Accountability in Healthcare – What People Think of the Coming Changes

Posted on December 16, 2011 by Michael D. Miller MD

Following up on my pre-Thanksgiving post, I’m reporting back on what friends and relatives think about some of the terms for new healthcare delivery entities, e.g., Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

What I heard is consistent with my previous conversations: People think that ACOs are like HMOs, and Medical Homes might be nursing homes, home health, or hospice, etc. One great insight came from my cousin who is a teacher. She told me that teachers react negatively to the word “accountability” because of the No Child Left Behind (except those who don’t measure up) law – which according to a RAND analysis from the summer of 2010 is “encouraging teachers to focus on some students at the expense of others, and discouraging the development of higher-thinking and problem-solving skills.” (Yikes! That doesn’t sound good for long-term innovation, economic growth, and international competitiveness.)

Solutions for Engaging the Public with Healthcare Transformation

I’ve been talking to a variety of people involved with health transformation at the national and local level about this information/perception gap, and am looking for ideas for raising the public’s understanding about why more team-based and coordinated care will improve quality and efficiency for them as individual patients. If you have any thoughts on this, please feel free to comment. In addition, I’ll be talking to more friends and families during the remainder of the holiday season about their impressions of the new terms, (such as ACOs and PCMHs), as well as the benefits of the healthcare delivery changes that are on the horizon, e.g., why the iconic one-on-one relationship with a solo Dr. Welby-like primary care physician may not be the way to get the highest quality care.

Healthcare Turkey Talk

Posted on November 21, 2011 by Michael D. Miller MD

Thanksgiving is a great occasion for learning what people think about the future of the US healthcare system.* This year, I’m going to find out what people are thinking about some of the coming health delivery system changes – particularly Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

I’ve conducted this two-question informal survey with handfuls of people and found their level of knowledge and positive reactions equivalent to Congress’s approval rating, i.e. 9%. This is worrisome, since if transforming the US healthcare system to increase value and quality will be partially based on ACOs’ and PCMHs’ superior care coordinating abilities, it will be hard to improve cost, quality, and access at the local level if the average person/patient doesn’t know what these organization are, there is inherent aversion to their names, or there is resistant to unexplained “changes.” (For example, several people I’ve talked to have thought Accountable Care Organizations seem like HMOs, and Patient-Centered Medical Homes are home care, nursing homes or hospice.)

So fair readers of this blog, let me know what you hear at your Turkey dinners and associated holiday events – and I’ll post back next week what I heard from my disparate and decidedly unrestrained friends and relatives.

*Unlike most meals and gathering of family and friends, Thanksgiving dinner goes on for a long time, there are no ceremonial interludes, and it is generally a sit-down affair so you can’t move on to someone else – or out the door. This means “Aunt Sally” can pull your ear or kick your leg (either figuratively or literally) for upwards of 2 hours about what’s wrong with the US healthcare system and what how to fix it. My advice is to ask questions to find out root concerns and to gauge people’s understanding of the coming ACA changes in both healthcare delivery and insurance coverage. Also, if you find yourself referring to a recent study from Commonwealth or Kaiser Family Foundation, (or a similar organization or government group), STOP, put food in your mouth and nod encouragement for them to keep talking, because quoting the best studies to someone impassioned about their healthcare will be about as successful as convincing your 7-year-old cousin that 3.14159 is a great dessert.

Smoking is So Bad For You That……..It Makes Me Sick

Posted on October 13, 2011 by Michael D. Miller MD

The evidence for the ill effects of smoking keeps getting stronger and scarier. If one were to construct a balance sheet of tobacco’s pros and cons it would look much worse than the one Bernie Madoff was hiding from his investors and the SEC.

Making the Risk of Smoking Personal

I was recently talking with one of my IT consultants and we started discussing tobacco use since he thought his smoking might have been one reason he’d been denied health insurance. What he – and many people – don’t realize is that the major health risk from smoking is not lung cancer, but how damaging it is to the heart and blood vessels, i.e., your cardiovascular system:

On Monday USA Today reported on a study showing that smoking cigarettes doubles a person’s risk of stroke.
Studies have shown that second-hand smoke increases the risk of heart attacks – which is why many states and even the country of Ireland have prohibited smoking in bars and restaurants.
When Ireland banned smoking in pubs the rate of hospital admissions for heart attacks dropped by more than 10% in the following year.

