Better outcomes for patients ignored

I posted this to the National Journal Healthcare blog this morning:

I waited to write this blog because I was hopeful that someone would comment on the July 2, 2009 New England Journal of Medicine article, “The Effect of Medicare Part D on Drug and Medical Spending.” What Zhang, Donohue, Lave, O’Donnell, and Newhouse reported was that “Groups that had no or minimal drug coverage before the implementation of Part D had reductions in other medical spending that approximately offset the increased spending on drugs, but medical spending increased in the group that had more generous previous coverage.”

These findings bring to the forefront the reality of our health care system - just because you do the right thing for a person’s best health does not mean that it will reduce cost or have the same effect for everyone. We can all agree that it is better to take medicine than to have “other medical spending” because it means that you are able to manage your disease. This was the outcome for those who had the least coverage before Medicare Part D. For those who had more coverage the findings are harder to interpret.

In the same way that Medicare Part D was the right choice for patient health, expanding health insurance coverage to all, including preventive care coverage, is the right thing to do now. But we must be honest. Just because it is the right thing to do does not mean it will save money.

The key point is that health care is complex and deserves more than sound bites especially because it is about life, death, and the difficultly in measuring the quality of life.

Health Care Costs: More than Dollars

I posted this to the National Journal Healthcare blog this afternoon:

Today’s New York Times article ”In Health Reform, a Cancer Offers an Acid Test” is the type of analysis and discussion that makes me shudder when I think of how easy it is to misuse the findings from proposed comparative effectiveness research when the focus is just cost. The Times has a chart comparing the average cost of the five types of treatment for prostate cancer. What is lacking is how each procedure impacts the life of the person receiving the treatment.

I propose that all those considering health care reform remember to take the perspective of the patient and health consumer. For each procedure what needs to be included as part of any cost or effective analysis there is also a new measure that takes into account consumer’s assessment of PAID (pain, absence from work, invasiveness of procedure, and disability.) for each procedure under consideration. Patients need more information but it is more than just cost of the procedure.

Reading between the lines

There has been much hubbub about the New Yorker article comparing El Paso to McAllen and virtually nothing about Richard Cooper’s article, ”States With More Health Care Spending Have Better Quality Health Care: Lessons About Medicare.” (December 4, 2008 Health Affairs – Web Exclusive). It is easy to understand why.

The New Yorker analysis resonates to the mythology that pervades thinking about health - that there is great variability in costs of health care because in some areas physicians are not doing what is good treatment but rather taking actions that will only increase their income. The suggestion is made that where there are high Medicare costs it is because there is much waste and the suggestion is stretched to explain all the waste in health care.

Cooper’s analysis however looks at all health spending instead of the slice represented by Medicare data. Cooper finds that, “Medicare spending per enrollee correlates poorly with total health care spending per capita.” He takes it one step further with the data he presents to state that regional variation in Medicare is not a valid measure of how well the health care system is working.

My question is simple - then why do we keep using Medicare data the way we do?

Best Outcomes for All

I just finished the first edits on my book (look for it in early 2010) and am so glad that I will be able to write my blog again. The best part about writing a new book is that it is an opportunity to look across sectors and see what is on the horizon that will shape our health and well being. In many ways the new developments left me hopeful. At the same time it became clear that it was time to rethink some of the terms used by the health cognoscenti.

Let’s begin with discarding the conceptual framework of ED (not the one of blue pill fame) but as in “Elimination of Disparities” a term which over the past decade has had increased popularity. Too often ED became the new code for addressing the health care needs and concerns of Hispanics, African Americans, Asian Americans, Native Americans, and other communities.

The research that ensued documented the differences in care and treatment. With ED too many made the assumption that the best treatment would be the same for all. I knew that was a mistake because too often the goal of equal treatment did not sufficiently focus on outcomes.

There are differences among individuals and the best health care for a non-Hispanic woman in Minnesota may not be what is best for a Latina in Santa Fe. If fact, there is a growing body of evidence that the Latina is less likely to practice unhealthy behaviors like smoking and is likely to live longer that the woman in Minnesota.

