Neupert On Health : Healthcare

The Six Billion Pound Challenge -- How a Focus on Driving Outcomes can Improve Health Faster and Better than Legislation

pnblog — Wed, 11 Nov 2009 02:30:00 GMT

I commend the administration for shining the light on the need to improve health in America! While I want to be optimistic about change, I’m skeptical about how much real improvement we will really see under the guise of healthcare reform. Like I’ve noted before, the national conversation we are having -- which bill will pass, a public option or not, an abortion amendment or not, which party is winning -- is just the wrong conversation. Imagine if we were to take all the TV time, print space, blogs, and so on, consumed by the political debate and use it to advance an audacious goal like improving the state of our health! Imagine what we could accomplish with a big sustainable campaign across schools, employers, state governments and the media -- just imagine!

Today’s reality is that more than 75 percent of America’s healthcare costs stem from six chronic diseases. About 133 million Americans -- nearly one in two adults -- live with at least one chronic illness -- and the numbers are forecasted to grow unless we do something differently. Realistically, the only way to maintain some fiscal responsibility under any reform scheme is to address the controllable elements of chronic diseases.

What if we were to focus on a couple of conditions like obesity and diabetes? Two-thirds of American adults are obese or overweight, leading to chronic diseases like diabetes, heart disease and other conditions. Currently, obesity alone costs the health system $147 billion a year! What’s more, obesity is one of the biggest risk factors for developing the six chronic diseases that drive the majority of direct and indirect costs to our system, including diabetes ($218 billion), cardiovascular disease and stroke ($437.5 billion). Not to mention childhood obesity with equally alarming statistics (one in six children are obese), the most alarming of which is that children who are obese have a 70% chance of being obese as adults. Yet, obesity is completely within our control to manage/prevent.

According to CDC, the average American adult (age 20 and 74) is 5’6 ¾”, weighs 177.65 pounds and has a BMI of 28 (Note: an adult who has a BMI between 25 and 29.9 is considered overweight and an adult who has a BMI of 30 or higher is considered obese). To achieve a BMI of 24, America needs to lose 29 pounds per person. With the U.S. adult population at 205,639,360, that means 5,963,541,440 pounds…almost six billion pounds.

If we were to collectively lose this weight, we would have a direct impact on obesity and as a result, diabetes and other conditions. Healthier diet and exercise are things we can immediately start doing -- without legislation. Not to sound trite, but losing weight can be the “quick fix” for our health problems and rising costs. Obese individuals incur an 42% more in medical expenditures -- about $4,800 for per person per year -- compared with normal weight individuals, who incur an average of about $3,400 in such expenses. And little things matter -- for example, walking half an hour a day, five days a week cuts the incidence of diabetes by 40%. Think of the impact we could have on costs and the economy!

I know losing weight is hard work, but letting the growing waistlines of America continue unchecked will only doom us to continue the cycle of out-of-control healthcare spending. While I’m not sure I agree with Japan’s approach to legalizing waistlines, it does seem to have an impact. If we can send a man to the moon, create 200 different versions of yellow sticky notes and other wonders of the modern world, we can figure out how to lose a few billion pounds!

And it should all start with a public education campaign. Even though this is fundamentally marketing, it does belong in the domain of government action. It doesn’t take much to create a great ad campaign, viral marketing and so on. Look at the popularity of shows like the Biggest Loser -- now there’s a whole line of products and services. There have been a lot of one-off “celebrities” championing the cause of weight loss -- Mike Huckabee, Valerie Bertinelli, and others. But these have been isolated. Imagine if the government organized a group of great marketing companies -- Nike, Apple, Proctor and Gamble -- and got them together to create a campaign about obesity and health -- and involve popular sports heros or celebrities -- in a sustained way over a period of time. I’d bet there’d be some impact. Another great example of something that could easily and inexpensively be rolled out to schools nationally is the preventative childhood obesity program driven by the Columbus Research Foundation. These folks thought deeply about how to influence middle school students, and developed a program focused on education around diet/nutrition and exercise -- including a virtual cross-country competitive walk (students used pedometers connected to the Internet via HealthVault to track their progress). Ten middle schools were involved with nearly 1000 participants.

