Field Notes Inside an Integrated Communications Agency

Kaiser Health News posted a terrific article today debunking the popular -- but utterly misguided -- notion that repealing health insurers' limited anti-trust exemption will reduce health care costs.  It is remarkable to me that members of Congress and public option fans are so passionately devoted to a concept that is obviously a red herring upon even a cursory review of the facts.

The authors – a Seattle anti-trust attorney and a Boston University health economist – also point out that overregulation on the health insurer side could well have the unintended effect of raising health care costs if it tips market balance in favor of large hospitals and provider groups.

Eighty to eighty five cents on the premium dollar goes to hospitals, doctors and drug companies.  No matter how unpopular insurers are, their cut just isn't big enough to significantly change health care costs no matter how hard you squeeze it.

We need health care reform -- not just health insurance reform.

Any remaining hopes that Congress might abandon the battle for partisan advantage to get something done on health care were definitively dashed by the recent Health Care Summit. Both sides stuck like glue to the intractable positions that have deadlocked the issue. Is anyone really surprised?

Both parties' stances are disheartening – poll-driven, cynical and oblivious to practical policy decisions that must be made to move forward. For their part, the Democrats continued to hang their hats on the vilification of insurers, an approach that polls well, but shoots the messenger while ignoring the real cost drivers in the system. Repealing health insurers' anti-trust provisions or creating additional layers of rate regulation will be popular with the left flank of the Democratic base, but do nothing to rein in health care costs or expand access.

Too much of the debate was wasted arguing over whether the CBO found that costs would go up or down under reform. Republicans are right that there is a fundamental difference between bending the cost curve and shifting costs through taxpayer subsidies. But they're wrong in asserting that this means doing nothing is the answer. The President would be better served by admitting there is a hefty cost, and explaining the long term benefits that investment could buy.

Republicans say legally requiring Americans to buy a product is a slippery slope. Fair enough, but I believe we have already crossed the Rubicon on that issue. Under 1986's Emergency Medical Treatment and Active Labor Act (EMTALA), anyone who shows up in an ER gets treated, regardless of their ability to pay. So if Federal law already requires health care to be provided to citizens, then it has to either compel them to contribute towards its provision or come up with another funding mechanism.  Once again, government proves equal to the popular task – guaranteeing care – and unable to complete the considerably less popular task of paying for it. Hence our crazy quilt of cost shifting and hospital charges that bear little relation to actual costs.

I find it intriguing that in 1993 some of these same Republicans argued in favor of mandates on individuals to buy health insurance. At that time the individual mandate was seen as an "individual responsibility" approach superior to the employer mandates championed by the Clintons. Now, they argue that such mandates are patently unconstitutional. This is not a simple issue and it is very possible that the U.S. Supreme Court will agree with them.

Even more painfully, Rep. John Boehner (R-OH) trotted out the old saw about the U.S. having the "greatest health care system in the world."  Such mindless boosterism ignores the inequity and inefficiency of health care in America.

We have already created a system where there is guaranteed access to care – too little, too late in many cases, but guaranteed nonetheless. Fair enough. Now Congress needs to find the backbone to require everyone to pay their fair share, too.

Unfortunately, the GOP has apparently decided that its members can comfortably run on "defeating" health care. Getting Democrats to commit to a difficult and complex reconciliation approach to run over them will be difficult – especially with unfavorable polling on health care looking like a major liability to moderate Democrats nervously facing stiff mid-term opposition.

It makes you wonder.  If neither the majority nor minority party can get what it wants done, why are they fighting so hard to run Washington?

Nowadays everyone carries a mobile phone whether it be an ordinary flip phone, an iPhone, Blackberry, etc. With over four billion mobile phone subscriptions worldwide, accessibility to patients, via mobile devices is beginning to garner much attention in health care.

Several pharmaceutical companies and health care provider groups are using SMS messaging to remind patients of upcoming appointments and prescription refills and even opportunities to join clinical trials. This list can go on, but early study results have shown that such methods of communication are increasing patient adherence to medication and reducing the number of missed appointments -- which are key steps to improving patient care.

But what if this type of interaction between provider and patient was taken to the next level, say on Twitter? A recent blog post suggests Twitter may be a good avenue to communicate health care "support" activities. Below are a few ways that health care providers and pharma companies can use Twitter to disseminate information:

• • Prescription management, including pharmacy refill reminders
• • Daily health tips from authoritative sources
• • Clinical trial awareness & recruitment
• • Issuing dietary/lifestyle tips
• • Exercise management and encouragement

**For a complete list visit Phil Baumann's blog post here.

So I pose the question to you…have any of you opted in to receive text messages or other digital communication from your health care providers? What are your thoughts on the role of Twitter in this arena? Does it have a place? Is it crossing the line? Is it too public?