Additional evidence about the risks of smoking is pervasive – sort of like finding a piece of hay in a bale of hay – including a report from the US Surgeon General indicating that smoking ONE CIGARETTE can increase the risk of heart disease as well as cancer. In scientific terminology this means that there is no lower limit or threshold below which tobacco causes no harm.

Similarly, the concept that tobacco in forms other than cigarettes aren’t so bad is, well BS: cigars and “chewing tobacco” are bad for you too – just in different ways depending on how they are used and how often. And the propaganda that hookahs (smoking flavored tobacco through a water pipe) are safe is hooey – smoking a hookah for an hour can be like smoking ONE HUNDRED (100) cigarettes.

So after going through these facts to help my IT consultant put smoking cigarettes into perspective, (i.e., tobacco damages your heart and blood vessels etc.) – and adding a few points about how smoking increases a person’s risk for dementia, Alzheimer’s, other cancers besides lung cancer, and sexual dysfunction – I prioritizing the bad things he could possibly be doing to himself:

Crystal Meth - which rewires your brain in very bad ways that are hard or impossible to reverse
Heroin
Having unprotected sex with multiple IV drug abusers
Smoking cigarettes…. or using any form of tobacco

The Positive Attributes of Tobacco

The positive side of tobacco’s “balance sheet” is pretty slim:

Income for tobacco farmers
Income for companies that make and sell cigarettes and other tobacco products
There are a few rare conditions where nicotine may help prevent flare-ups
It’s “cool” and it makes people appear older. (Smoking actually does make people look older by causing skin changes on the hands and face, including wrinkles that can make a 35-year-old smoker look 45 or 50.)

Bottom Line

So adding this all up into a Bernie Madoff-type balance sheet it seems that smoking cigarettes is like:

Driving without a seat belt – and twenty bowling balls and big pieces of broken glass in your passenger seat
Sleeping with a loaded gun in the waistband of your pajamas
Scuba diving or flying an airplane without lessons
Riding a motorcycle while juggling

Like smoking, there will be people who might be able to do these things for years without ever developing a “problem.” But I suspect that most smokers don’t understand the real risks they are taking, and certainly wouldn’t take similar risks for themselves or their children by doing other things like replacing their smoke detectors with oil lamps.

And lastly, I believe healthcare professionals are not doing enough to help people stop smoking. Kicking the nicotine addiction isn’t easy, but there are ways to help: counseling, support groups, prescription and OTC medications, and even financial incentives from health insurers and employer including higher (or lower) insurance premiums. As an additional incentive, some companies are not hiring people who smoke - although some states have passed laws protecting smokers’ off-duty “rights” to such self-injurious conduct. So unless you’re living in an alternative universe where the job market is “smoking,” putting yourself at a disadvantage for getting a job (or a better job) because you smoke doesn’t seem like a very good career move. It might be better to have committed felony financial fraud since at least that demonstrates some math skills and not just the ability to suck in poisons.

Selling Healthcare Changes – Loss Aversion & Adoption of Innovations

Posted on September 26, 2011 by Michael D. Miller MD

Healthcare issues ranging from national health reform to stem cell research have become a major force in political rhetoric – often overwhelming substantive information. This creates challenges for individuals and organizations seeking to achieve positive changes as their communications are swamped by election-driven messaging.

Creating and implementing successful communications programs in this turbulent environment is easier when the principles of “loss aversion” and the factors affecting the adoption of innovations are used constructively.

Loss Aversion & Campaign Messages: Swinging Votes Not Actions
Campaign communications – particularly negative messages – are very effective because they use loss aversion principles to leverage people’s reluctance to embrace change.

I have repeatedly heard that people need to believe they will receive a gain that is twice as large as their potential loss before seeking to make a change. However, that 2:1 ratio is derived from some specific social psychology experiments, while loss aversion research demonstrates that the ratio varies depending upon the magnitudes of the risks and rewards for the individual. For example, many people would willingly wager 10 cents on a coin flip if they could win 11 cents by guessing correctly – if nothing else just for the “fun” of playing, and because losing 10 cents isn’t a big deal. However, very few people would wager $1,000,000 on the same coin flip for the chance to win $1,100,000 – even though the odds and the loss-gain ratio are the same, (and in the player’s favor), because the significance of the risk is much greater.

Source: Kahneman et. al. 1991

While these principles are not unique to healthcare, their power for influencing people’s perceptions and actions is greater for healthcare issues because of healthcare’s very personal nature and most people’s impression that they have some healthcare expertise acquired through first-hand experience. [Reader Participation: Insert your story here about a friend or relative who has "educated" or "advised" you with a personal healthcare story, or how someone - perhaps a stranger - has offered healthcare advice based upon something that happened to them, or someone they knew, or they just heard about from someone else.]

