Category Archives: Public Health

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

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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:

  1. Crystal Meth - which rewires your brain in very bad ways that are hard or impossible to reverse
  2. Heroin
  3. Having unprotected sex with multiple IV drug abusers
  4. 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.

Healthcare Prevention – Value, Savings and Strategies

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Prevention is often portrayed as either the savior or the step-child for reforming, transforming, or saving the US healthcare system.  How prevention would specifically benefit people and society is presented in various ways to make these points:

US Doing Worse in Prevention Activities

The Commonwealth Fund recently released a study showing the US is doing poorly in reducing deaths from preventable causes. (Variations in Amendable Mortality – Trends in 16 High-Income Nations.)

From Commonwealth Funded Study - September 2011

While this study isn’t a definitive prescription for systemic changes, it illustrates the performance deficiencies of the US healthcare system – and is consistent with other reports looking at related metrics.

Prevention is a Very Effective Strategy

The American Academy of Family Physicians’ journal “American Family Physician” had an editorial last September titled, “Preventive Health: Time for a Change,” which noted that, “According to recent literature, primary prevention appears to work better than any other strategy in medicine.”  This article also had a great poster “prescribing” the formula for good health. (See below.)

Modified From "Preventive Health" Editorial AFP, September 15, 2010

[Note: I've modified it to indicate 5-10 recommended servings of fruits and vegetables. In addition, it should also be recognized that the weight goal requires a long-term strategy - while the other activities are more immediate - and an often cited weight reduction goal is 10% since people generally see that as reasonable, and a 10% weight loss for someone who is obese has been shown to improve clinical outcomes.]

Politics of Prevention

The 2010 Federal health reform law included $15 billion over 10 years for a Prevention and Public Health Fund to assist state and community efforts in preventing illness and promoting health.  However, like many things in the 2010 Federal health reform law, this funding has been targeted for elimination in order to reduce overall government spending. As the Health Policy Director for the Republican staff of the Senate Committee on Health, Education, Labor and Pensions stated during a session hosted by Politico last week, “While everyone supports the idea of prevention, there isn’t a lot of data that suggests that those programs actually reduce healthcare costs,” and this part of the health reform legislation is a “slush fund.”

Conclusions:

So like many things in healthcare, definitions are important – as are priorities and savings calculations – since what I suspect the Senate HELP Committee’s Republican Health Policy Director meant was that many prevention programs haven’t been shown to save money for Medicare or Medicaid, i.e., reduce Federal spending projections. This isn’t too surprising since Medicare is for the elderly and disabled, so prevention in that population may often be secondary rather than primary – and Medicaid faces similar “those who pay may not be those who benefit” challenges. However, such a narrow programmatic and financial mindset fails to recognize that improving prevention for the overall population can slow the growth in total healthcare spending and improve productivity. My “proof” for that sweeping statement – particularly the worker productivity piece – is that growing up in Hartford, CT it was common knowledge that the insurance companies, (most of which had their headquarters in Hartford), had the best prevention and employee wellness programs.  And this was not by chance – they knew it was good business to keep their employees healthy and productive.

Patient-Centered Care? Or Not?

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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….

Smoking, Exercise and Obesity – The Big Three

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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.

Smoking Rates (Tobacco Use) 1965-2008

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:

Smoking Rates - Tobacco Use (Age >25) by Education Level

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.

US Obesity Maps 1985

US Obesity Maps 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.

Historical Perspective on Health Reform – Part 1, Medical Effectiveness

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Since the time-line for health reform legislation has continued to be stretched, I recently spent some time cleaning out old files.  In my excavations I came across papers, articles, memos and briefing books which demonstrate that no matter how much things change, some aspects of health reform have stayed the same.  For example, below are a couple of snippets from memos about a proposed Medical Effectiveness Initiative from circa 1989:

Establishing a Medical Effectiveness Initiative at the OASH [Office of the Assistant Secretary of Health] level. (FY90 request = $52 million) This initiative would assess which medical treatments are cost-effective, and identify inappropriate and unnecessary medical practices. This knowledge would be used by reimbursing agencies in containing health care costs. [FYI – for budgetary comparisons, FY89 budget authority for the NIH was $7.15 billion, and $536 million for the FDA, and $141 billion for HCFA - now CMS.]