The prestigious British medical journal Lancet made big news this week by retracting a 1998 article citing a link between autism and the measles, mumps and rubella vaccine(MMR). The study had claimed that eight out of 12 children attending a routine hospital clinic had reported problems with GI disturbances that led to autism-like symptoms within days of MMR injections.

A vaccine required for school enrollment might trigger autism? Profoundly troubling. Parents abandoned vaccines in vast numbers, leading to a resurgence of measles. Multiple, rigorous studies have since been unable to substantiate an autism link. The methodology of the original study was questionable at best, and was further compromised by an unreported conflict of interest – parents already convinced of the MMR-autism tie helped fund it. Even after the Lancet retraction, some parents may remain wary of vaccines, preferring to risk virulent diseases rather than vaccines that repeated studies say are safe and effective.

MLOS - Mothers and Apple pie

Sadly, emotion's predominance over reason in health matters is hardly unusual. In the mid-1990s North Carolina passed a "maternity length of stay" (MLOS) law guaranteeing insurance coverage for a minimum 24-hour hospital stay after childbirth. The MLOS law came into being through a floor amendment proffered on the final day of the Legislative Session, after a new mother was sent home too quickly from the hospital in the opinion of her mother-in-law, a state legislator.

Sure, there had been no committee debate and the database was a single case, but talk about motherhood and apple pie! The vote was not close. Only several years later did data emerge showing that the average stay for a normal, vaginal birth at the time the bill passed was already about 24 hours. (After the law passed, of course, the average stay crept up considerably, because discharges don't happen in the middle of the night. A 2006 study published in Pediatrics showed the longer stays produced no change in the one-year mortality for infants.)

Breast Cancer and Bone Marrow

In the late 1990s, a raging controversy emerged over coverage for high-dose chemotherapy plus autologous bone marrow transplant or “HDC-ABMT” in the parlance of dedicated supporters. Insurers were denying coverage for the procedure based on its high ($80,000) cost, combined with a dearth of evidence of advantages over cheaper and less risky treatment options.

Despite extremely limited evidence of HDC-AMBT’s effectiveness for breast-cancer patients, hysterical media coverage featured tales bean-counting insurers withholding payment for life-saving care. Intensive lobbying and a rash of legal challenges built into a backlash that lead many states to mandate coverage for the treatment. Numerous, rigorous studies have since raised serious questions about the efficacy of the approach relative to other options. An article published in Health Affairs suggests that "health insurers spent more than $3.4 billion during [a] ten-year period on a treatment that turned out to offer no appreciable medical advantage over standard-dose chemotherapy, which can be had for less than half the price."

Death Panels

Which brings us to… Death Panels. As I've blogged before, the idea that President Obama planned to cut Medicare costs by whacking your grandma was based on a pretty selective reading of legislative language guaranteeing coverage for counseling on end-of-life issues. Yet the concept caught fire along ideological lines, overwhelming a reasonable attempt to encourage people to consider the issue and execute living wills.

Then there's the recent flap over cancer screening. A government panel weighed evidence that suggested the benefits of early screening for younger women were outweighed by the risks inherent in additional exposure to radiation. Government rationing was the immediate and predictable response from conservatives and right-wing nut jobs, but disease advocates also fanned the flames and respected organizations like the respected American Cancer Society dug in hard in support of early screening. The Obama Administration, unwilling to give the GOP another shibboleth, missed the opportunity to champion evidence-based medicine by backing off the new standards almost immediately.

If all this makes you a bit worried about America's ability to translate scientific evidence into rational health policy, well, yeah -- me too. The health care debate is so polarized along partisan and ideological grounds that people seem unable to think clearly. Those of us who communicate on health issues must remember the ideological and emotion filters through which information on health care passes.

I'm open to ideas on how to get people to turn off Bill O’Reilly AND Keith Olbermann in pursuit of more even-handed analysis. In trying to give reason a better shot, promoting The Health Care Blog or Health Affairs Blog might be a good place to start.

There's an article in today's Wall Street Journal about a radically new idea in Massachusetts: pay global fees to groups of doctors to encourage efficiency and better coordination of services.  Wow, what a radical notion.  Man, that's never been tried. 