The principles of loss aversion make it very, very difficult for potential short-term and individual gains to be the foundation for effective communications campaigns about healthcare improvements for the following reasons:

Loss aversion means that most people are going to want to see a potential gain that is a multiple of the potential loss – and those most affected by a proposed change will see the potential loss as much more significant, and thus require an even larger potential gain in order for them to not oppose it. (And those most affected will also be the most active and vocal in their opposition.)
For most people, healthcare changes have significant levels of perceived personal risk – whether it’s changing their health insurance benefits, choice of physicians or hospitals, how they can obtain access to new or experimental treatments, or even very specific changes such as stem cell research, abortions, end-of-life counseling, genetic or autism screening, etc.
While potential losses are well understood by most people – since they know what they currently have and realize that change will be “something different” – potential gains are usually much harder to visualize and believe in. (This is why the current Administration has said that under the new health reform law people can keep their current health insurance plans if they like them.)
People’s trust in government and large organizations, (e.g. corporations), has plummeted in recent years, greatly reducing people’s confidence that changes advocated by these sources will actually produce the promised gains. Specifically, in “calculating” potential losses and gains most people will greatly discount potential gains from government or corporate initiatives. For example, suppose a proposed government healthcare change is described as having a gain of 10 and a potential risk of 3. [These numbers are obviously only arbitrary representations of the magnitude of how potential changes might be valued.] This change might be seen as having a gain-risk ratio of 10:3, but a general distrust of government actions could discount the potential gain to 25%, (which is about where Congress’ approval rating is right now), resulting in a perceived gain-risk ratio of only 2.5:3 – and this assumes that people don’t inflate the potential losses because of their low opinion of government, which could make the perceived ratio 2.5:6 or 2.5:9. Clearly this is not a situation where people would eagerly support a change in something as important as their health.

This means that even for a proposed change where the best projections indicate significant benefits to many, many people, any individual or organization who opposes the change, (for political or other reasons), has a very easy time crafting messages and images that are very effective in undermining support for the proposed change. (For example, the combination of the following phrases has been effective in undermining support for the new health reform law: “Government Takeover,” “Death Panels,” “Unconstitutional,” and “You Lie.”)

Overcoming Loss Aversion and Negative/Counter Messaging
The solution to overcoming such undermining messages that play on people’s concerns about losing what they have (and know) – as well as their mistrust of governments and other large organizations – is to present proposed changes in ways that expand people’s confidence in and understanding of the potential gains, while also minimizing the perceived loss potential. One way to do this effectively in a communications strategy is to address the 5 factors influencing the adoption of innovations that Rodgers first described in the 1960s:

Relative Advantage
Compatibility
Simplicity
Observability
Trialability
[These are derived from Rogers 2003 book and it's earlier editions, and described by Dealy and Thomas in their 2006 book.]

Selling Health Reform as Positive Innovation
Shifting to a “selling” campaign that incorporates these factors – while minimizing the potential affects of loss aversion – moves the communications dynamic away from the slippery losing slope of loss aversion’s context to one that is more favorable to thinking about the longer-term and more tangible benefits of the proposed changes. For example, the broad communications campaign for the bipartisanlly supported Medicare prescription drug benefit, (Part D - enacted in late 2003, benefits started in 2006), emphasized how much individuals would save, rather than the long-term value and security of having insurance – which is what Part D plans are, they are insurance, not a discounted purchasing scheme. (A USA Today article stated that an average person who enrolled in a Medicare Part D plan would save $1,100 in 2006.)

The Result: While people who did purchase Part D plans were generally happy with their plans, about 10% of Medicare beneficiaries (~4.5 million people) didn’t have prescription drug coverage in 2007 despite some plans costing less than $10 per month. The large number of people who decided to not purchase this very low cost insurance is even more striking because individuals’ premiums increase by a “penalty” of 1% per month for every month between their initial period of eligibility and their enrollment date. (This penalty is to reduce adverse selection, which occurs when people wait until they are ill before getting insurance.) Unfortunately, the number of Medicare beneficiaries without drug coverage doesn’t appear to be declining – in 2010 it was still about 10% of beneficiaries, and this compares very poorly to the very low percentage of people who declined Medicare Part B coverage.

