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.

Resolutions For 2009 - “Ten Things to do in 2009 to Improve Health”

As we welcome in 2009 a year filled with hope and promise I thought it would be a good time to make up a list of Ten Things to do in 2009 to Improve Health.

1. Make it the norm for everyone to have health insurance and access to care.

2. Pay health care providers to communicate with consumers in the language the consumer understands.

3. Give consumers information in a useful format; there are more people who can watch a DVD than there are persons who can read.

4. Give consumers questions they can ask and provide answers so they understand what they may be told.

5. Encourage each person to talk about the level of care they want and include end of life issues.

6. Develop solutions for long term care that include a mix of private, public, and home based alternatives.

7. Encourage the sale of fresh vegetables and fruits in all communities.

8. Work to increase opportunities for persons of all ages and sizes to engage in physical activity.

9. Have EPA enforce clean air and water standards so we can breathe freely and safely drink tap water.

10. Remember that health care is more than science and numbers it is about body, mind, and spirit.

And a healthy and happy New Year to you too!

Future Health Solutions - Part II (of many)

Health is full of “trendy” words or things that sound good until you look at it more closely and try to decipher what will be the real impact. For example, much is written about the need for evidence-based medicine. Sounds like a good idea but the implication is that either, before, medicine was not based on evidence, or that now we have a better way to analyze the evidence. Unfortunately, much of what is discussed today is evidence based on studies that are over a decade old and are based on research on non-Hispanic white males.

It is not surprising that existing evidence-based protocols fail us as individuals. Too often the data that define the evidence do not include the other 2/3 of the population that is female or something other than non-Hispanic white. The evidence fails to acknowledge what we have documented during the first part of the 21st century, i.e., that there are gender differences and that there are differences in how individuals metabolize medicines and everything else we ingest or absorb. The challenge remains to acknowledge that there are persons excluded from our current models of evidenced based medicine.

It is no wonder I shudder when I hear that future treatments, and of course the reimbursements to which they will be linked, will be based on the existing evidence.

Future Health Solutions - Part I (of many)

American politics offer a spectacular view of what makes our country great. While we had a major election and shift in government there were neither tanks in the street nor bullies to keep people away from the polls. We waited on long lines to exercise our American rights and show the world who we really are. Although some of us may take our comforts for granted we have much to be proud of and that will see us through the economic turmoil which is still to come.

The freefall in the investment community and the government bailout surely indicate that our capitalism needs to be tempered with decisions that take into account the greater good. What has that got to do with health? Absolutely everything. Ethics must guide decisions not only in the non-profit world but also in the for-profit sector. We can craft an uniquely American health solution that involves both the private and public sectors...but only if the greater good guides our decisions in both sectors. After an election it is our resolve as a nation to work together and solve problems that will lead to solutions which are totally American. The best is yet to come.

Uninsured ER Overcrowding . . . It’s a Myth

Perhaps the most frequent scapegoat for the crisis in our health system is the uninsured.  For decades the litany of attacks on the uninsured has been they are overcrowding emergency rooms and using scarce resources because they do not go in for regular ongoing care.  But buried in today’s newspapers, ensuring that it will get scant attention, was reporting on new research released by the Journal of the American Association (JAMA) that turns conventional wisdom on its head.

The study found that the uninsured are less likely than those with insurance to use emergency rooms.  In fact, while 17% of persons in our country are uninsured, they only represent between 10% to 15% of emergency room visits.

When you talk to people who are uninsured they tell you that they do everything they can to take care of themselves; after all not everyone gets sick leave.  They also avoid emergency rooms because they are already living at the edge and are concerned that the costs they incur from an emergency room visit will push them off the precipice to which they are clinging.

According to the JAMA study, insured patients represent the majority of increased use of emergency rooms over the past decade.   So while providing health insurance to those who cannot afford it is critical, it does not go far enough to make our health system what we know it should be.  Access is about more than having coverage.

Science Speaks and EPA Listens . . . Sometimes

Today, the EPA announced it was following the advice of its Clean Air Scientific Advisory Committee to set standards for lead in air that are 10 times stricter than we have today in order to protect children’s cognitive development. This follows on the heels of the decision by EPA in July to recommend the ban of carbofuran, one of the most toxic pesticides still in use.

