The author in early 2010 and mid 2011
I’ve been thinking about how to write this story for a long time. Should it be a book? A blog? A self-help guide? Ever since I realized I’d lost 60 pounds over the course of a year and a half, I knew I wanted to find a way to talk about it, and maybe help others. This is my first public attempt.
A note about the rounding of my roundness: My peak weight, shortly after I began weighing myself in 2010, was 242 lbs. My lowest weight since I started weighing myself has been 183.2 lbs — right in line with where I should be, at 6’3″ tall. I’m sure that I weighed more than 242 lbs. at peak, but frankly, I don’t care that I don’t have the data to account for those last 1.2 lbs.
Adam Davidson’s New York Times Magazine story, “How Economics Can Help You Lose Weight,” helped organize my thinking about how to finally write this. In his story, Adam explains that the rigid protocol his doctor puts him through acts as a kind of economic incentive for him to stay on the diet. I’m highly skeptical that the special liquid meals he can only buy directly through his dietician will help him keep off the weight. I tried all sorts of diets in the many years that I was overweight and though I never tried the Adam’s solution, it doesn’t sound like a recipe for long term success. At least twice, I lost weight and then gained it all, and more, back. (Meta note: I feel terrible writing that. Adam, I wish you the best. Maybe something you read here will help you keep off the weight you have already lost, and congratulations on that difficult achievement.)
Now that I’ve managed to make weight loss sound simple, and sound smug about my success (I’ve stayed within the 183-192-pound range for more than two years now), what’s my big secret? It’s data. Just like I said in the headline, I keep a Google Doc spreadsheet in which I’ve religiously logged my weight every morning for the last three-plus years, starting on January 1, 2010, when I knew I had to do something about my borderline obesity.
“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.
Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.
On March 20, 2013, the media picked up a story about CVS Caremark’s latest wellness program. In summary, CVS will be requiring all of its employees to complete a health screening in order to qualify for a reduction in their health insurance premium. For those employees who participate, the employee’s screening data goes to a third party, and CVS never sees it.
Such wellness financial incentives are commonplace and have been around a long time. And if that is how the media had described the CVS program, it’s doubtful anyone would have even paid any attention to it. Unfortunately, that’s not how the media ran with the story. Let’s look at how the media sent the wrong message – using ABC News as an example – and why it matters to get the message right.
Sending the Wrong Message
ABC’s Good Morning America segment was emblazoned with the headline, “Who’s Watching Your Weight – CVS Employees Required to Disclose Weight.” Their website ran a similar headline, “CVS Pharmacy Wants Workers’ Health Information, or They’ll Pay a Fine.”
American consumers know more about the quality and prices of restaurants, cars, and household appliances than they do about their health care options, which can be a matter of life and death. While we have made some progress in getting consumers reliable quality information thanks to organizations like Bridges to Excellence and The Leapfrog Group, for most Americans, shockingly little information still exists about health care prices, even for the most basic services. And several studies have shown us that the price for an identical procedure can vary as much as 700 percent with no difference in quality. Moreover, with health care comprising 18 percent of the US economy and costs rising every day, it is extremely troubling that most health care prices are still shrouded in mystery.
Our organizations have been steadily pushing health plans and providers to share price information more freely, and we are seeing progress. But public policy—or even just pending legislation—can provide a powerful motivator as well.
Unfortunately, our new Report Card on State Price Transparency Laws shows most states are not doing their part to help consumers be informed and empowered to shop for higher value care. In the Report Card released Monday, 72 percent of states failed, receiving a “D” or an “F.” Just two, Massachusetts and New Hampshire, received an “A.” The Report Card based grades on criteria including: sharing information about the price of both inpatient and outpatient services; sharing price information for both doctors and hospitals; sharing data on a public website and in public reports; and allowing patients to request pricing information prior to a hospital admission.
This is how sexy the chatter gets over cocktails at health policy wonk-ins in Washington. This is how sexy the chatter gets over cocktails at health policy wonk-ins in Washington.
“No pre-ex’s, community rating, guaranteed issue.”
“No, that’s Obamacare stuff,” I said to my colleague, as she read a summary of Congressman Paul Ryan’s House Republican budget plan released on Tuesday. “Everyone in Medicare already has those. You must have the wrong memo.”
She scrolled to the top of her iPhone and pointed at the screen. “Summary of the Ryan Budget Plan – Medicare.”
“Maybe just a gimme for popular support?” I speculated, knowing from headline coverage earlier in the day that the Ryan plan sought to repeal Obamacare, not strengthen its most popular consumer protections. “Guaranteed issue but no mandate — that would sure hang the insurers out to dry. But why would you put that in a budget?”
“Here’s why,” she read. “‘Seniors buy coverage through new Medicare Exchange.'”
Consumers need protections only when they are turned into consumers. And that is what Congressman Paul Ryan’s budget seeks to do for — or do to, depending on your feelings about medical capitalism — future Medicare beneficiaries.
Almost 20 years ago close to 4,000 people from 200 companies gathered in San Diego for a conference to discuss the future of health-care information technology. This was before the Web. This was back when computers in physicians’ offices, to the extent they were present at all, were used only for scheduling and billing patients. Paper charts bulged out of huge filing cabinets.
It was one of the first big conferences held by the Healthcare Information and Management Systems Society (HIMSS). I was among a grab bag of physicians, technologists, visionaries, engineers and entrepreneurs who shared one idealistic goal: to use information systems and technology to fundamentally change health care.
We didn’t just want to upgrade those old systems. We imagined a future that looked a lot like what we were being promised throughout the economy as it sped into the Internet era. Computers would enable improvements in the practice of medicine—and make it safer, higher quality, more affordable and more efficient—all at the same time. We wanted people to be healthier.
I find myself, probably like many of you, spending way too much time in front of my computer.
When I do face-to-face meetings, my colleagues and I typically met around some conference table, sometimes at an airport lounge (nothing like getting the most out of a long layover), and quite often at coffee shops (hello Starbucks!). But that means that the most common denominator across all these locations wasn’t the desk, or, the keyboard, or even the coffee. The common denominator in the modern workday is our, um, tush.
As we work, we sit more than we do anything else. We’re averaging 9.3 hours a day, compared to 7.7 hours of sleeping. Sitting is so prevalent and so pervasive that we don’t even question how much we’re doing it. And, everyone else is doing it also, so it doesn’t even occur to us that it’s not okay. In that way, I’ve come to see that sitting is the smoking of our generation.
“The more you learn, the more you realize you don’t know.”
You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.
The implication of this for the practice of medicine is that a little knowledge can be very dangerous.
What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.
I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)
The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.
Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.
Apple Incorporated has grown to be among the most valuable and most envied companies on earth. Its products are ubiquitous and beloved by many of their users. Last year, the firm generated nearly $26 billion in profits on revenues of $108 billion. When physicians and others working in health care discuss the lessons that the medical establishment can learn from these types of corporate successes, the conversations almost always revolve around the promise of information technologies, such as electronic record keeping or electronic prescription writing, and the need for increased use of these in medical practice. While these technologies are important, the most valuable lesson from Apple’s success is a demonstration of the power of empathy and the subsequent need for health care providers to emotional connect with our patients.
It is widely known that Steve Jobs and Steve Wozniak built the first Apple computer in Steve Jobs’ garage; what is not as widely known is that they quickly brought in a third partner, Mike Markkula, to join and guide the company. He began by writing a one page statement entitled “The Apple Marketing Philosophy”. This philosophy stressed only three key components of bedrock company principles; the first and most important was empathy.
In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in – well, actually, poured in not that much money at all when you think about it – lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.
Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.
The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.