The significant number of Medicare beneficiaries who decided not to purchase a Part D plan could be due to their aversion to a perceived loss being stronger than the positive messages used to sell the benefits of the plans. This imbalance results from the gains being presented as short-term financial savings, (rather than the long-term benefits of having insurance), and thus didn’t utilize the factors for improving the adoption of innovations, i.e., Part D insurance plans is comparable to other insurance they have, it is not complicated (except for the initial large number of choices), they can observe it, the plans can be tried, and the insurance provides a significant relative long-term advantage.

Bottom Line – Sell the Value & Spirit, Not the Calculation
The bottom line is that selling the value of healthcare changes – whether it’s national reform or narrow innovations – needs to encompass broader, longer-term, and tangible values, rather than short-term calculations that may be both uncertain and not believed, while also deflecting and undermining opposing arguments, i.e. capitalize on the factors that ease the adoption of innovations while minimizing people’s inherent aversion to potential losses.

And in closing, (at least for this posting), how these principles were used in a negative way to sell a non-healthcare change might be a useful illustration:

Buying a house with an unaffordable mortgage was seen as OK before 2008 because the potential for loss was believed to be very small – since prices were rising and foreclosures were rare so there was very little to trigger an aversion. And owning a home is compatible with most people’s desires and daily lives, home ownership is observable, renting is akin to a trial of ownership, brokers and agents made it all very simple, and home ownership has potentially great financial and social advantages. However, in retrospect it’s clear that purchasing a home was vastly wrong for many people – and potentially involved outright fraudulent communications – because they had been led to believe in illusory loss-gain (a.k.a. risk-benefit) calculations.

Patient-Centered Care? Or Not?

Posted on July 11, 2011 by Michael D. Miller MD

The term “patient-centered care” has increasingly been used to describe healthcare structures that deliver better quality care – as well as often doing so with lower costs. And today there was a news story about how some medical schools are assessing applicants’ interpersonal skills, something that is fundamental for being a patient-centric clinician.

While there are have been numerous articles demonstrating the value of patient-centered care and concluding that it is better and should be promoted – including those looking at the ill named “Patient-Centered Medical Homes” – I’ve found myself pondering the following questions:

“What type of care have clinicians been providing if it hasn’t been patient-centered? Has it been clinician/physician centered? Or revenue centered? Or just intentionally confusing and impersonal care designed to stymie the adoption of evidence based standards of care?”

“And along those lines, is the widespread delivery of non-patient-centered care the reason why the IOM concluded that it takes about 17 years for valuable healthcare information to be adopted into clinical practice? Or why Atul Gawande found that hospitals in other countries have widely adopted surgical checklists to reduce medical errors and adverse outcomes, while only 25% of US hospitals are using these checklists?”

I’m just asking….

Cultivating Health Reform and Transformation

Posted on July 5, 2011 by Michael D. Miller MD

Listening to various speakers at a two-day HIT/Delivery System Transformation Summit last week reinforced my thinking about the concept that reforming (or transforming) the US healthcare system is more like farming than business management.

Transforming healthcare is like farming because it involves cultivating collaborations and coordination among independent people, organizations, and stakeholders who all have varied interests and reporting/governance structures. In this way, “managing” or “leading” health transformation is like growing plants – the soil needs to be prepared, the plants (or seeds) need to be planted, and then they need to be watered, fertilized, weeded, pruned, etc…. And depending on the plant, (i.e. what crop you expect to harvest), the time-frame from planting to results can be weeks, months, or years. This is just like changing healthcare, where seeing the fruits of the labor/investment can take months, (e.g., for new practice guidelines like checklists), to years for some healthcare IT systems. [Note: These time-frames are for seeing value from the change, not the time required to develop the technology or the evidence to demonstrate the value of the changes - which generally takes many years.]

Cultivating successful health transformation also takes coaches, change agents, and data – all of which are used to promote change among independent individuals and organizations by creating and reinforcing internal and external aligned interests and visions. Of course successful alignment leaders are also responsible for cultivating the development the appropriate deployment of these coaches and change agents, as well as the data capabilities and learnings.

This type of cultivation (versus “management”) is something I’ve done in various roles – most recently in an initiative that has brought together the leading stakeholders in a mid-sized city to improve the quality and value of healthcare for the entire region. (My title has been “Project Manager” – Perhaps I should change it to “Project Agronomist.”) In other situations I’ve been more directly responsible for people and projects in matrixed organizations and with virtual teams. But even when working inside one organization, creating shared vision and engagement requires cultivating every individual in different ways – just as every crop has different soil, water, light and nutrient needs. And from observing other people’s mismanagement adventures, I’ve seen how applying traditional management practices to this type of situation can be like tilling a wheat field with a rolling pin, i.e. a rolling pin is effective for wheat, but only when it has been grown, harvested and milled into flour and made into dough.

