The Health Care Blog – Page 945 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Shifting costs from public to private payers

Dec 12, 2008• 22

By Charlie Baker

The other day, the American Hospital Association, the Blue Cross /
Blue Shield Association, Premera Blue Cross and America’s Health
Insurance Plans (FYI – HPHC is a member and I’m on the Board of
AHIP) released a joint study on public and private payment rates.

The
study was prepared by Milliman, Inc., one of the nation’s most well
known number-crunching health care consulting firms. Readers of
this blog will not be surprised to learn that the study shows that
Medicare and Medicaid pay a lot less for health care services than the
Blue Cross and private health plans pay. But I must say, even I was
a little surprised by the size of the differential.

Electronic Medical Records and Obama’s Economic Plan

Dec 12, 2008• 33

By John Halamka

On Dec. 6, President-elect Obama announced the
three major pillars of his economic recovery plan: rebuild our
roads/bridges, enhance our schools including broadband, and deploy
electronic health records for every clinician and hospital in the U.S.

I can summarize all my advice to the new administration in one sentence: Allocate
Federal funds of $50,000 per clinician to states, which will be held
accountable (use it or lose it) for rapid, successful implementation of
interoperable CCHIT certified electronic records with built in decision
support, clinical data exchange, and quality reporting.

Open source is a transparent Trojan horse

Dec 12, 2008

By Scott Shreeve Scottshreeve

I have been blogging and twittering
from the World Health Innovation and Technology conference this week
while waiting to present today. The keynote speaker before me was Scott
McNealy, the Chairman and founder of Sun Microsystems. He has a long
and storied history with Sun, and a well earned reputation as the “human quote machine.”

He delivered.

His talk started with several examples of his health care experience
(long time user as a hockey player and father of four boys) and
business experience had so many corollaries. The fight for standards.
The fight for common interfaces. The fight for privacy and security.
The find for high quality, low cost, and transparency.

Healthcare and the Job Market

Dec 12, 2008• 25

By MERRILL GOOZNER

Looking for a bright spot in Friday’s dismal job report? Think how
bad it would have been had the health care sector not added 52,100 jobs
last month.

That’s right. While the rest of the economy was shedding nearly
600,000 jobs and the nation’s once-proud automobile industry went
begging for a bailout so it could continue to pay for, among other
things, its employees and retirees health care bills, hiring remained
robust at the nation’s hospitals, physician offices, diagnostic labs,
nursing homes, and home health care agencies.

This raises an interesting conundrum for health care reformers who
are primarily concerned about the unsustainable rise in health care
costs. Who in the midst of a deep recession will be willing to whack
away at medical waste when it is one of the only sectors generating
lots of new jobs for thousands of fearful Americans?

TECHNOLOGY

Dec 11, 2008

Why Clinical Groupware May Be the Next Big Thing in Health IT

By David C. Kibbe

Clinical Groupware is intended for use by groups of people and not just
independent practitioners or individuals. It is not the same thing as
an electronic health record, but may share a number of features in
common with EHRs, such as e-Prescribing, decision support, and charting
of individual visits or encounters, both face-to-face and
virtual. Neither is Clinical Groupware bloated with extra features and
functions that most providers and patients don’t need and, with good
reason, don’t want to pay for.

Permalink
| Matthew Holt

Comments
(37)

The Best $20 Billion You’ll Ever Spend

By MARK LEAVITT

Dear Mr. President, please
accept my heartfelt congratulations for recognizing health information
technology (IT) as one of the most promising targets for public
investment at this crucial moment.

As a (formerly practicing)
doctor, I’d diagnose our economy on the verge of a Code Blue, and our
healthcare system with a more chronic but equally threatening
condition. You’ve recognized how these two illnesses interrelate, with
spiraling healthcare costs damaging business competitiveness and job
losses threatening healthcare coverage. If I may offer a second
opinion, I concur 100% with your decision to apply the chest paddles
now, charged with $20 billion of investment.

Permalink | Matthew Holt
Comments
(22)

Five “Shovel-Ready” Health Care Reforms

By BRIAN KLEPPER and DAVID C. Kibbe

Microsoft Health Vault’s leader Peter Neupert has a wonderful blog post
that makes two important points
really well. One message is that health
care reform is about the outcomes, not the technology. We should think
expansively about which technologies to invest in, based on the results
we want to get.

