Musings on Healthcare… and Seeking Value-Based Healthcare

Spending the least amount of money to achieve the best outcomes for everyone should be the goal of every healthcare enterprise. We make progress and we lose ground on this front. During the Covid-19 pandemic, we got very creative in how to stretch resources. One of the biggest temporary regulatory maneuvers, was to expand telehealth within states and across state lines- reciprocity licensure. Telepsychiatry across state lines turned out to be extremely beneficial. This was especially beneficial for college students, suddenly scattered across the country, with established care through their institutions of higher learning. There were all kinds of benefits including working with a person from your own culture, in your native language and continuity of care. Now that the pandemic is over and the emergency measures are being rolled back, we must regress to pre-pandemic practices. Is this the right thing to do? In the current issue of JMR, Ludmila de Faria and colleagues address this important question.¹

How did telehealth get its start? In 1957 Reba Benschoter, with a PhD Psychiatry and an MA in Television and Education, was hired by Cecil Wittson, MD, head of the Nebraska Psychiatric Institute, future Chancellor of the University of Nebraska Medical Center. He was a Navy psychiatrist who knew the value of telecommunications and of education. He encouraged Dr. Benschoter to put serious effort into education and communications. And she did. A media technician, van Lear Johnson, wired the building, and eventually remote sites, for sound and eventually cable television. (I can attest to the fact that there were big cameras in every room and cables everywhere in that building when I was a student.) After 9 years of local testing, on December 2, 1964, the first two-way closed-circuit telemedicine system was put to work. It connected the Nebraska Psychiatric Institute with the Norfolk State Hospital 112 miles away. It radically changed the way psychiatrists and neurologists conducted exams, individual and group therapy, as well as how residents at the remote site learned. These physicians were able to teach and do work during the many hours that they would previously been driving to the remote sites. The Norfolk State Hospital with 27 wards, 900 patients, and a staff that felt like custodians and not therapists, was transformed. By 1968 the number of inpatients was reduced to 476, the staff was able to perform therapy again, and many families were able to take their loved ones home on remote therapy and medications. It was great! It radically changed clinical medicine forever. University of Nebraska Medical Center became known as the 500-mile-wide campus.

In 1966 Dr. Benschotter addressed the New York Academy of Sciences on the use of interactive television to teach and treat patients remotely. She beat NASA! Well-funded by the National Institutes of Health and others, Dr. Benschoter put new technologies into use on a nearly daily basis through the 60's, 70's, and 80's with regard to telehealth and distance learning. Medicine and therapeutics from a distance were not completely new. In the Middle Ages healers would get letters from afar with a flask of urine to run diagnostics on.² In return they would recommend therapies or send medications. Now we interact with our healthcare providers via e-mail and text messaging between visits. We have reinvented the wheel of telehealth and remote education many times. Is the future even brighter for connecting remotely?

Most of us agree there is nothing like an in-person interaction with our providers, but there are not enough of us. The pandemic has highlighted the inequality to basic and advanced care for our citizenry and how limited the capacity of our facilities is. It has also pushed the healthcare workforce to the highest level of exhaustion, burnout, and self-harm. We need desperately to resuscitate our physicians, nurses, and other providers. We need to expand training capacity for young physicians, nurses, physician assistants, and others. Computer based learning in healthcare during Covid has helped but is fraught with lack of clinical skills. Perioperative care cannot be performed remotely, though one time head of CMS, Don Berwick did suggest that a few years ago. Anesthesiologists billed ourselves as “made for this moment.” We continued to run the operating rooms for urgent and emergent cases. We stepped up to perform critical care and mange airways—increasing our personal risks, time commitment and the intensity of the work tremendously. All the while the race riots and gun violence strained our system and our souls to keep going. The onslaught of demand for care continues as we desperately try to catch up with the postponed needed “elective” surgeries. Our current residents have only practiced during Covid…How will they fare? What will the new normal be? They have resilience and I am optimistic.

Outside the operating room, many people who present to their local hospitals are evaluated by telehealth to determine whether transport to tertiary centers is necessary. Currently, substance use disorder is being addressed with the assistance of telehealth. In this country, one person dies of an overdose every 5 minutes.³ Many of these individuals got “hooked” after elective surgery and more education is needed regarding pain control and prescribing strong analgesics and benzodiazepines after procedures. Narcotics are required for severe pain in the first day or so after painful surgery. Benzodiazepines may help with certain muscle spasms, but greatly increase the dangers of overdose in combination with narcotics. The CDC now recommends that every prescription for narcotics be accompanied with a prescription for Narcan. We must increase the ability to safely discard unused narcotics, so the temptation is not there for those who come across them in their homes. Tylenol, Motrin, and physical activity is effective and in many instances controls pain better and with fewer side effects than narcotics long term. Tele-counselling and medication assisted treatment is tricky, but we must stop the tremendous loss of human lives.

I firmly believe that healthcare in this country has a bright future. As we add individuals from every race, creed, color, and belief to our healthcare workforce, we will connect in more meaningful ways with those we serve. New knowledge, better patient education by a more diverse workforce in a more robust system with telecare or in person access to care for all will prevail. As history has proven, we will be surprised by how the future unfolds!

Stay well. Lock up your guns and ammunition. Turn in your unused controlled substances.