But back to the HIT/Delivery Transformation Summit. In talk after talk, people from across the country noted the challenges they face in getting their data systems to work together as well as aligning different stakeholders. But while many of the speakers noted the greater than expected technical difficulties in integrating data systems and sources to create information pictures robust enough to guide future efforts, (and inform clinicians and hospitals about their performance), the leadership, coaching and interpersonal “cultivating” challenges were equally (or more) challenging.

The bottom line is that advancing healthcare IT, implementing health system changes, and creating successful broader transformation requires careful cultivation of many different crops of stakeholders who all need to be smelling the same flowers for them to achieve their common desired goals of improving healthcare quality and efficiency, i.e. so they can have their cake and eat it too.

Medical Homes (PCMH) in 2011 – Patient and Consumer Centric

Posted on February 23, 2011 by Michael D. Miller MD

Patient-Centered Medical Homes (PCMH) are continuing to be a bigger and broader part of the real-world discussions about health reform and transformation in the US. According to the the National Committee for Quality Assurance (NCQA) at the end of 2010 there were 7,676 clinicians in 1,506 recognized PCMH practices in the US. This information was released last week by NCQA with their updated 2011 PCMH Standards.

Another marker of medical homes’ increasing pervasiveness is the blurb – “Home sweet medical home” – in the March 2011 issue of Consumer Reports magazine that starts with, “If you haven’t already heard the term ‘patient-centered medical home,’ chances are you will soon.”

Consumer Reports – “Home Sweet Medical Home”
The Consumer Reports blurb is part of an article about what primary care physicians wish their patients knew. Interestingly this longish blurb notes that any practice can be more patient-centric without being officially certified, and it lists the important features patients should look for:

Can you get an urgent appointment within 24 hours?
Can you reach somebody in the practice by phone at night or on weekends?
Can you get test results quickly via e-mail or telephone, or on-line?
If you have a chronic condition, is there a system for tracking how you’re doing?
Does the practice include non-MD staff members such as nutritionists or nurse practitioners to help you manage your medications or chronic conditions?
Does your primary-care doctor keep track of your treatment by specialists?

NCQA’s 2011 PCMH Recognition Standards, Elements, and Factors
The 2011 PCMH Standards NCQA released last week are much more detailed about what a primary care practice should look like to provide high quality primary care – and they are a logical evolution from their 2008 Standards. Specifically they:

Reduce the number of Standards from 9 to 6 – which should make them easier to understand and implement.
- The 6 Standards have multiple Elements. And each Element has various Factors that contribute to the scoring for that Element.
Integrate newer health IT standards and requirements.
- NCQA provides a cross-walk between the Elements and the corresponding Federal Meaningful Use requirements for health IT that enable clinicians to receive higher Medicare and Medicaid reimbursements.
Include a patient survey, which will be available in 2012.
- The optional survey will provide more patient-centric feedback about people’s experiences and enable practices to score extra points towards the recognition Tiers.

NCQA also continues to have three Tiers of possible recognition – with Tier 3 being the highest.The new NCQA standards also continue to have “Must-Pass” Elements (in bold/italics below) for the 6 Standards. And practices must score at at least 50% on all those Elements to receive any recognition Tier.

Standard 1: Enhance Access and Continuity
Access During Office Hours, e.g., same day appointments and telephone or email communications

Standard 2: Identify and Manage Patient Populations
Use Data for Population Management, e.g., using medical record data to remind patients about getting evidence-based care for specific preventive services and treatments for chronic conditions

Standard 3: Plan and Manage Care
Care Management, e.g., individually written care plans and addressing barriers to patients achieving their treatment goals

Standard 4: Provide Self-Care and Community Support
Support Self-Care Process, e.g., providing educational resources and tools to enable patients to improve their self-care and healthy lifestyles/behaviors

Standard 5: Track and Coordinate Care
Referral Tracking and Follow-Up, e.g., coordinating and following-up on referrals to specialists, including testing done by specialists and their recommended treatments

Standard 6: Measure and Improve Performance
Implement Continuous Quality Improvement, e.g., setting goals and acting to improve care for patients with chronic conditions, (such as diabetes, heart disease and depression), and preventive services, (such as immunizations, and cancer and osteoporosis screening)

It is also worth noting that among the various Factors that make up the Elements, NCQA designate some as “Critical Factors,” i.e., they are required for any scoring on that Element. And two of these Critical Factors are for Must-Pass Elements:

“Providing same-day appointments”
“Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families”

Thus, to achieve any level of recognition as a PCMH from NCQA, practices must have these two capabilities.