The Secretary’s Effectiveness Initiative for promoting the public health has as its goals:

  • improving the quality of health care received by Americans through the provision of effective, appropriate care, and involving the consensus of the medical community;
  • control of health care costs through elimination of ineffective and unnecessary medical treatments and comparison of the cost-effectiveness of alternative treatment modalities, thus insuring access to care;
  • enhancing the scientific basis of medicine through application of current technology (e.g. meta analysis; mainframe and software design) to the issues of medical treatment effectiveness; and
  • enhancing the competitive basis of the health care industry through provision of information to patients and providers on risks and benefits, including cost-effectiveness of medical treatments.

While the budgetary size of the proposal is very small compared to current initiatives, (e.g. the $1.1 billion for Comparative Effectiveness Research enacted earlier this year in the stimulus legislation), the wording and rationale for the proposals sound very similar – except that this initiative would explicitly use the information to alter government reimbursement  practices, which was precluded under the ARRA bill.

One difference that dates this language is the phrase “mainframe and software design.”  There have been significant advances in computer technology – which we now term IT – and these advances enable much better and rapid monitoring of quality, as well as and spending and utilization.  Such near real time quality and cost monitoring is important for implementing programs that provide cost and quality information to clinicians, patients, payers and others.  The ability to deliver analyses based on information which is days, weeks or maybe a month or two old, and reflects individual actions, is much more effective for changing behaviors and practice patterns than is data which is years old, and may be aggregated information for a population or across a region.  In addition, IT advances have made risk adjustment a much more robust process – if not exactly precise.  This is critical for the success of quality improvement and cost control programs because the first response from every clinician presented with information that the care they provide is costlier, or somehow lower in quality, than their peers’ practice patterns is that their patients are more severely ill than average and that explains why their costs are higher and outcomes poorer.

Next Up: Part 2 – Historical Perspectives on Universal Coverage and Cost Containment

Advancements in Understanding Head Trauma and Preventing Long-Term Problems

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When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war.  Over the past year I’ve been talking with friends and colleagues about another connection between war and football – how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation.  While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.

There have been more than a few reports about former NFL players having neurological problems after retiring; In particular, former Patriot Ted Johnson, whose problems with post-concussive syndrome was reported 2 years ago in the Boston Globe.  And just today, the Boston Globe had an article about how the brain of an 18 year old football player, (who died from nonviolent causes), showed early signs of irreversible damage from repetitive head trauma – something that had not been documented in professional football players younger than 36 years old.

War is different than football: In war, the goal is to avoid head trauma and steps can be taken to avoid it or minimize its effects through better vehicles and helmets – and by taking people out of harms way after head trauma has occured.  Conversely, in football, the contact, hits and subsequent head trauma are essential parts of the game.  While helmets have been made better and players can be taken out of the action after even minor head trauma, football can’t be played with complete cushion suits like those sumo-style outfits used in late-night and reality TV shows.  Last summer I wrote about how professional baseball teams are becoming more aware of the lasting effects of concussions on their players – but baseball isn’t inherently a contact sport.  I wish I had a good answer for football and football players.  Unfortunately I don’t think switching to flag or touch is going to make it as an alternative to full contact football. I’m a fan, but I don’t have good suggestions, and understanding the long-term consequences of repetitive minor head trauma, often makes it difficult for me to watch a football game – professional, college or high school.

Health Reform – Achieving Universal Coverage

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During the holidays the Obama Health Transition Team urged people to organize discussions about health care in their homes and communities – and then to report back. Reading about these discussions – including the one that Secretary Designee Tom Daschle attended in Indiana – made me think about what things are going to be needed to make health reform actually work.

My end-of-year reflections and ruminations led me to conclude that one of the most challenging parts of health reform will be to actually get more people enrolled in whatever expanded coverage plans are developed and implemented.  Enrollment barriers are not new, but they are frequently not highlighted because they may present great political and fiscal risks.