The other message is the economic stimulus package is different than
the reform effort. It is moving at hyper-speed through Congress, and it
may be difficult for staffers and other advisors to sort through and
incorporate what may seem like opposing Health IT views against a
backdrop of traditional ideology and extremely forceful special
interest lobbying.

Permalink
| Matthew Holt
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(18)

Washington, Please don’t bail out the health care industry

By Rick Peters

A health care Marshall Plan — $50 Billion stimulus to get
electronic health records (EHRs) in every doctor’s hands or $50,000 to
each physician -– what an incredible marketing job. Detroit, are you listening? Stop whining to Congress that you need a
bailout. Tell them you want to be the new alternative energy Manhattan
Project, get the money, and then keep building SUVs and flying around
in corporate jets. To Congress, Daschle, and Obama, please don’t do this. Our industry,
health care, combines the worst of the Big Three automakers with the
worst of the hubris, dishonesty, and failure of the public trust of
Wall Street. Please do not bail us out.

Permalink
| Matthew Holt
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(41)

An Open Letter to the Obama Health Team

By David C. Kibbe & Brian Klepper

It seems likely that the Obama administration and Congress will spend a
significant amount on health IT by attaching it as a first-order
priority to the fiscal stimulus package.The easy solution would be to spend most of the health IT funds on
EHRs. The EHR industry has made it easy by establishing a mechanism to
“certify” EHR products if they incorporate certain features and
functions.

Permalink
| Matthew Holt
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(18)

Stimulus bill offers docs big incentives for technology, but demands effective use

By John Haughton, MD

The economic stimulus bills are a great step forward for health information
technology and medicine.

The two bills,
“HR1” and “S1,” continue to barrel down the legislative track and
continue being amended, but as currently written they create real
incentives for adopting certified electronic health records – upwards
of $40,000 per physician starting in 2011.

The legislation
emphasizes rewarding designs that improve care and create a path for
certification of records with added functions, such as decision
support, order entry, connections to other systems and reporting on
quality measures. The bill focuses on implementation by tying the
physician bonuses to proven, effective use. The stimulus package also
formalizes the Office of the National Coordinator for Health
information Technology (ONC).

Permalink
| Matthew Holt
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(8)

A Shared Roadmap and Vision for Health IT

By John Halamka, Mark Leavitt & John
Tooker

Today’s economic crisis has highlighted our need for breakthrough
improvements in the quality, safety and efficiency of health care. The
nation’s business competitiveness is threatened by growing health care
costs, while at the same time our citizens risk losing access to care
because of unemployment and the decreasing affordability of coverage.
Meanwhile, the quality variations and safety shortfalls in our care
system have been well documented.

Permalink
| Matthew Holt

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(6)

Next Steps for Interoperability

By JOHN HALAMKA

There are some folks in Washington who have made statements that we
should delay investments in EHRs because current vendor products lack
the functionality needed to support a coordinated healthcare system.
Others have said that we lack the standards or security framework to
implement interoperability. Here are my thoughts.

Take a look at
the successes in Massachusetts and New York with commercial EHR
products. We’ve implemented eClinicalWorks, which includes decision
support, e-prescribing, administrative transactions with payers,
clinical summary sharing across the community, and quality measurement
(all the National Quality Forum high priority measures). It’s
web-based, using a service oriented architecture in a cloud computing
environment. By implementing this product at BIDMC, we’re meeting all
the payer guidelines for delivering appropriate, coordinated, high
value care. Vendor products from Epic, Allscripts, NextGen, GE,
Meditech, eMDs, MedSphere, and other CCHIT certified vendors have
similar features.