Since EPA is being receptive to science click here to send EPA Administrator Johnson a letter calling on EPA to revisit its March decision on ozone standards. EPA ignored the very same committee's recommendation and set standards for ozone that were higher than recommended. According to published research that move is estimated to result in 5,650 unnecessary deaths annually. That’s not to mention the thousands of cases of cardiac events (heart attacks and respiratory illnesses) that could have been prevented.

Clearly, there’s still much work to be done to clean our air; following the scientific recommendations is a good place to begin.

And for this we have government?

The October 6, 2008 USA Today article “Sleuths go door to door to sniff out Medicare fraud” is a good example of how we can go so very wrong with how we focus on reducing costs. I do not know what other people read but for me it was a waste of government dollars to send out the sleuths. What did they discover? That an 86 year old man was able to go on walks and therefore was not eligible to get the home health care costs of having a nurse go to the house to give him his injection. Sounds odd?

While we all celebrate that the man could take a walk; walking involves being able to move your feet while injecting yourself involves your hands. It seems that Medicare only pays for the nurse to go to the home if the person is homebound. The sleuth who discovered the man commented that the man’s nervousness about giving himself an injection was not sufficient reason to qualify him for the nurse visit. Is it reasonable to expect that every 86 year old person should be able to inject themselves? Did anyone take into account the savings that Medicare accrued since the man was able to live at home because he had this help? Moreover, the reporter confused the work of the nurse and that of the health aide.

While the sleuth may have been using the Medicare standard; it is obvious that the standard has to change. We need to have more sanity in how we care for each individual. Blanket rules such as this do more damage than good— rather than cover they suffocate.

Our Future....Hispanic Students

Our future is tied to this generation of youth.  If you are the parent, grandparent, teacher, mentor or friend of a Hispanic college student looking to a future in a science, technology, engineering, or math (STEM) field please encourage them to visit alliancescholars.org. 

Yesterday the National Alliance for Hispanic Health (the Alliance) announced the opening of the Alliance/Merck Ciencia (Science) Hispanic Scholars Program. We are making two types of awards:

• High School Seniors -- $42,500 Scholar Package.  Promising Hispanic high school students from Brownsville, TX; Elizabeth, NJ; and Los Angeles, CA are invited to apply to become one of ten Alliance/Merck Ciencia Scholars that will be selected in the Spring of 2009.  Scholars will receive up to $20,000 in scholarship (up to $5,000 each of four years of college) and up to $22,500 in summer internship stipends (up to $7,500 each of three summers).  Scholars will also receive mentorship and professional development support to complete a Bachelor's degree in a STEM field and pursue a STEM career.

• College STEM Majors -- $2,000 Scholarship. Hispanic college students from all 50 states, the District of Columbia, U.S. territories and Puerto Rico pursuing a Bachelor’s degree in a STEM field major are invited to apply for a $2,000 one-time scholarship of which 25 will be awarded in the Spring of 2009.
  

This program of the Alliance and the Health Foundation for the Americas (HFA) is being conducted in partnership with the Merck Institute for Science Education (MISE) with support from The Merck Company Foundation.

Just this morning the Census Bureau released new data showing that there are 1.7 million recent Hispanic high school graduates enrolled in college.  Innovation in communication, genomics, and earth sciences all hold the prospect for a golden age of discovery....but only if our youth have the educational background to lead such discovery.   At the Alliance we are working to help secure that future of hope and prosperity for all.

The Consumer and Direct to Consumer Advertising

How consumers make health care decisions is complex. Consumers do not make health decisions in the same way that they make choices about objects they purchase.

For this reason and many other reasons I was surprised at the backlash that pharmaceutical companies met when they began to push for direct to consumer advertising. The outcry was that consumers would see their health care provider and demand a particular drug. Really? More than likely what happened was that the consumer would TiVo the ad (along with their favorite program) and then skip it because it was “simply advertising.”

However, in some cases the consumer had new information and actually now had something to ask their health care provider about. For example, very few knew about ED and those that experienced it were reluctant to speak about it. This is no longer the case.