Eligible But Not Enrolled
Medicaid experts have long known that a significant number of people who are eligible for Medicaid but are not enrolled. According to a 2006 Report from the Commonwealth Fund, 62% of “uninsured children and two-thirds of uninsured, poor parents qualify for publicly funded health coverage programs but are not enrolled.”  And enrollment barriers have been seen in Massachusetts as it has implemented its health insurance coverage expansion program.  For example, Bill Walczak, the CEO of the Codman Square Health Center in Roxbury, (a low-income section of Boston), has stated that they have 1400 patients who are eligible for free health insurance, but they can’t get them enrolled because of paperwork barriers.

For several years, Washington DC has also had a health insurance expansion program called the Health Alliance.  Unlike the Massachusetts program, there are no mandates or penalties for not enrolling.  But, Bread for the City, which runs two free clinics in DC, has seen the same enrollment problems as Codman in Boston.  Both Codman and Bread have staff dedicated to helping people collect and submit all the necessary paperwork, but they still have significant enrollment barriers because of clients moving, not following up on mail, chaotic lives and trouble finding the right proofs.  I also suspect that literacy may be a problem for some people – since how can people respond to mail or find the right documents if they cannot read them?

Cost of Enrollment Barriers
Although the uninsured clients at Codman and Bread receive care when they show up, not having insurance makes it much more difficult for them to get needed medicines and specialty care.  And of course, not having health insurance hurts people in the form of poorer health.  This situation also hurts the clinics financially since they would be getting paid for this care if the patients were insured.  Codman’s CEO wrote that if their 1400 uninsured patients had insurance, they would receive an additional $250,000 per year – An amount that would make a significant difference in their ability to provide care to patients.  They face the quandary of whether or not to hire more people to help clients apply for free insurance, since this only makes sense if it brings in more money than it costs to hire someone.

In Massachusetts, Codman is not the only healthcare organization suffering financially from this problem.  The Cambridge Health Alliance recently noted that they may have to scale back services or close one of their hospitals because of shortfalls they are seeing under the new health program – some of which is due to their not getting paid for care they provide to patients eligible for insurance.

Uninsured in Massachusetts
The paperwork barriers to enrollment in Medicaid, (and other free or very low cost insurance programs), also raises questions about the number of uninsured in Massachusetts.  The number of people without insurance has certainly declined, with the latest report indicating that 2.6% of people don’t have insurance – a very significant decline from 7.4% in 2004 before the State’s new program began.

However, I’m curious about how well the surveys that generate these numbers are actually capturing the lack of insurance in vulnerable low-income populations – both because of the paperwork barriers and their higher rate of churning – even though the report indicates that rate of uninsurance for people below 300% of the Federal Poverty Level is more than 5% [See Chart below, and also see page 9 of Kaiser Family Foundation’s Medicaid Primer for discussion of the effects of “churning” on Medicaid enrollment.]

Uninsured in Massachusetts in 2008 Source: “Health Insurance Coverage in Massachusetts: Estimates from the 2008 Massachusetts Health Insurance Survey,” December 18, 2008

Solutions and Challenges
Certainly one solution would be easy and automatic enrollment.  Basically, this could be as simple as the patient signing a form stating that they meet the eligibility requirements for the health insurance program.  [Click here to see the Massachusetts Medicaid application]

The problem with a simple form is that it could lead to fraud – either by people who are not eligible so they can get free health insurance, or clinicians enrolling people so that they can just get bill Medicaid for services they aren’t providing.  One possible solution to this fraud problem would be to require that the form be signed by both the patient (or their guardian) and the clinician (or someone in their office that they designate), BUT only clinicians that the State has pre-authorized could sign and submit the auto-enrollment forms.  That way the State could limit the authorization to clinicians who already are providing care to large numbers of Medicaid patients, and thus reduce the number of organizations it would need to examine for fraud.  And of course these clinicians would be responsible for attesting that these patients are believed to be eligible for the Medicaid program.

Such a system could work by having the enrollment counselor at an authorized clinic go over the eligibility criteria with the patient, and if they meet the requirements, then together they would fill out a one page form.  Such a form could have the patient sign a single line which reads something like: “I believe my income is below the level required to be in the Medicaid program, as it has been explained to me by _________________ [Name of person signing below].”