Conclusions:
While it may be coincidental that Consumer Reports lists 6 criteria for patients to consider in evaluating primary care practices for their “medical homeness,” and NCQA has 6 Must-Pass Elements, the two lists do parallel each other.

NCQA and Consumer Reports are targeting different groups of stakeholders – which is appropriate. NCQA’s requirements enable practices and providers to become recognized, while also informing payers and regulators so they can determine how to utilize a practice’s recognition in their policies and practices – including reimbursement levels.

Similarly, Consumer Reports is seeking to educate consumers, (a.k.a. patients and families). What is reassuring is that Consumers Reports doesn’t try to compare medical homes or clinics using its normal format of tables of numbers and those great red and black circle symbols. That type of evaluation works well for commodities like TVs, but medical care is a process not a product, and it needs to be individualized for the patient – so what is a good medical home for one person may not be as appropriate for another. (Atul Gawande’s recent New Yorker article “Hot Spotter” includes some examples of how cultural appropriateness can be a determining factor for the success of care for severely ill people.)

NCQA’s standards focus on structures and processes, and thus are not the beginning and end of what is needed for a successful patient-centered medical home. But certainly rigorous structural and process standards, combined with consumer education – along with other contributing drivers like cultural change motivators and incentives for achieving better outcomes – should lead to better quality, value, and efficiency in our health care system.

Let me know what you think about Medical Homes.

[Full Disclosure: I was given the Consumer Reports magazine by a friend who bought it because it has an article about TVs - and now I have to help her go buy a TV.]

Smoking, Exercise and Obesity – The Big Three

Posted on February 2, 2011 by Michael D. Miller MD

I’ve been working with a Midwestern community for the past 7 months to improve the quality, efficiency, and value of their healthcare – as measured by public health population status, and the cost and quality of medical services. This experience has reinforced what I’ve been hearing repeatedly for the 28+ years I’ve been working with healthcare challenges: The three most significant areas for improving quality and controlling costs related to illness and healthcare are reducing smoking, increasing exercise, and reducing obesity. (The latter two are connected, but they also have separate and important benefits.)

While I will be writing more about each of these health problems in the coming weeks, (along with many other health policy issues involving innovation, system transformations, and the ongoing debate about health reform legislation), I first wanted to lay out some top line perspectives on smoking, exercise, and obesity.

Smoking
While many people think that smoking is no longer common in the United States, the data says otherwise. The chart below from a recent CDC report shows that while smoking rates have declined significantly since the 1960s, about 20% of the US population still smokes.

This report also states, “Tobacco use is the leading cause of preventable illness and death in the United States.” It doesn’t get much simpler than that.

A deeper look into the data also shows that smoking rates vary dramatically by education level achieved:

This makes another great case for the value of education.

Exercise
Exercise has gotten lots of attention lately – particularly in the context of obesity. However, exercise has significant benefits aside from weight reduction and control – where is certainly can play a very important role. For example, a January 1, 2010 article “Physical Activity Guidelines for Older Adults” indicates that there is strong evidence that physical activity in adults results in:

Decreased Risk of:
- Early Death
- Heart Disease
- Stroke
- Diabetes (Type 2)
- High Blood Pressure
- Adverse Blood Lipid Levels
- Metabolic Syndrome
- Colon Cancer
- Breast Cancer
Reduced Depression
Improved Cognitive Function (in older adults)

In addition, the article also lists improving sleep quality and decreasing the risk of lung and endometrial cancers as benefits where there is moderate evidence.

Another point often missed about exercise is that the type of exercise doesn’t matter too much – just as long as it involves moving in some significant way. For example, pushing a lawnmower and raking up the clippings may be just as beneficial as lifting weights and going for a walk. (Conversely, thumb scrolling on a Blackberry, texting on a cell phone, or pushing buttons on the TV remote don’t count.)

If the benefits of exercise for cancer risk, mental health status, (and even controlling the symptoms of arthritis), were more commonly appreciated, maybe there would be greater emphasis on recommending exercise as part of integrated courses of therapy for a wide range of health problems – particularly since there is evidence that such recommendations are effective: An editorial accompanying the Physical Activity Guidelines article referenced above cites a New Zealand study that found prescribing physical activity and referring people to community resources resulted in an average of 35 more minutes of exercise per patient per week.