Oh, wait.  That does sound a bit like the capitation models pioneered and eventually abandoned by managed care companies. You know, those (onimous major chord here) HMOs that were bigger than grunge rockin the early  90s?

Problem was then that NC's supposedly integrated groups (primary care plus multiple specialists) weren't really all that integrated.  Flat, shared fees or not, doctors pretty much practiced as they always had. Fast forward a few months to the stunning, conclusive failure of many of these early integrated groups. 

Doctors argued that capitation didn't work because 1) the fees just weren't high enough and 2) incentives "to withhold care" are a fundamentally bad idea anyway. 

We can argue endlessly whether the fees were "right." But it's not like the practices came up a little short.  Some of them were 90 percent off the utilization rate needed to be profitable. My sense is that the potential savings from more efficient patient handoffs never materialized, because such teamwork never really happened.  Doctors can be fiercely independent and neither traditional medical training nor fee-for-service payment systems foster teamwork skills.

And as for capitation encouraging overly parsimonious care, you have to balance that concern with the tendency for  traditional-fee-for-service payments to promote unnecessary, duplicative or inefficient care. Organized medicine at the time seemed to argue that with incentives to do too much, doctors could be trusted to make good choices, but with incentives to do too little, they couldn't. Huhn?

As the stories of Michael Jackon's final days indicate, doctors actually have a pretty hard time telling patients no, even when the services they're are dubious or just plain dangerous.

So here we are again, twenty years after capitated fees were decried as a horrible, demonic plot by HMOs and other nefarious characters.  (As an HMO lobbyist, I was once called a fascist and a communist in the same physician rant).  

In the end, doctors will have to operate on some kind of budget. Either it will be of their making (capitation or something similar) or a top-down rationing system that no one will like.  Too early to tell which the people of Massachusetts should expect. 

There was a terrific article in the New Yorker last week that points out why the debate is Washington over how to "fix" health care is focused on the wrong things.

Fans of a single-payer system -- as legion and ardent as any crowd of Deadheads you'll ever meet -- subbornly equate "reform" with a government run system.  Period.  Anyone with doubts about putting 16 percent of our nation's GDP in the hands of the same folks who brought us FEMA trailers are painted as reactionaries, obstructive, self-interested or worse.

This confuses universal coverage with public sector control. Yes, Canada and England have a single system, but Germany and Australia get the job done with a public-private mix.  Or think about how Medicare and private supplemental coverage works.  While our current system doesn't pool risk as effectively as it could, the primary problem is not the funding mechanism.

Which brings me to a terrific article in the New Yorker by Atul Gawande.  Dr. Gawande examines two Texas towns of similar demographics and health status, but startlingly different health care costs.  Why, Gawanda asks, is McAllen, Texas, the "most expensive town in the most expensive country in the world?"  An interesting question, especially since Medicare costs in the demographically similar population in nearby El Paso county are HALF what they are in McAllen.

The good folks at the Darmouth Atlas program have been documenting such oddities in great detail for a quarter of a century.  Yet local health care providers, from specialists to hospital administrators, couldn't explain this cost differential, and some were surprised to find that their costs were high in comparison to other markets.

The evidence supports none of their guesses as to why this is.  We give better care.  (But outcomes aren't measurably better.)  We have so many sick and poor people here. (But McAllen's population is not very dissimilar from many other locations with much lower costs.)  Our town is more litigious. (But Texas tort reform has significantly curtailed malpractice costs.)

What seems to be the problem is that McAllen's health care providers simply provide more care, LOTS more care, of virtualy all kinds. And there are more of them in McAllen doing it.  Why not?  That's what our do-more, earn-more reimbursement system rewards.

We could, instead, pay for the most cost-effective care. Federal stimulus legislation funds studies on comparative quality in health care that would make this possible.  Creating a comprehensive database on what methods, devices and drugs work best should be a road map on how we should reimburse health providers and manufacturers. 

Resistance to this small section of the bill was fierce, and it only passed when it was specified that this research would not impact reimbursement practices.  See, you can't cut health care costs without someone making less money.  And what group or organization will volunteer to do that? 

Any system, public or private, that doesn't break this logjam won't give us the real reform we need.  

With my Psychology background from college, I couldn't resist the "Therapy 2.0: Mental Health for Geeks" session at SXSW09. This core conversation organically took on the feeling of a support group meeting. I honestly kept waiting for someone to stand up and say, "Hi, I'm Bob and I'm addicted to my mobile device" and for the group to chime in unison, "Hi Bob."