Permalink
| Matthew Holt
Comments
(9)

New NRC Report Finds “Health Care IT Chasm,” Seeks New Course Toward Quality Improvement and Cost Savings

By DAVID C. KIBBE

Like the Institute of Medicine’s (IOM) 2001 counterpart report,
“Crossing the Quality Chasm,” a new report from the National Research
Council of the National Academies
is complex, full of new ideas assembled from multiple disciplines, and
is likely to have seminal importance in framing public policy from now
on. “Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions”
was released last month in draft, but there is so
much to comment on that I think it’s wise to begin with a quote from
the committee that sums up the central conclusion:

Permalink | Matthew Holt
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(20)

The greatest health care IT generation

By John Halamka

In Washington, Healthcare Information Technology policy planning is
accelerating at a pace that is faster than at any time in history (at
least my 30 years in healthcare IT). Over the past few days, the House Ways and Means Committee completed the Health Information Technology for Economic and Clinical Health Act (HITECH), as part of the American Economic Recovery and Reinvestment Plan. At the same time, the House Appropriations Committee has completed a bill
that is not meant to stand alone. It outlines $2 billion in funding for
the programs authorized by section 4301 of the Ways and Means Committee
bill.

Permalink | Matthew Holt
Comments (1)

It’s the platform, stupid

By Scott Shreeve MD

I read with interest a recent article by my favorite health care reporter, Joe Conn, who has long time interest in the commercial success of the VistA Electronic Health Record system developed by the VA.

VistA has an incredible, well described impact on the clinical and
system peformance of the VA. Given its availability through the Freedom
of Information Act, it can and should seriously be considered as a
potential solution for government-based health care information
technology. I mean, why not? The several billion dollars already
invested, and the several billion dollars already wasted on
alternatives, would hopefully help the new administration come to their
senses to realize the development of a common platform for all
government related health IT would make good business sense.

Permalink | Matthew Holt

Comments (6)

Freenomics and Healthcare IT

By ROBERT ROWLEY

Freenomics is a term coined in Silicon Valley to describe a free web
service paid for by other revenue sources (usually advertising) –
Google searches, Yahoo mail, Wiki lookups, YouTube videos are all
examples of free services paid for by other revenue sources. Applying
this business model to EMRs is groundbreaking. An ad-based EMR that
maintains a robust, professional, full-featured offering challenges how
we think of the EMR business.

Permalink | Matthew Holt

Comments (19)

Quality, Cost and Connected Health

By JOSEPH KVEDAR Connected health is the use of messaging and monitoring technologies to
bring care to where the patient is, when the patient needs it. This
approach has enormous opportunity to increase quality while lowering
the overall cost of care. Early returns on this approach are quite
encouraging. We are starting to weave connected health into the fabric
of our health care system, with good results.

Permalink | Matthew Holt

Comments (8)

The Technology Hype CycleWhy Bad Things Happen to Good Technologies

By ROBERT WACHTER

Robert_wachter
Fresh on the heels of my recent bar coding epiphany
comes another “unintended consequences” article. It turns out that the
whipsawing that accompanies the adoption of new technologies is
completely foreseeable, the “Why doesn’t this thing work right?” phase
is as predictable as the seasons. You can chart the course of virtually any
health information technology on the Hype Cycle curve. In the case of
computerized provider order entry (CPOE), the trigger was the
development of the technology in the 70s and 80s (the first CPOE system
was implemented at El Camino Hospital during Nixon’s presidency). The
Peak of Expectations was turbo-charged by the research in the 1990s by
Bates demonstrating its value in one highly unusual organization
(Brigham & Women’s Hospital), working with a homegrown system. The
apogee was the endorsement of CPOE by the Leapfrog Group in 2002.

A Transparent Health Record

By Adrian Gropper, MD

Transparency, in the form of a complete, patient-centered and
accessible health record is a policy principle that can drive the next
wave of health care innovation. Investing exclusively in institutional
EHRs will further stifle efficiency, innovation and improvement.
Web-based clinical summaries (CCR+DICOM+PDF) that are available for
patient control foster patient-centered care, clinical collaboration,
and research, and must be included in health care reform if we are to
effectively improve provision of health care for patients and
clinicians.

Fact or Fiction: Electronic health records save money

By JEREMY ENGDAHL-JOHNSON

Of all the initiatives endorsed by outgoing Secretary of Health Mike
Leavitt, few are likely to be met with as much agreement as the need for wider adoption of electronic
health records (EHR). While there is general agreement on the need for
this technology investment—both presidential campaigns included EHR in
their health platforms—the cost ramifications are still up for debate.
Will electronic health records reduce costs? There are compelling
reasons to answer both “yes” and “no.”