As we enter one of the most robust debates we have had on health care, the need should not be to standardize treatment but to design systems that achieve the best outcome for all (BOA). The goal should be “Best Outcomes for All”; not on the average but at the individual level. That is something we can all get behind.

Saving money is not always good news

It will be refreshing when I go to a meeting and people present data in a way that tells the full story. Take the recent thrown around fact that we have spent less money on Medicare Part D than had been projected. Isn’t it great that we saved billions of dollars? The reality is that half of the savings come from the failure to enroll all of the modest income persons who are eligible for extra help in paying for their medicines. While the savings may sound good, the challenge remains to enroll all those eligible in a program that helps them get the medicines they need.

Hispanics Have Highest End-of-Life Costs

A study published this week in the Archives of Internal Medicine found that in the last six months of life cost for care for Hispanic patients ($31,702) was 60% higher than for non-Hispanic white ($20,166) patients. I have been there at the end-of-life for four people who were very close to me. If the costs are higher for Hispanics than for non-Hispanics whites I would say it is because no one took the time to talk to the patient and the patient’s family.

Hispanics are the group least likely to have a regular source of care. This means we are also less likely to have a relationship with a provider who understands our wishes on end-of-life issues. Ensuring the dignity and comfort all people deserve at the end-of-life is one more reason why health reform is so important. Hispanics must have access to health care providers who can understand their patient’s language and cultural values and can support families in their decisions about end-of-life care. It’s a simple matter of quality of care.

Five Popular Health Care Myths in 2009

In my latest post to the National Journal Healthcare Blog, I identify five popular health care myths in 2009.

Early Death Means Health Care Savings

While there is much agreement about the need for health care savings we also need to agree on how we define good health services and outcomes.  CBO Director Elmendorf’s comment below needs our careful consideration:

"Even if successful, measures to reduce smoking and obesity—two factors linked to the development of chronic and acute health problems—might not have a substantial impact on health care spending for some time.  In the long term, spending on diseases caused by poor health habits could decline substantially, but the impact on federal costs would also have to account for people living longer and receiving more in Medicare benefits (for the treatment of other diseases and age-related ailments) as well as other government benefits that are not directly related to health care (including Social Security benefits)."

--Douglas W. Elmendorf; Director, Congressional Budget Office 

   Testimony before the Senate Finance Committee

   February 25, 2009

Prevention Is Not About Saving Money; It’s About Saving Lives

There are so many discussions going on about health that it is hard to keep track of which policy would make the most impact. Too often it is a case of holding on to the old models that defined the business of health care. Just as business has learned that fundamental aspects of their models were flawed the best health policies change some of the fundamentals of the current health debate. A good place to start is to rethink the purpose of prevention.

Prevention may save money and it may not. Last month Health Affairs reported that “... hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them.” As The Washington Post pointed out, when prevention works it extends life and there are the costs of using health care over those additional years of life. Also prevention requires reaching large population groups and that requires resources.

The additional costs of prevention is a matter of what we value. The benefits of breathing with ease from not smoking, not dying young from cancer through early detection, or not having a heart attack from starting to exercise are well worth the costs.

The cost savings through prevention is not what should make it worth doing but rather how it contributes to the vibrancy and productivity of our society. Prevention is important simply because it is the right thing to do.

How Business Misses the Boat and the Consumer

St. John Knits represents what many executive women wear. I have shuddered at the prices but enjoy the basics and the decades of wear classic pieces provide. I also admit that I never paid full price. Many of my purchases were at last call sales and outlets. Nevertheless, these were investment pieces for many women.

So I wondered what George Sharp, Executive Vice President of Design for St. John Knits was thinking when he had Marie Gray (the founder of St. John) send a letter to her customers saying that the basic color black was being replaced by a new shade of black that would be their new standard. The new environmentally friendly collection would be called Caviar.

During these times does anyone think that women want to purchase new basics? Caviar is not black. And basics are basics. This is another example of how business thinking and strategic planning can lead people down a path that is no longer valid.