I personally came over to the dark side three months ago when I caved and bought my very own shiny Crackberry. I don't know that I'll ever be able to find my way back into the light, that thing comes with me everywhere.

All joking aside, in today's over connected world, the ability to have true solitude becomes more and more difficult to come by. It's hard to just "be" in a space when our devices represent a constant reminder of our digital responsibilities. Yet this is the world we've actively chosen to be a part of, so how to we manage our love hate relationship with our devices? The two moderators of this session, Thomas Roche and Dr. Keely Kolmes, left us with five things we can do in our everyday lives to feel more balanced.

1. Create a weekly gratitude practice/journal.
2. Use breathing exercises and mindfulness practice throughout the day.
3. Make an extra effort to connect with others for social support offline.
4. Exercise in some way every day.  Study after study proves its positive stress reduction/management effects.
5. Use thought tracking to become more aware of your moods.

To my fellow geeks out there, are you able to distance yourself from your devices or do you experience information anxiety from time to time? What techniques can you share that help you stay balanced?

I'll get us started.

• "Hi, I'm Laura. (Hi Laura.) Sometimes I send Kira an Instant Message to ask her a question instead of just asking it out loud. She sits right beside me."
  
• "To stay balanced, I take a Yoga class every Monday night at my gym. It starts my week out on the right foot." 
• Come on folks, who's next?

Martin Lindstrom's oversimplification of the impact of health warnings on tobacco use in his book Buyology is dangerous and irresponsible.
 
In today's New York Times, Lindstrom argues that the FDA should abandon its policy of providing warnings about serious health consequences for tobacco. His rationale focuses on brainwave studies measuring brain activity when people read warning labels on cigarette packages. He doesn't reference behavior. He doesn't reference research that shows what factors have been responsible for reducing smoking rates from 30 to 20 percent nationally. He doesn’t consider the most effective way to communicate the consequences of tobacco use.
 
Here on Tobacco Road, we have evidence that communicating serious health consequences prevents teens from using tobacco. Our state has invested millions of dollars from North Carolina's portion of the Master Settlement Agreement in grassroots outreach and media campaigns that convey the potential impact of smoking or using smokeless tobacco.
 
I've seen the reaction of teens to stories of cancer survivors who have lost their voice box or been disfigured by oral cancer. These stories, the visual images and the facts get their attention. More importantly, communicating the serious health consequences produces results. According to research from UNC Family Medicine, 34,000 fewer North Carolina teens are using tobacco today thanks to these efforts. And, the most recent Youth Tobacco Survey shows North Carolina's teen tobacco use rates are at historically low levels. That's quite a feat for a state steeped in tobacco heritage and real, tangible evidence that health warnings, done the right way work.
 
Oversimplifying facts and making provocative statements may sell books, but it's not the way to attack the number one cause of death in the US. Mr. Lindstrom, I urge you to look at all the facts before making reckless recommendations to our country's new administration.
 
http://www.nytimes.com/2008/12/12/opinion/12lindstrom.html?_r=1&th&emc=th

 

There are few things in the universe more evil than carnival food. Check out Newsweek's list of the 7 most unhealthy carnival foods.

7. Cotton Candy
One large cone of spun sugar is 200 calories. It's practically health food.

6. Snow Cones
The sugary syrup used is 100 calories an ounce. A 12 oz. snow cone will end up being 550 calories, depending on how syrup-heavy you take it.

5. Corn Dogs
a.k.a the "nitratesicle" contains 375 calories and 21 grams of fat and 1170 mg. of sodium.

4. Deep Fried Twinkie
One deep fried Twinkie contains 420 calories and 32 grams of fat. That doesn't include any sugar or jelly topping.

3. Deep Fried Oreos
Each cookie contains 157 calories and 10.1 grams of fat.

2. Funnel Cake
An 8.3 oz. cake contains 760 calories, 44 grams of fat, 80 grams of carbs and 20 mg. of cholesterol.

1. Deep Fried Candy Bars
Everything from Snickers, Mars, Milkyway and 3 Musketeers is deep-fried and slapped on a stick. A king-size, deep-fried bar has over 700 calories and 44 grams of fat.

What's your favorite carnival food?

In the distant future, health care is a commodity the average person can access only by winning a highly publicized lottery. A bad sci-fi movie, possibly starring Sylvester Stallone or Bruce Willis? No, it's a real program underway in Oregon.

Can't a country routinely affording $3.60 cups of coffee can do better than to let citizens gamble their lives on the long odds of winning a lottery?