We are entering the season of presidential politics, of bunting and cries of “What about the children?” and star-spangled appeals to full-throated patriotism.
So here’s mine: Do you count yourself a patriot? Do you care about the future of this country? (And while we are at it, the future of your hospital.) If so, bend your efforts to find ways to care for the least cared for, the most difficult, the chronically complex poor and uninsured.
“But we can’t afford compassion!” Wrong, brothers and sisters, we cannot afford to do without compassion. “But why should we pay to take care of people who can’t take care of themselves?” Because we are (you are) already paying for them — so let’s find the way we can pay the least.
The problem of the overwhelming cost of the “frequent fliers,” people with multiple poorly tracked chronic conditions, has always been that the cost was an SEP — “somebody else’s problem.” Now, increasingly, hospitals and health systems are finding that they are unable to avoid the crushing costs of pretending it’s not their problem, are not being paid for re-admits, and are finding themselves in one way or another at risk for the health of whole populations. They’re also facing more stringent IRS 990 demands that they demonstrate a clear, accountable public benefit.
At the same time, employers and payers are realizing that they end up paying the costs of the uninsured as well as those of the insured who are over-using the system because they are not being tracked. These costs become part of the costs of the system, and the costs are (and must be) shifted to those who do pay. There is no magic money well under the hospital.
Last year Priceline founder Jay Walker bought TEDMED –a conference that licenses the TED style and brand but is separately owned from its famous cousin. While there was some fun controversy about the sale, Walker made two key decisions. First he moved the conference from San Diego to Washington D.C. to try to get it more central to the health policy debate, and second he initiated a set of 50 Great Challenges from which the community voted a top 20. These are things like tackling the obesity crisis, getting transparency in medical research, training next generation of leaders and more.
Much of the fun and high production value entertainment from previous years stayed, but there was a new sense of urgency in the air concerning making changes from a top down and bottom up level in the way policy works for science and technology. There was rather less information technology than in years past and more emphasis on things like training of physicians, food policy, and basic science.
Like TED there’s a strong sense of celebrity at TEDMED with entrepreneurs like Walker and buddy AOL founder Steve Case on hand, mixing with newscaster Katie Couric and volleyball pro Gabby Reece. There’s also an interesting (and we hear not cheap) sponsorship model with the exhibit hall being more about zones for discussion rather than tradeshow demos. We like Philips sleep discussion and Booz Allen Hamilton’s discussion area.
There are times I wish I had a macro for the beginning of a post on obesity. Some way to say obesity is bad, obesity is prevalent, and nothing seems to work. You know the drill.
But there’s a new study in Health Affairs that was surprisingly promising:
We performed three related field experiments at a single fast-food restaurant to determine whether these reported sentiments could be translated into a strategy to alter calorie consumption. All of the experiments addressed three important elements of eating behavior.
First, do people spontaneously request smaller portions—that is, even if smaller portions are not specifically noted as an option on a menu or signage? Second, do people accept explicit spoken offers to take smaller portions in order to reduce calories? Third, does taking a smaller portion of one meal component lead to indulgence in other meal components, so that the calorie “savings” from downsizing are immediately lost?
Each experiment addressed an additional question. In experiment 1, we explored whether offering a nominal (twenty-five-cent) discount for downsizing would result in more customers’ accepting the offer than offering no discount. In experiment 2, we examined whether offering an opportunity to accept a smaller portion would be more effective than providing calorie labels in encouraging moderation. In experiment 3, we investigated whether downsizing appealed only to customers who would otherwise have thrown away uneaten food, thereby affecting calories ordered but not calories consumed.
Let’s start with experiment 1. First, they measured how many customers would spontaneously request a smaller portion of a high-calorie, high-starch side dish. Not surprisingly, only 1% did. But if customers were asked, on the other hand, one third accepted the offer, regardless of whether a discount was offered. What’s more, those that did downsize did not compensate by up-sizing any other portions of the meal. Those that downsized ordered significantly fewer calories, 100 fewer on average.
Lots of interesting feedback on my post on sugar regulation. Some of you have accused me of making straw man arguments; others have used straw man arguments to question my post. So let me take a few minutes to be clear about what I was saying. The article I referenced specifically questioned whether sugar should be regulated like alcohol and tobacco.
We regulate alcohol by making it illegal to use it before the age of 21. Period. We regulate alcohol by making businesses get a specific, and often hard-to-get, license to sell it. Where I live, it’s illegal to sell it on Sunday. We don’t regulate alcohol by limiting the amount you can put in a drink. Any bar can make any drink they like, with as much or as little alcohol as they want.
We regulate tobacco by making it illegal to use it before the age of 18. Period. We regulate it by making businesses sell it in specific areas, often hard-to-get at. It’s illegal to put it in vending machines. But we don’t regulate tobacco by limiting the amount you can put in a cigar. Any cigar maker can put as much or as little tobacco in as they want.
So when someone says that they want to regulate sugar like alcohol or tobacco, that’s what I think of. And it was what they meant, according to reports:
Sugar is so toxic it should be controlled like alcohol, according to new report that goes so far as to suggest setting an age limit of 17 years to buy soda pop.
If there’s one thing everyone in Washington can agree on it’s that prevention is good. And that’s about as far as the agreement goes.
As for the rest of it – who is responsible for prevention, how to define prevention, what is the government’s role in prevention, how much to spend on prevention and when to spend it – is not so clear, and wrapped up in the bitter politics (and difficult economics) of the day.