And the person assisting them from the clinic would sign below stating, “I attest that, to the best of my ability and in good faith, I believe that __________________ [Name of person filling out top part of form] meets the requirements to be eligible for Medicaid.  I also understand that signing this form without having discussed the actual requirements with this person or reviewing any documents they have provided or are otherwise available to me which may indicate whether or not they meet the eligibility requirements, constitutes fraud and may subject me and _________________ [Name of organization] to financial and  criminal penalties – including imprisonment.  In addition, if the person signing the top of this form is found to be fraudulently enrolled in Medicaid, they could also be subject to financial and criminal penalties.  Thank you for assisting with this process.  Your contribution to improving our healthcare system is greatly appreciated. Have a great day!”

I’m sure there are problems with such a simple form, and that other people could improve on that language.  And I invite comments, edits and criticisms to this suggestion because unless we figure out how to actually enroll eligible people in free health insurance programs, then universal coverage will remain a vision outside our grasp. [Also see the Commonwealth Fund Report on how auto-enrollment might work and what Federal policies would facilitate auto-enrollment.]

Closing Observation
Anticipating that someone will suggest that other countries – like England – have figured out how to do universal enrollment and don’t seem to have the fraud I’m concerned about, I would like to note that a major operational difference between our system and England’s National Health Service is that the NHS employs the physicians and owns the hospitals, whereas Medicaid reimburses for specific clinical services.  What this means in terms of financial fraud, is that the NHS has a fixed amount of money to spend each year, (like the Veterans Health System here in the US), and if they run short of money at the end of the year they have to cut back on the care they provide.  Conversely, Medicaid just keeps paying the bills.  So in England, if people are fraudulently enrolled in their system, they are just “stealing” resources from others in the form of preventing or delaying other people from getting the care they need.  Conversely, Medicaid fraud results in Medicaid spending more money, but access to care for those who are legitimately enrolled isn’t significantly compromised because Medicaid doesn’t “run out of money” the way the NHS or the VA can.

Transparency in Non-Profit Organizations

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The ongoing series of financial failures and scandals have made me more interested in financial transparency for non-profit organizations – which economic theory states are really supported by everyone because their donations are tax deductible which reduces total tax revenues.  My thinking about the finances of non-profits has also been piqued because of an accounting class I’ve been taking, as well as by my last post about transparency in health reform legislation.

One recent example of non-profit organizations increasing their transparency is colleges and universities issuing press releases and sending letters to alumni about how the economic downturn has effected their endowment, and what steps they are taking to be more fiscally conservative – such as freezing hiring or delaying construction projects.

This type of communications and transparency is not just good PR.  How non-profit organizations communicate their internal financial workings to the public and their financial supporters can help create an extra level of trust – which can translate into more donations.  For example, when I was a Board Member at Bread for the City in Washington DC – and chaired the Fundraising Committee – we saw this when the organization received press kudos for a fundraising letter that included pie charts showing where the organization’s funds came from and what they were used for.

Now Bread for the City has taken a huge step forward in transparency by putting their audited financial statements on their web-site.  This document goes well beyond their annual report or tax return, and includes detailed information about spending for very specific functions and activities – basically the same information that the Board of Directors gets every month.

So if you’re looking at where to make your end-of-year charitable donations, think about how transparent the organization is about their finances. Be sure to look for information about where they get their funds – to make sure they have broad support – and how they are spending their funds – to make sure they are being spent on the organization’s mission, and not on just raising more money or talking about the problem they really should be solving.

And of course, you can click here if you want to donate to Bread for the City – which I have no official connection to, I’m just a big fan.

Health Reform – How Much Expansion?

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Morton Kondracke, a columnist for Roll Call newspaper, (sorry on-line subscription required to read the full article), had a very interesting and insightful piece yesterday where he outlines some of the reasons that health reform in 2009 will be more expansive than in might have been a few years ago.

He makes two very concrete and connected observations.  First, that the economic downturn will increase the number of people without health insurance by 5-6 million, and probably add a similar number to the rolls for Medicaid and SCHIP – which will add to States’ budgetary problems.  And second, that the costs of health reform are likely to be much greater than expected – assuming of course that there isn’t a dramatic economic rebound.  The number he puts forward is “more than $3 trillion” over 10 years.