Comments
(21)

Google Health and the PHR: Do Consumers care?

By Keith Schorsch

Google Health’s unveiling last week and Microsoft’s HealthVault
launch last October are important milestones in the evolution of Health
2.0. Both of these heavyweights have the resources and potential to
improve the health consumer’s customer experience. What’s missing from all of these conversations is the elephant in
the room: Do consumers really care about having online personal health
records?

Untangling the electronic health data exchange

By David Kibbe Kibbe

This post is to help a non-technical audience
untangle some of the confusion regarding health data exchange
standards, and particularly come to a better understanding of the
similarities and differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document
(CCD). But what I’m most interested in is getting beyond the
technical, political, or economic positions and interests of the
proponents of any particular standard to arrive at some principles that
demonstrate in plain language what we are trying to achieve by using
such standards in the first place.

The Wisdom of Patients – Social Media In Health Care

By Jane Sarasohn Khan

People
— citizens, patients, caregivers, “consumers” — are early adopters of
social media in health,
compared to other industry stakeholders
including providers, plans, payers, and suppliers such as pharmas and
medical equipment companies. This is but one of many findings in my report, The Wisdom of Patients, which was published yesterday by the California Healthcare foundation.

Management guru Tom Peters likes Health 2.0, Wennberg, PLM, Millenson, but not the medical establishement

Dec 10, 2008• 4

By Matthew Holt

I didn’t know that Tom Peters (the In Search of Excellence guy) knew or cared about health care, but he certainly does.

In just one blog posting he reveals his impatience (putting it mildly) with the general level of doctors skills, his approval of Michael Millenson’s and the Dartmouth group’s work on medical quality variation, and he shows that he likes Health 2.0 and PatientsLikeMe — not least because he thinks that the medical establishment is reacting negatively to them!

Who should Obama pick for FDA Commissioner?

Dec 10, 2008• 8

By John Mack

It seems like everyone in the Pharma Blogosphere and the press is recommending who president-elect Barack Obama should nominate as the new FDA Commissioner to replace Dr. Andrew von Eschenbach.

A few weeks ago, I created the “Who Should Obama Nominate for FDA Commissioner?” online survey to determine who readers of Pharma Marketing News think should be the next FDA Commissioner. I received many interesting comments and decided to open the survey up to as many stakeholders as possible, including consumers, healthcare professionals, former FDA and other government officials, pharmaceutical employees, and others.

I hope readers of The Health Care Blog will also participate (see how below) and I thank Matthew for allowing me to make this post to THCB.

Holland, pay-or-play and the WSJ Opinion page making sense?

Dec 10, 2008• 8

By Matthew Holt

Don’t worry, the WSJ Opinion only makes sense because they let Zeke Emmanuel and Ron Wyden write an op-ed. The article is called Why Tie Health Insurance to a Job? and it’s impossible to argue with the logic about why we ought to move away from employer-based insurance.

There is of course an argument amongst those of us who both want to move to a social insurance system and want to have universal insurance as to whether this should be done in the voucher-type model that Emmanuel & Vic Fuchs have proposed (which looks a little like how the Dutch now do it) or whether we need to go to a modified single/multiple payer system like the French/Japanese/Brits/Australians.

I gave a talk in Canada the other night suggesting that there was some potential for convergence, and I used the very recent Commonwealth Fund data looking at the experiences of the chronically ill in seven nations. What is very interesting to me is that in terms of access to primary care and in terms of disease management, the Canadians and Americans look roughly similar—and not too good. As for specialty care, well as we know the Canadians & Brits ration by time and the Americans ration by money (or socio-economic status).

