everything I can think of requires preparation to do well and a serious, respectful attitude to do that preparation. This certainly includes writing — something I can legitimately claim to do at a professional level.

    When I teach writing, I convey some of the preparatory fundamentals. And then I observe lots of students failing to do the fundamental things they profess to know they should do to improve. This is very common.

    It’s probably not always a lack of seriousness, a lack of respect. But sometimes it could be. Whatever the endeavor, if this is the source of the problem, it’s rather disappointing, isn’t it? I would think recognizing that should be ample motivation to change.


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  • Healthcare Triage News: Time Zones May Not Be Great for Your Health

    A brand new study indicates that where you live in a time zone can reduce how much you sleep, and have general negative impact on health. So, do we actually need time zones?


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  • Healthcare Triage: Why Have Doctors Been So Slow to Embrace Email?

    Medicine has been slow to catch up with the idea of email communication in the workplace. Electronic consultations are less expensive and can be more convenient than in-person visits, but they aren’t without cost.

    This episode was adapted from a column Austin wrote for the Upshot. Links to sources can be found there.


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  • Plantar Fasciitis, and Finding a Balance in Following Doctor’s Orders

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page A17 of the print edition on April 16, 2019.

    People rarely follow a doctor’s orders to the letter.

    We often seek treatments that meet our preferences, and adapt them to our personal routines and responsibilities.

    This isn’t necessarily a problem. A treatment you don’t (or can’t) follow won’t help you, so the odds are better if you pick one you can.

    In addition, not every treatment works for everyone — sometimes the best treatment we have works for just one of 10 people.

    These truths came to mind as I recently addressed my plantar fasciitis— an injury to the tissue in the underside of the foot causing heel pain and afflicting about 10 percent of the population. I’d unwisely been trying for about six months to ignore the condition in both my feet. I kept walking to work and standing once I got there (by choice — I have a desk job) despite the discomfort.

    Predictably, this rigid adherence to my lifestyle caused only more harm. Yielding a bit to my screaming feet, I stopped standing at work and cut my walking to a minimum, swimming for exercise instead.

    This helped, but not enough to heal fully. The pain diminished but didn’t cease. Clearly, I needed to bend a little more, but which way and how much? Those are questions medical science and doctors cannot answer precisely.

    Although somewhat disappointing, this is also empowering. There are dozens of therapies for the condition. I prioritized those that were recommended by doctors and for which there is good evidence, and that I felt I could stick with.

    Although sometimes more invasive approaches are necessary with some modification of activity, most soft tissue injuries heal themselves in time. For 90 percent of patients, nonsurgical approaches to plantar fasciitis heal in four to six months. After that, you are looking at years to a lifetime of maintenance to avoid relapse. “Treatment” is really “lifestyle change.”

    The log I kept. I didn’t want to break my streak.

    And what does one do over this duration? As with other soft-tissue injuries, addressing plantar fasciitis usually includes a mix of reducing and replacing injuriously repetitive body mechanics (which I had already done), calming inflammation or repairing tissue micro tears, and increasing flexibility and strength.

    To choose an approach, I listened to my doctor’s advice. I also searched online and talked to friends who’d had the condition. And I consulted medical research to see if what was recommended had any validity. Finally, I targeted and stuck with treatments I felt I could fit into my life, always knowing that if they didn’t work, I could make a bigger change later. For example, though some studies support it, I did not pursue acupuncture because of the time involved in going to appointments.

    There are several noninvasive or home-based remedies for planar fasciitis. Among the most common are orthotics, night splints (which hold your foot flexed to stretch the plantar fascia and Achilles’ tendon) and physical therapy (or at-home stretching/strengthening).

    What does the research say about these? Orthotics help. Evidence shows that over-the-counter ones are just as effective as custom-made ones, and cost about one-tenth. They’re a set-it-and-forget-it approach. Unless they’re a bad fit, you won’t notice them, and there’s nothing to do to use them but stick them in your shoes. This was easy to work into my life. I bought some.

    To provide additional support, you can also apply kinesiology tape, a stretchable athletic tape. A few studies suggest a benefit. I tried this, but only when I could not avoid long walks. At a few dollars per application to your foot, the tape is expensive. It also takes a few minutes to apply. Although perhaps a bit helpful, I didn’t perceive it worth it for daily use.

    Night splints also work. Combining them with orthotics can accelerate healing. They can be difficult to sleep with, however. There are lots of types, but for each one there at least some patients who say they disrupt rest. I used them as much as I could (about three hours per night) and abandoned them as I felt better so that I could more easily sleep. To a large extent, lifestyle considerations (adequate sleep) triumphed over this therapeutic approach.

    The evidence on the effectiveness of stretching for plantar fasciitis is not strong. Nevertheless, it is frequently recommended, and I did find that it helped relieve discomfort in the short term. There are dozens of stretches. A study that compared two popular ones — a standing calf stretch and a seated foot stretch — found the foot stretch to be superior. Whatever stretching I did, I made sure to include that one.

    At three times per day for about 10 minutes, a full stretching regimen takes considerable time. To fit it in without much disruption, I often did the foot stretching under the table during meetings and on conference calls. As for the calf stretch, I could do some of it while brushing my teeth or waiting for the train during my commute.

    Trigger point therapy — massage, basically — can also help. If nothing else, it feels good. I threw that into my therapeutic mix, too, working my feet with massage balls as I typed and my calves with my hands as I read.