This editorial also concludes: “By implementing an evidence-based approach to promoting physical activity, we have an opportunity to improve the health of the public – particularly the older population. As a society, we need to increase our commitment to promoting physical activity. To be successful, we need continued leadership and involvement from primary care physicians.”

Obesity
With all the focus in recent years on obesity, it is still shocking to see the data. Below are the US state obesity maps from the CDC for the years 1985 and 2009.

While comparing these maps is interesting, you can also see an automated slide-show on the CDC’s website that shows the year-to-year changes – click here.

Obesity is clearly a huge problem involving not only medical and nutritional issues, but also broad sociological, cultural, and economic challenges.

Bottom Line
There is clearly overlap in the benefits people (and society) can get from stopping smoking, increasing exercise, and weight reduction, so calculating clinical or economic value from any single initiative can be difficult. While the synergistic effects among initiatives creates analytical challenges, it also present opportunities for better real world results. For example, besides helping with weight reduction, increasing exercise (as noted above) improves many other measures of health status and quality of life.

Similarly, smoking, exercise and obesity are all related to diabetes – a disease that is more than just “a little sugar,” and a condition of great concern because of how it decreases quality of life and produces tremendous costs to society. Specifically, diabetes is the leading cause of kidney failure, blindness, and lower leg amputation. And someone with diabetes has the same risk of having a heart attack as someone who has already had a first heart attack.

To close with one example of the bottom line of the bottom line, an estimate in the year 2000 put the US costs of obesity and overweight, (which included how it contributed to diabetes, heart diseases, etc.), at $117 billion/year.

—–

That’s all for now. In the coming weeks I’ll explore how clinical, technological, community-social and “other” advances and interventions can address the issues of smoking, exercise and obesity within the US healthcare system as we move toward transformed financing and delivery systems. As the same time, I’ll also bring some more quantitative perspectives to these issues, since in the current fiscal environment the economic implications of health proposals are of great interest and concern.

The Internet Solves Everything in Healthcare – - – NOT

Posted on April 23, 2010 by Michael D. Miller MD

Improving healthcare will require people having better information. That concept is generally agreed upon. The challenge is getting the right information to the right people at the right time. That is the interconnected goal of different facets of health information technology – from EMRs and PHRs, to health information exchanges.

People Are Complex
However, the complexity of medical care and individual variability – both human physiology and patient preferences – makes collecting and analyzing health information so that it is useful for individual clinical decisions much more difficult than presenting information about TVs, computers or cameras on a website such as CNET.

However, that distinction is not apparent to a friend of a friend who I had dinner with recently. This person told me how the internet will solve everything in healthcare by making quality information from patients available to everyone else so that drugs don’t need to be approved by the FDA and doctors don’t need to be licensed. He also believes that this full access to information from other people about the quality of every health care option – from specific medicines to individual surgeons – will make health insurance unnecessary, since people will be able to decide what they want to pay for based upon how high a quality of care they want to obtain.

As a polite dinner guest of a friend I didn’t argue with his Libertarian perspectives. Rather I tried to point out the complexity of analyzing health information because of different patient specific factors, and why risk adjustment is very difficult in assessing the quality of any healthcare option. For example, I mentioned the piece I wrote last winter about a study of different assessments of hospital quality in Massachusetts, and how this showed the difficulty of exactly what this person believed should be easy and currently possible, e.g. if you were a patient in Massachusetts trying to decide which hospital you should go to for a specific condition, how would you decide. As I noted then, the different quality assessments came to conflicting conclusions.

Profit Seeking Isn’t Always A Good Thing
I also noted how the profit motive can lead unscrupulous people to sell fake medicines that can actually do more harm than no treatment at all – such as fake anti-malarial pills containing aspirin, which don’t treat the malaria but do reduce the fever so people think they are getting better. Similarly, the concept of modern snake oil salesmen taking advantage of people’s hope was reinforced by a recent cartoon in the New Yorker showing two people looking at a display of pill bottles adorned with a sign saying “As seen on TV,” and the caption reads, “The active ingredient is marketing.”

However, I found my insights didn’t make much of an impression, and I did make a faux pas by pointing out that there was $1.1 Billion in last year’s stimulus bill for research to get more of this type of information and make it available to people. Unfortunately, this fact only elicited a shaking head in hands response which I took as his disgust at more wasted government/taxpayer money.