As consumers we do not ask enough questions. And while some health care providers bemoaned that they had to talk to their patient about why the medicine they were asking for was the wrong one for them, other providers saw it as an opportunity to engage the consumer in their own care. Conversations with a consumer are a good and essential part of health care. This needs to be encouraged and we need to reimburse providers for this one-to-one education. And of course in a multicultural world, the conversation must be in the language that the consumer speaks.

9/11

My daughter goes to college 90 miles north of New York City. On her campus September 11 is remembered in a way to respect the lives that were lost. In Washington, D.C. there are variety of commemorations too including those personal ones…a moment of silence, a prayer…something to make us recall what time can make too easy to erase.

On September 11 we lost many precious lives. They deserve a moment of our time to reflect on how the events of that day changed every part of our lives.

We are not Canada or Sweden

Having just visited Sweden and other countries in the region, and heard about their health system first-hand, I am reminded that our system is different because we as Americans have different expectations. We expect more from our health care system but paradoxically we do not want to pay higher taxes.

Think about your typical American; they want answers in real time. In Canada and Sweden consumers have to wait for everything from a visit to a specialist to test results. That same approach would be unacceptable in the U.S. and might even be considered malpractice in some instances.

More to the point is that in the United States we made the decision in 1965 to provide a level of health care to persons over 65 regardless of income that is unheard of in most other countries. We care for older folks. All this makes our American health care system, with all its flaws, operate under a different set of values and constraints; the comparison to some of these other national health plans is useless and too often misguided. And it’s an important distinction to make as a new Congress and Administration will take up health care reform and policy wonks start declaring that the grass is greener in Canada and Sweden.

Top 10 lessons I learned when I went to the hospital.

That most people say they are happy with their health care is not very meaningful when you consider that most people are healthy.

Like lots of other people, I have gotten to know the most about health care when I have been sick or have had to care for someone else.

Here are some key things I have learned:

1. Public or private insurance gets you in the door but not necessarily the care you need.

2. There is a shortage of health care providers.

3. Mistakes happen.

4. Patients and providers want answers immediately.

5. There is little time left for patients and providers to get to know each other.

6. There are communication problems even when everyone speaks the same language.

7. People have to take more responsibility for their own health records even when they do not want to or do not have the skills.

8. It is important to make clear what one wants.

9. While evidence based medicine is a factor to consider; clinical judgment must also be valued.

10. You need to have someone with you.

We have a lot of work to do to make our health care system better.

Economics does not apply to health.

Our biggest mistake has been to use economic models to explain consumer behavior towards the purchase of health care. The underlying economic assumptions of the “rational consumer” or “all things being equal” are not valid. When we purchase health care we make a decision that may not be seen by others as rational but to the individual represents a valid choice.

Even if there’s just a small chance a treatment may work, if you are in pain or suffering, any chance is better than none and you want access to that treatment. It may not be rational but it’s human nature.

The rules for how we make decisions about health are just not the same as when we buy a cell phone or any other item. Health is neither a brand nor a commodity. Each individual addresses health choices at a very personal level.

After all, it is about one’s life and you just can’t buy another one.

Finally, on another note, we're thinking of all the families who have been displaced and otherwise affected by hurricane Gustav today. And our prayers are with those who lost family members to the storm.

Trimming the Fat or Cutting Muscle?

Too often those who beat the drums of cutting out the fat in the health care system ignore the reality that at some point there’s just no more fat to cut. The enthusiasm for saving dollars is now cutting connecting tissue and muscle too!

I’ve seen it most in visiting friends who are taking care of older family members. Our health care system is not prepared to handle the increase in older patients and the support they need.

Families and friends are often surprised and too often overwhelmed by the amount of attention they must provide even in the best of health care settings to make sure their loved ones get the care they need. Cost cutting has created a shortage of nurses, social workers, and all the members of a health care team. It has put a stopwatch on the time our health care provider can talk to us making the profession more difficult to practice and frustrating patients who no longer feel cared for.

We just can’t trim more from health care expenditures when the number of older people (and by definition sicker people) is getting larger.

Tax credits and insurance pools will only take us so far…we need to accept that health will be a larger portion of our country’s GDP. That is inevitable. The challenge is to create a system that is better and covers many more lives. That will take more and new dollars.

What do you think?