As for me this means that St. John is no longer the good investment. St. John is showing as much volatility as the market. One of my colleagues who usually paid full price will not buy the new and refers to her old classics as “Period St. John.” The lesson for business is obvious. It seems consumers adapt; and, we are not adapting by just buying more.

Charity Navigator - Why Many Good Organizations Are Not Listed

Charity Navigator only covers 5,300 organizations and while that may sound like a lot it is only a fraction of the not-for-profits in the U.S.

Did you ever wonder why that is the case?

At the National Alliance for Hispanic Health we are of course proud of our exceptional work in terms of health but we also consider ourselves to be a role model for our stewardship of our finances. We were concerned that somehow we had missed being listed by Charity Navigator. So we went through the process of submitting all the information that they required.

We waited and waited and received no response. Our most recent communication from them provided insight into their process.

“Thank you for contacting Charity Navigator. Due to the volume received, we are unable to give status reports regarding charities suggested for evaluation. Please know we have in excess of 1,800 eligible charities awaiting review. Given our limited resources, we dedicate most of our efforts to updating the financial information of those charities already in our database. We add new charity evaluations, but not as frequently as we have in the past. We will contact an organization prior to publication of a rating.”

It seems that that being listed in Charity Navigator is not as informative as some think. Better to do your own due diligence when you want to make a donation.

Meanwhile, we are still hoping that our $100 million donation will come with the next visitor we receive.

The first Obama health care victory?

This morning I posted comments to the National Journal Healthcare blog on the likelihood that the effort to reauthorize the State Children's Health Insurance Program (SCHIP) will serve as an early Obama Administration healthcare victory. I note that "On the eve of a vote on the already dialed back SCHIP bill the Senate draft has dropped coverage for legal immigrant children and pregnant women." Read the full post here.

The Washington Post Calls for FDA Regulation of Tobacco

In its house editorial this morning, The Washington Post calls for the regulation of tobacco by the Food and Drug Administration (FDA). This is an effort that we have been working on for decades; it is long overdue.

Here are some excerpts:

• It is inconceivable, then, that the most deadly product legally sold in the United States is exempt from federal regulation. (Meanwhile, the Food and Drug Administration oversees dog food, perfume and, yes, nicotine gum.) The new Congress should pass legislation that would give the FDA authority to regulate Big Tobacco.

• For too long, cigarette makers have decided what's safe for consumers. Their concern for the health of smokers -- or lack thereof -- has led them to disguise the dangers of their products with labels such as "light" and "low tar," and to lure young smokers by peddling candy-flavored cigarettes. The proposed legislation would eliminate such misleading labels and severely curtail Big Tobacco's ability to market to youths. The legislation would also require tobacco companies to disclose the ingredients in their products and place larger warning labels on cigarette packs. Most significant, it would give the FDA the latitude to take further steps to curb addiction, such as requiring the removal of harmful additives.

• The proposed economic stimulus bill will be Congress's top priority, but legislation regulating Big Tobacco shouldn't be far behind. The threat of a filibuster by Sen. Richard Burr (R-N.C.), and of a veto by President Bush, prevented the legislation from passing last year. But with Mr. Obama in the White House, and a strong Democratic majority in the Senate, there are fewer obstacles -- and no excuses. By regulating tobacco, the new Congress can secure an early, bipartisan victory that would help set the tone for the rest of the session.

Paying for our Resolutions for 2009

Now that we are in 2009 we need to find ways to pay for the health system we want.

How do we raise revenue or reduce costs? Here are seven areas to consider:

1. Increase the tax on tobacco and alcohol with proceeds going to health. (Disincentives for smoking, including citywide smoking bans, have been proven to work.)

2. Enforce clean air and clean water laws.

3. Make companies pay for health consequences of their actions.

4. Encourage widespread use of health information technology.

5. Use mobile phone/messaging systems to support consumers in managing their own health.

6. Reinvent the school nurse/clinic model.

7. Create luxury taxes with proceeds going to health.

Unfortunately, what we do now is either play a shell game with costs or reduce services and resources from the groups that squeak the least. Both of these are unacceptable. The reality is that since we want to provide more people with health care and we want better care for all, total costs will increase.

If we want more, then we will have to accept that our total costs will be more too.