The Medical Home Bandwagon and the One-Hoss Shay: Expectations and Assumptions

Dec 10, 2008• 12

By RICHARD REECE, MD Reece

Have you heard of the wonderful one-hoss shay that was built in such a wonderful way? Logic is logic. That’s all I say. Now in building of a chaise, I tell you there is always somewhere a weakest spot. — Oliver Wendell Holmes (1809-1894)

Expectations are high. States, health plans, and the Medicare program are making substantial financial bets that implementation of the medical homes will lead not only to improved care but also to long-term savings, largely by reducing the number of avoidable emergency room visits and hospitalizations for patients with serious chronic illness. Some see the medical-home model as a means of reversing the decline in interest in primary care among medical students and residents, and others argue the broad implementation would reduce health care spending overall. — Elliot Fisher, MD, MPH, “Building a Medical Neighborhood for the Medical Home,” NEJM, Sept. 2008

When people jump on the bandwagon, they get involved in something that has become very popular. The term “bandwagon” is usually applied to politics but spills over into other fields. It is also called the herd instinct, or going for the apparent winner. — Various Sources

When I think of the Medical Home, a concept introduced by the American Academy of Pediatrics in 1967, just now rapidly gaining speed and traction, two images spring to mind,

A bandwagon.
The wonderful one-hoss shay, which ultimately collapsed because of minor defects in its construction.

Bandwagon
Everybody is jumping on the medical home bandwagon. And for good reasons. It’s so damn logical. Health costs are out of control. The population is aging. Countless studies show primary–based systems are popular, cost less, satisfy patients, and achieve better quality and outcomes. Besides, American primary care physicians are unhappy with the present system, and so are American patients. It’s time for a change. The problem, logic says, stems from our specialty-dominated, fragmented system and growing shortages of primary care physicians.

A New Approach?
Why not, then, create a new approach where primary care physicians form medical homes, and with the help of a newly hired care coordinator, and a team of providers operating under the guidance of the doctor, offer continuous, comprehensive, coordinated care of chronic diseases (the 4 C’s of medical homes)?

Logic Builds Momentum
The logic of this approach explains why everybody is enthusiastically leaping on the medical home bandwagon. Leapers include:

Medicare and CMS, who are paying for a three year demonstration project, to be completed by 2010, to see if this new wagon works, has wheels, saves money on hospitalizations, and makes for a sustainable growth rate for health costs.
The Obama Administration, which has vowed to reform health care and save money through more primary care physicians, prevention, EMR use, and chronic care management – the medical home pillars.
Major primary care associations – the American Academy of Family Practice, The American Academy of Pediatrics, The College of Physicians, and The America Osteopathic Association – have joined forces under the umbrella of the Patient-Centered Primary Care Consortium to issue a set of Joint Principles and are churning out white papers on medical homes.
State legislators, who have taken the lead from state medical societies and the Physicians’ Foundation, and are endorsing Medical Home demonstration projects in at least 20 states. The numbers grow each month.
Academic institutions, such as Johns Hopkins, Duke, and the University of Rochester, who are pouring money and other resources into building and testing medical homes and other outreach programs.
The American Medical Association, the American Association of Medical Colleges, and societies of medical directors and state medical society executives, all of whom have bought into the concept.
NCQA, who think medical homes contribute to improved medical care.
Even the health plans, especially Aetna and the UnitedHealthGroup, who would like to serve as intermediaries in the process, selecting what doctors qualify for being medical home participants and what they will be paid.

“Almost” Everyone
Almost everyone, in other words, across the political spectrum have concluded medical homes are a leap forward and are willing to climb aboard for a bandwagon ride. The key phrase here is “almost” everyone. Forming and paying for medical homes are very much political processes, where “everybody” may not include those who want a piece of the action or feel their economic status is threatened.

Assumptions
It is assumed, of course, coordinated, comprehensive, continuous care of chronic disease in an aging population is an overwhelmingly logical thing. I agree, but it is still useful to examine medical home assumptions.

I am reminded of the story of the economist stranded on a desert island with fellow castaways. The castaways are surrounded by thousands of miles of ocean, but are blessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turns to the economist for an answer, and he says, “First, assume a can opener.” We’re assuming here that medical homes will serve as can openers to save the system. The cans, however, may be full of worms.

Perhaps it’s time to examine the assumptions that might cause the wheels of the Wonderful One Hoss Shay, known as Medical Homes, to come off.