Then, there’s the question of the Prevention and Public Health Fund created by the Affordable Care Act to enable states and communities to try to prevent illness and promote longer, healthier lives. To backers of the law, the fund is an engine for public health, community transformation, and a pivotal part of the effort to create a “health care” system instead of a “sick care” system.
To foes, it’s a “slush fund”, a $13.8 billion monument to everything they don’t like about the 2010 legislation. It’s $13.8 billion that could easily end up on one of the deficit-cutting chopping blocks.
In the last month, the Obama administration announced programs to reduce racial disparities and increase prevention in health care. Neither program was funded with actual money, so they are about political showmanship as much as any real desire to tackle the worthy causes. After all, who would oppose such programs? I half-expect the administration to follow-up these announcements with one focusing on moms and apple pie.
But have a closer look at what Iowa Democrat Tom Harkin said at the press conference introducing the latter initiative. “For every dollar we invest in prevention, we save $6. We need to provide an approach that makes it easier to be healthy and harder to be unhealthy.”
I haven’t found the report on which Harkin bases his assertion about the returns on health prevention efforts, but my sense is its more complicated than Harkin would have us believe. Some screening and prevention programs are not effective at all. Others are effective, but prohibitively expensive. Any national program to improve prevention needs to evaluate each potential component to assure it reflects Harkin’s focus on cost-effectiveness.
This week I had the occasion to be at UCLA for a very interesting meeting (more on that in a future post). As I arrived at LAX to return my rental car, I drove past a huge billboard at the corner of 96th Avenue and Airport Blvd (just across from the Renaissance Hotel) that made me do a double take. The billboard, said in gigantic white letters on a red background: “This year thousands of men will die from stubbornness.”
Naturally, my first thought was this: Why thousands? If men can die from stubbornness, aren’t they all doomed? If stubbornness is the proximate cause of death, we are looking at a wipe-out of society on a pretty imminent basis. The bad news: no more future generations. The good news: no one will hassle us women about buying too many shoes and all the top-paying private equity jobs will soon be available.
So figuring that I had misread this billboard, I actually made a U-turn and drove past it again (not sure what made me do it: alarm or wishful thinking). What I noticed on my second pass was the very fine print, which said, “Learn the preventative medical tests you need. AHRQ.gov.”
The billboard is apparently part of an U.S. Government Agency for Healthcare Research and Quality Department ad campaign targeted to get men to stop avoiding the doctor and to go and get the medical screening tests recommended each year, such as those for cholesterol, diabetes, high blood pressure, cancer and other illnesses.Continue reading…
Sorry, folks, but I have been so swamped with work that I have been unable to produce anything cogent here. I see today as a gift day, as my plans to travel to SHEA were foiled by mother nature’s sense of humor. So, here I am trying to catch up on some reading and writing before the next big thing. To be sure, I have not been wasting time, but have completed some rather interesting analyses and ruminations, which, if I am lucky, I will be able to share with you in a few weeks.
Anyhow, I am finally taking a very close look at the much touted Keystone VAP prevention study. I have written quite a bit about VAP prevention here, and my diatribes about the value proposition of “evidence” in this area are well known and tiresome to my reader by now. Yet, I must dissect the most recent installment in this fallacy-laden field, where random chance occurrences and willful reclassifications are deemed causal of dramatic performance improvements.
So, the paper. Here is the link to the abstract, and if you subscribe to the journal, you can read the whole study. But fear not, I will describe it to you in detail.
In its design it was quite similar to the central line-associated blood stream infection prevention study published in the New England Journal in 2006, and similarly the sample frame included Keystone ICUs in Michigan. Now, recall that the reason this demonstration project happened in Michigan is because of their astronomical healthcare-associated infection (HAI) rates. Just to digress briefly, I am sure you have all heard of MRSA; but have you heard of VRSA? VRSA stands for vancomycin-resistant Staphylococcus aureus, MRSA’s even more troubling cousin, vancomycin being a drug that MRSA is susceptible to. Now, thankfully, VRSA has not yet emerged as an endemic phenomenon, but of the handful of cases of this virtually untreatable scourge that has been reported, Michigan has had plurality of them. So, you get the picture: Michigan is an outlier (and not in the desirable direction) when it comes to HAIs.Continue reading…
I find it fascinating how our brains have this propensity to latch on to what is at the margins at the expense of seeing the bulk of what sits in the center. This peripheral only vision is in part responsible for our obscene healthcare expenditures and underwhelming results.
I have blogged ad nauseam about the drivers of early mortality in the US. In one post I reproduced a pie chart from the Rand Corporation, wherein they show explicitly that a mere 10% of all premature deaths in the US can be attributed to being unable to access medical care. The other 90% is split nearly evenly between behavioral, social-environmental and genetic factors, of which 60%, the non-genetic drivers, can be modified. Yet instead of investing the bulk of our resources in this big bucket of behavioral-environmental-social modification, we put 97% of all healthcare dollars towards medical interventions. This investment can at best produce marginal improvements in premature deaths, since the biggest causes of the effect in question are being all but ignored.
A couple of other striking examples of this marginal magical thinking have surfaced in a few recent stories covered with gusto in the press. One of the bigger ones is the obesity epidemic (oh, yes, you bet it was intended), and its causes. This New York Times piece with its magnetic headline “Central Heating May Be Making Us Fat” entertains the possibility that because of the more liberal use of heat in our homes we are no longer engaging our brown fat, which is a furnace for burning calories. And this is all well and good and fascinating, in a rounding out sort of a way.