“Living is Easy With Eyes Closed, Misunderstanding All You See”
While for those of us not blinded by the limited wonders of computers and the internet, and who understand the complexity of actual healthcare decisions and analyses, the challenge is communicating this reality to people who believe that the internet is rapidly solving all our information problems…… As a society our goal should be to convey this knowledge to people before they or a family member becomes seriously ill – at which point the complexity of making healthcare decisions will be immediate and personal. And just as there are no atheists in foxholes, people facing serious life altering medical decisions want validated and reliable information, not subjective, anonymous opinions from the internet – which may be fine for picking a restaurant, but is certainly problematic for picking a surgeon or a medicine.

Politics of Health Reform: Selling Anger or Catharsis

Posted on March 22, 2010 by Michael D. Miller MD

With the health reform legislation process winding up, it is clear that going forward politics are – and will be – front and center, with the divide between the Democrats and Republicans as wide as the orbit of Pluto…… the planetoid, not the Disney character. This divide is depicted in black, white, and red in the National Journal’s March 13th Insiders Poll question, “If Congress enacts something close to President Obama’s latest health care reform plan, how would that affect your party in the midterm elections?” 87% of Democrats thought it would “help a lot” or “help a little,” and 100% of Republicans thought it would help them.

They can’t both be right.

Each party is banking on their ability to sell health reform their way: Democrats will present it as a significant step towards fixing many of our healthcare system’s and country’s problems. Conversely, the Republicans will characterize it as fundamentally evil and something that will end individual freedom and civilized progress because of “government takeover of healthcare” being run by a “healthcare czar.”

These sentiments and strategies are clear in the quotes accompanying the National Journal’s poll:

Republicans:
“The tax increases, the wild spending, and the backroom deals and threats will shock voters of all parties, producing a GOP revolt.”

“Passing the bill will help the GOP by fueling voter (especially senior) anger at an arrogant majority that knowingly ignored popular opinion.”

Democrats:
“It will help a lot of people, show that Democrats can act, and get the ‘sausage making’ off the news.”

“If it passes, people [will] see it’s not the end of the world and learn more about its benefits. The more they know about it, the more supportive they are. Best of all, we can begin talking about something else.”

However, one Democrat in the 9% who thought enacting the law would “hurt a lot” said, “The Right hates it, the Left is not satisfied, and the middle is scared.”

Majority v. Minority – Catharsis v. Anger
Without dissecting the merits of their positions, these divergent perspectives are due to the parties’ different roles in our two-party democracy: The majority needs to present their actions in a way that fosters catharsis in people, (particularly in voters), by actually improving some problem. Their goal is to turn that catharsis into positive feelings about the majority party, leading to votes in future elections. Conversely, the minority party needs to create anger about what the majority party is doing or proposing, with the goal of turning that anger into….. (no surprise here)…… votes in future elections.

Thus the key for the party leadership, individual elected officials, and their communications and campaign staffs, is how to best create catharsis or anger – depending upon which side of the fence they are on.

An old friend, Dan Wasserman, the political cartoonist for the Boston Globe, in his March 2nd cartoon depicted this very nicely:

[This cartoon was also reprinted in the March, 6th issue of National Journal]

Challenges of Political and Policy Communications
How people, (i.e. voters), perceive the issues and problems – and potential solutions – is strongly influenced by how they are presented and described. It is this communications process that builds or derails political and policy initiatives and campaigns. No matter the long-term success or failure of the health reform law, the road from now until the November elections will be filled with messaging to instill voters with either catharsis or anger – particularly swing voters in key states and CDs. For the Democrats, creating cathartic feelings will be much, much easier as specific provisions of the law become effective.

For Republicans, creating anger will be possible from the outset. In the near term having a new law will give them a focal point for anger, with proposed regulations and rules being easy and rich targets. In the longer term, as the new law actually improves many people’s lives, it will be harder to accomplish that goal. However, by that time, if they can use the near term anger they’ve created to take control of one or both houses of Congress, or the White House, as the majority party they will be the ones trying to create catharsis – so some successes via implementation will be to their benefit. In addition, if that happens, for political reasons Republicans will not want to repeal or significantly unravel the new law since continued implementation of health reform – without dramatic alterations – will deny Democrats one of their main campaign issues that they have historically used to generate anger among their base and swing voters.

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Post Script: Turning Anger Into Productive or Destructive Action
[Omitted for space considerations.]

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