Higher costs are largely due to a greater number of people without health insurance, which would be consistent with the experience in Massachusetts:  In Massachusetts the initial estimates of the number of uninsured were too low, and more people than projected enrolled in subsidized plans resulting in higher than expected costs.  More people having health insurance is a good result from the perspective of moving towards universal coverage, (and for all the benefits it provides to individuals and society), but it is a bad result from the budgetary perspective.

How these expanding challenges are met in what is actually agreed to for health reform in the coming months, (for the legislation), and years, (for the regulation and implementation), will be important for both our individual and national health and finances.  While it would be nice to say that it is important that health reform be done “right,” because so much of what will be done is new – either in substance or scope – that I think it is more realistic to hope that the specifics of health reform don’t include too many missteps or components that need to be significantly revised in the future to correct unexpected outcomes.

What do you think?

Making Physicians Better, and Making Better Physicians

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A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions.  The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

  1. Ask permission to enter the room; wait for an answer
  2. Introduce yourself; show your ID badge
  3. Shake hands
  4. Sit down. Smile if appropriate
  5. Explain your role on the health care team
  6. Ask how the patient feels about being in the hospital

Clearly these actions are all directed towards creating a stronger person-to-person connection between the physician and the patient as a step toward improved communications – which is the foundation for developing and effectively delivering a treatment plan to and for the patient.

Physicians Getting Rest
Another challenge physicians have in this process is being awake and aware enough to actually engage in those 6 steps. (Having enough energy also would effect their ability to engage patients empathetically – something I’ve written about before.)  [Also see the previous posting about napping being better than caffeine for improving verbal and physical memory and learning.]

How much sleep physicians need to act appropriately – and avoid making errors – is the subject of a recent Institute of Medicine report, (“Resident Duty Hours: Enhancing Sleep, Supervision and Safety”), that makes new recommendations for limits to the work hours for physicians in training:

  • Duty hours should not exceed 16 hours per shift; For 30 hour shifts there should be an uninterrupted five hour break for sleep
  • Residents should have variable off-duty periods between shifts based on the timing and duration of shifts to increase residents’ opportunities for sleep each day, as well as regular days off that enable residents to recover from chronic sleep deprivation.
  • Medical moonlighting, (additional paid healthcare work), should be restricted
    [A chart comparing the current and new recommendations is available here.]

While all these changes would certainly make for more aware and awake residents, the IOM also estimates that recruiting and paying professional staff to substitute for the work hours the residents would have been (over)working, would cost about $1.7 billion.

Besides figuring out how to pay for these new staff hours, one policy question for implementing these recommendations is how to find the clinicians to actually work these hours considering there is such a shortage of non-physician clinicians.

Anther policy question these recommendations raise, is why they should they only apply to physicians in training?  Why shouldn’t they also apply to physicians who’ve finished their training and are supervising, teaching, and mentoring residents and medical students – and of course are directly responsible for patients?  While it might be argued that most physicians don’t work these long hours, for some that may not be the case – particularly in hospitals without many residents.

Considering that many quality improvements for medicine have been taken from the airline industry – such as the pre-flight/pre-surgery checklist – then why shouldn’t the limits on pilot shifts and hours also be applied to fully licensed physicians?  [I suspect that this will not make me popular with some physicians, but I wonder how they will defend their right to treat patients round-the-clock without sleep?]

Conclusions
Perhaps work hours and etiquette should be other aspects of quality improvement and patient safety that are considered as part of health reform discussions at the Federal and State levels. Certainly well-rested, empathetic physicians trained to interact with their patients with etiquette should improve the quality of healthcare by reducing errors and making physician-patient communications more effective.

How to integrate all these “innovations” into physician training and practice will be a significant challenge, because teaching such skills and promoting their use is not very exciting or technological, and it will be hard for such behaviors to be tied to economic incentives – which are often the carrot or stick for quality improvement initiatives.  Hopefully, as health reform ideas move forward and become crafted into comprehensive packages and plans, they will expand beyond direct economic incentives for improving clinical processes, to include non-economic inducements to promote quality enhancing actions and attitudes for clinicians as well as patients.