“We have nothing as bad as America’s worst, and nothing as good as America’s best,” wise words said to me by someone many years ago, and this principle has stood the test of time. There are certainly many dreadful things in American healthcare, but there are also wonderful services and excellent innovation with a rigorous evaluation for each of them. In my collection of ten classic articles on better value healthcare, eight come from the United States. This is a paradox. Although they have no finite budget and do not have full population coverage, the thinking and the innovation within healthcare organisations such as Kaiser, or universities such as Harvard or Dartmouth, is streets ahead of the debate in the United Kingdom. But let’s not feel too bad as we have nothing as bad as the worst, for example, the Republican views on healthcare, and the millions who are uninsured. more…

Here is my third and final blog on the USA trip: After Seattle’s integrated care organisations, we visited CalPERS. They fund $6.7bn worth of healthcare for 1.3 million people (roughly twice what we have per person in Lincolnshire). They see themselves as “active” purchasers: managing the market to reduce costs. About two thirds of their members are in capitated plans (for instance Kaiser) whilst the remainder are in a PPO plan (Preferred Provider Organisation). Simple examples of their interventions were to remove co-pay from preventative care for members, to have fiscal and chronic disease management targets and to set a tariff for knee replacement–it all felt familiar. What wasn’t was their analysis by price for knee replacement. It revealed a staggering variation from $15k to $120k. With 46 hospitals they agreed a tariff of $30k but patients could choose to use hospitals that refused the tariff – so long as they paid the difference. It made me think why a tariff for planned procedures may not be such a bad idea. more…

Following our visit to Kaiser Permanente, we travelled north to Seattle and visited the Virginia Mason hospital and Group Health. Linked but distinct, the relationship between the two provided a contrast to Kaiser Permanente – though, as organisations seeking integrated care, there were common themes.

We spent a day at Group Health and yet again I was struck by their emphasis and focus on Primary Care as the central driving force for delivering value: high quality care associated with (relatively, for the USA) lower costs. The term they use for this concept is Medical Home. As at Kaiser, there was a strong culture of medical leadership; the primary care physician is valued as a leader and integrator of care. Their Primary Care Centre (Medical Home) managers all had a clinical background, as well. more…

Sir William Osler advocated the concept of a “quinquennial brain dusting“: which was my justification for taking a week out to visit some integrated care organisations on the West Coast of the USA, with a group from the NHS.

I know we feel challenged in the UK, but the scale and nature of the challenge in the USA made me wonder whether we shouldn’t really count ourselves lucky. The system there is definitely not one to be emulated. International comparators reveal high costs, inequity and, overall, poor outcomes for the population in general. Public spending in the USA covers 30% of the population and represents 8% of GDP. The UK spends 7.8% of GDP on the NHS, for 100% of the population. more…

Demonstrations for and against the question of abortion are going on all this week outside a clinic in Germantown, Maryland, in the suburbs of Washington, DC. Opponents of abortion have also broadened their attack to seek greater restrictions on sex education and reproductive health. They have particularly targeted government funding and services contracts for the medical charity Planned Parenthood. As that plays out, the BMJ spoke with a physician at the traditional epicentre of the US abortion wars. more…

Here in United States, the latest must have app contains software that blocks any mention of the actor, Charlie Sheen. Until recently, Sheen was the highest paid television star in the world but was fired last week after making caustic comments about his employers in public. Subsequently, he has just been awarded the Guinness World record for having the fastest time to gather more than 1 million followers on Twitter with his devotees presumably awaiting more linguistic utterances such as #biwinning or #tigerblood.  As has been pointed out elsewhere and recently, the Internet can be an unforgiving forum to bare one’s innermost thoughts especially if they contain expletives and unflattering comments about work colleagues. The medical profession seems to be particularly sensitive about this issue and a number of professional organisations have started to publish guidelines for medical students, junior doctors, and other healthcare professionals about how to behave online. It cannot be long before another new app will be created that can vacuum up embarrassing content from Facebook and other social networking sites and destroy the evidence for ever. However, this type of app is likely to be premium priced. more…

Here on the edge of Silicon Valley we have just had a visit from Barack Obama. His schedule included closed door meetings with the tsars of technology; Jobs (Apple), Zuckerberg (Facebook), and Schmidt (Google). Although the meeting agenda is unknown there is a suspicion in the technosphere that the president is hoping for substantial help from the Tech giants with healthcare reform, in particular by reducing the burden and cost from dealing with chronic disease. Certainly there are a huge number of start-up companies trying to get into the potentially lucrative healthcare market and unlike the rest of the Western world, there is also plenty of cash available. Venture capitalist companies have even taken to billboard advertising on the side of the major freeway that runs through the Valley from San Francisco to San Jose. more…

The theatre of politics has been on full display in Washington of late. Last week, the House of Representatives voted to repeal the Patient Protection and Affordable Care Act passed in March last year that, among many other things, will ensure that more Americans have health insurance coverage. The vote was largely symbolic for the new Republican-controlled House. For the repeal to become law, it would have to be passed by the Senate, where Democrats have held onto a slim majority, and would finally have to be signed into law by the President. Even with a Republican controlled Senate, the repeal would stall at President Obama’s desk. more…

“Only two things that money can’t buy, and that’s true love and homegrown tomatoes.” So sings Guy Clark in his cult country-western song. He was right about that last year, when the tomatoes in much of Massachusetts (including those in the backyard garden of yours truly) were hit with late blight. That’s the same fungus that caused the Irish potato famine. But he’s not right about that this summer. Growing conditions have been perfect for tomatoes, and we have a bumper crop.  At the Thursday farmer’s market in the affluent Boston suburb of Milton, organic heirloom tomatoes fetch roughly US$4 a pound. According to Mark Smith, the director of Brookwood Community Farm in Milton, which sells produce at this market, even that price doesn’t deter buyers. The tomatoes sell out quickly. more…

One of her ambitions is to climb Kilimanjaro. It’s a tough climb even for a determined and committed woman like Regina Benjamin, Surgeon General of the United States. And, if the Surgeon General sets a target, people will remember. We met, appropriately, at the American College of Sports Medicine meeting in Baltimore after she had given a short talk and led a walk around the harbour area. more…