The first assumption is that there are enough primary care physicians to make medical homes enough of an impact to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure (an EMR and a hired coordinator are mentioned as necessary medical home ingredients), to undergo the scrutiny of being audited for quality or complying with performance compliance markers, or to be paid enough to be motivated to create a medical home. Venture capitalists, alert entrepreneurs, retail clinic operators, and major corporations like Walgreens sense a primary care vacuum and are moving fast to set up primary care based worksites in major corporate sites having sufficient numbers of employees.
The second assumption is that new payment platforms will help create and sustain medical homes and be sufficient incentive to recruit primary care doctors through more lucrative “blended” payment systems – fee-for-service, a capitation fee for managing a patient panel, and patient-centered bonuses for rapid responds to same day visits and email or phone to patients. The predominant mindset among American physicians it to cure, fix, restore, or repair swiftly and episodically rather than manage or coordinate over the long haul. Whether new payment schemes will lure U.S. primary care doctors is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether lack of adequate compensation alone is the basic “turn-off” for medical students or residents considering primary care.
The third assumption rests on the notion that every medical home physician will have an EMR and will be able to talk, refer, and send complete electronic patient information to, other entities in the medical neighborhood – clinical colleagues, hospitals, pharmacies and other care providers. This is a giant leap of faith since only about 15% of physicians currently have EMRs and PHRs are in their infancy. It may be this barrier can be overcome through federal subsidies for EMRs, requiring physicians to meet connectivity standards, and rewarding collaboration through payment increases, pay for performance bonuses, and shared savings, but, in my opinion, the system is at least a decade away from this electronic utopia.
The fourth assumption is that primary care physicians will be comfortable with collectively “managing” the medical affairs of patient panels, making the data entries required, and massaging, analyzing, and responding to data determining the outcomes of a population health model. American primary care doctors, weary and wary of paperwork and third party hassles and managerial manipulations, may respond by choosing to opt out by rejecting Medicare and Medicaid participation; treating individual patients as they see fit; retiring; seeing fewer patients; going into concierge, cash-only, locum tenens practices; seeking employment outside the medical home, or medical careers unrelated to direct patient care. Instead we may see armies of physician extenders managing diabetes, hypertension, stable coronary artery disease, congestive heart failure, chronic obstructive lung disease, osteoarthritis, depression, upper respiratory infections, and gastro-esophageal reflex.
The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients may be annoyed by being asked to be in a medical home, when they only have one symptom or one disease that may not need to be “managed.” Also Americans are mobile with 20% of Americans moving each year. Many patients may not be looking for a personal physician or a medical home. Finally, keep in mind that most people who frequent emergency rooms do so because the emergency rooms are “there,” not because they are uninsured, underinsured, or lack a primary care doctors (Myna Newton, et al, “Un insured Adults Presenting to U.S Emergency Departments, “ JAMA, October 22-29, 2008).
The sixth assumption is that the medical home is a politically and financially neutral concept. This isn’t the case. Nurse practitioners, nurse doctors, physician assistants, and other medical specialists will lobby to set up their own Medical Homes, if for no other reason, than to make up for the primary care shortage. Another, probably more important factor, may the resistance of specialists. Organized medicine, now dominated by specialists, is aware that Congress’s present Sustainable Growth Rate (SRG) is supposedly revenue neutral, meaning if you reward primary care physicians through Medical Homes, you take away from specialists.

Conclusions
The medical home movement is logical and is intended to correct the current costly fragmented specialist dominated system by creating “homes” for patients with chronic disease to receive more coordinated and comprehensive care at less cost with better results. Medical homes are currently riding a political bandwagon, but the assumptions that the system will be transformed by medical homes remain politically and pragmatically untested. That’s why multiple demonstration projects are underway. Meanwhile, let us hope for the best and pray that a fundamental shift in the system towards more primary care occurs. Making medical homes a reality will take hard work and political arm-twisting.

Bad economy leads to poor health behaviors

Dec 10, 2008• 4

By Jane Sarasohn-Kahn

Half of people over 45 said in a recent AARP survey they’ve taken a generic drug or over-the-counter (OTC) medication instead of a prescription drug due to the current economic situation.

The AARP’s report, "Impact of the Economy on Health Behaviors," analyzes the survey responses of 820 Americans 45 years of age and older polled in October 2008.

Asked what health behaviors they may done as a result of the declining economy, the most common reactions among 45+ Americans were:

* Taking a generic or OTC medication, 51% * Delaying seeing a doctor, 22% * Cutting back on other expenses, 21% * Seeking assistance in getting prescription drugs at a lower cost, 21%.