    Finally, there’s strengthening. Here, there is good evidence that some approaches are very helpful, including a heel-raising variant previously described by The Times. It’s very tiring and time consuming, particularly if done according to the clinical trial (three or more sets per session), and requires a step off which to hang one’s heel.

    The “short foot” exercise — pulling your toes toward your heels and arching the foot upward — may also be helpful. It requires no equipment and can be done surreptitiously anywhere. Now pain free, I’m doing both. I brought a yoga block to work so I could do heel raises during calls.

    There is a lot of gray area in medicine. This mix of approaches worked for me, in large part because I found a way to fit its elements into my day, abandoning those I could not. Your approach — for this or any condition — may be different from mine. But one similarity may be that it is shaped not just by medical science, but also by the realities of life.


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  • Healthcare Triage News: Why Do Insulin Prices Keep Rising?

    Frederick Banting discovered insulin in 1921and didn’t want to profit off of such a life-saving drug. Fast forward to 2019, and the price of insulin continues to increase year over year. Why is that?


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  • Can Doctors Talk Teenagers Out of Risky Drinking?

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    I’m a pediatrician, and when I see adolescents in my clinic, I ask them if they are drinking alcohol (among other risky activities). Then I counsel them if they answer in the affirmative. I want young people to be safe.

    But doctors lack the evidence base — we don’t have enough studies — to know how much of a difference this makes.

    Here’s why we may want an answer. Excessive drinking is responsible for 88,000 deaths per year in the United States, about one in 10 deaths among working-age adults. The cost in 2010 was almost $250 billion.

    And drinking is a serious problem among adolescents. More than 9 percent of those 12 to 17 years drink alcohol, and almost 5 percent engaged in binge drinking in the last month.

    We know how to screen people for alcohol misuse. It’s not hard. The Alcohol Use Disorders Identification Test-Consumption asks three simple questions: how often people drink, how much, and how often they drink heavily.

    The Single Alcohol Screening Question asks simply, “How many times in the past year have you had 5 (men)/4 (women) or more drinks in a day?”

    The latter is positive (when the answer is more than once) in about 80 percent of people who have unhealthy use of alcohol (as defined by the National Institute on Alcohol Abuse and Alcoholism) and negative in about 80 percent of people who do not. That’s pretty good for a quick one-question screen.

    There are also specific screening tools that have been validated for pregnant womenadolescents and older people.

    Asking a question in a visit costs very little, other than time. It also has few harms. So why not recommend it for everyone?

    Screening is useful when a condition is prevalent, when we can screen in a cost-effective manner, when early diagnosis makes a difference, and when we know that acting on that screen will make a difference.

    Dr. Susan Curry, the immediate past chairwoman of the U.S. Preventive Services Task Force, told me: “There have simply not been enough studies that assess the effects of screening and behavioral counseling in adolescents to address this issue. In addition, many of the existing studies have been conducted in school settings, and it is unclear if the results would translate to primary care.”

    The effects of behavioral counseling on adults are proven enough to show a moderate benefit. The same holds true for pregnant women, although the evidence is a bit less strong. But when it comes to adolescents, the evidence is almost nonexistent.

    In a large systematic review, there were two studies (out of 68 total) that addressed how counseling interventions might affect adolescent alcohol use. One was a randomized controlled trial of 119 urban adolescents screened in a medical clinic, published in 2015, that used peer networks and motivational interviewing. Over all, it failed to achieve statistical significance with respect to reducing alcohol use.

    The other was a 2017 randomized controlled trial in Switzerland schools (not clinics) of a web-and-text-based peer-network messaging system to reduce single-occasion binge drinking. It decreased the chance of that happening by 5.9 percent in the intervention group. But it had no effect on how much youths drank over all or the estimated peak blood alcohol concentration during binge drinking.

    That’s all we’ve got. And before 2015, there was nothing.

    “We are calling for additional research in all areas related to screening adolescents for alcohol use and providing counseling interventions to those who need them,” Dr. Curry said. “It is also important to explore whether such interventions could reduce other risky behaviors. In the meantime, we encourage primary care clinicians to use their clinical judgment when deciding whether to screen their adolescent patients for alcohol use.”

    There’s disagreement on the definition of unhealthy alcohol use for adults.

    For men, risky drinking is more than four drinks on any day or more than 14 drinks in any week, according to the national institute. And for women, it’s more than three drinks on any day or more than seven drinks in any week. (The institute defines a drink as 12 ounces of beer, 5 ounces of wine or 1.5 ounces of spirits.)

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  • Healthcare Triage: Racial Disparities in Healthcare are Pervasive

    Study after study affirms that doctors treat their patients differently, depending on the patient’s race. Minority patients get different diagnoses, different treatments, and are often subject to being stereotyped by their physicians.

    This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.


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  • Healthcare Triage Podcast: Multiple Myeloma, Bicycles, and Working Toward a Cure

    This month, Aaron is talking to Dr. Rafat Abonour about multiple myeloma. Multiple myeloma is a cancer that forms in white blood cells, and Dr. Abonour tells Aaron about how the disease affects patients, and the cutting edge of research into treatments. And we get a nice story about biking.

    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

    As always, you can find the podcast in all the usual places, like iTunes and Soundcloud.


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  • Healthcare Triage News: There’s a New Drug for Postpartum Depression and it is EXPENSIVE

    This is HCT News from Friday…

    Postpartum depression is depressingly common, and it has lots of terrible consequences for moms, for kids, and for families. A new drug is about to hit the market, but it’s not a great fit for everyone, and it is PRICEY.


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