Real reform in healthcare isn’t solely the responsibility of government. It’s about individual responsibility and how we, as consumers, embrace our part of the current situation. I hope that reform will include changes to the payment system to enable and reinforce changes in behavior and stimulate innovation, but we don’t need to rely only on legislation to make things better. We can all individually start making better choices.

I understand that neither 'health reform' nor legislation are easy. As many have noted, whatever legislation passes will not include a 'silver bullet solution' to either goal 'bending the cost curve' or improving the value we get for our healthcare spend. Simple things can make a difference. By taking more responsibility for our own actions, we can impact the healthcare costs of our nation.

Reflecting on the healthcare system while waiting at the hospital for a loved one

pnblog — Wed, 30 Sep 2009 03:12:00 GMT

Often when we talk about healthcare reform, it can be a rather abstract discussion -- you watch some tv show with ‘experts’ reflecting on some 20 page bill or hashing through the merits of a public insurance option. Last week, however, all the intellectual and abstract ideas were brought into something very personal for me and my family.

My wife had a Hysterectomy, and I spent three days at Swedish hospital in Seattle caring for her. With all the waiting time, it was hard not to reflect on the experience and think about it in the context of health reform. I’m happy to say that my wife is now recovering on schedule, and she’s given me permission to share the story and my insights.

Once she had decided surgery was her best option, we became even more avid information seekers; we shopped for the procedure with the best outcomes and then the surgeon with the most experience and best quality results for this procedure. The best available counsel we found was for a Robot-Assisted Hysterectomy because there was less risk, less pain and faster recovery times vs. the alternatives. We didn’t have to shop for ‘price’ (thanks to Microsoft’s benefit plan, but that is a different future post)…but even if that were the case, we probably would have chosen a more ‘expensive’ option if it meant less risk and more productive days -- getting back to normal life as quickly as possible.

We all know that surgery can be pretty scary. Throughout the experience, everyone from the doctor’s office to the staff at Swedish helped to make the experience a positive one, allaying any fears and making us feel comfortable and confident. We often forget that healthcare is truly a people business. In just three days – the number of different people we dealt with was amazing -- five docs, seven nurses plus the ancillary folks (lab techs, transport and other helpers). They all took time to connect with our emotions while doing their jobs.

Swedish is leveraging technology to improve their systems. You see it throughout the organization, starting in the lobby, with signs advertising the hospital’s new EMR system. During the course of our stay, when there was time I asked various staff members about their experience with the new EMR, and they were positive about the system because they had all the information in one place. While a common complaint was that the data entry took them more time, they felt overall it made them more productive and effective.

This highlights that we need to remember that technology is a means to an end. It is NOT the introduction of technology that will make a difference, but rather how leadership leverages the right technology to make a difference…in both quality results and economic outcomes.

I also saw a real focus on patient safety, starting with the pre-op processes. Each member of the care team carefully checked her arm band, her chart and asked several specific questions to be sure she was getting the right action. For us, the repetition became frustrating, but if this process were to improve patient safety, then it would be worth it. Despite the technology investments, the core safety process was in the human factors.

After the surgery was completed, she spent two days recovering in the hospital. This was a day longer than originally planned due to very low blood pressure and a declining hematocrit. While I used the guest Wi-Fi for work and email, it was even more critical for answering key questions about her condition, the trade-offs, the next steps – which helped me to get some context and understanding to a) engage more thoughtfully with the care team about questions/choices and b) assure my wife about what was going on during the long time periods when neither doctor or nurse was around. I think hospitals should consider leveraging their video and wireless infrastructure more effectively for patient specific education and connecting with their care teams. This is potentially a big opportunity for improved patient compliance and care team coordination.

Because the low blood pressure persisted, I called her primary care physician to get her baseline BP. If we had stored this information in HealthVault, I wouldn’t have had to make the call – I would have just been able to look it up. Furthermore, I would have preferred to have gotten her discharge information automatically transferred to HealthVault. We were given paper copies. This should be easier.

So, what’s the moral of this story?

· We can’t lose sight of innovation and there’s a risk that could happen if the government were to become the primary funder of health.

· Technology is a means to an end, but we have a long way to go to figure out how to use it smartly.

· We can’t lose sight of how important the personal aspect of healthcare is. The emotional support and human caring delivered by the care team was the critical component of our overall satisfaction.

This experience reinforced for me that a ‘healthy’ health ecosystem requires consumer choice -- it is a critical component to the effective functioning of markets and innovation. We made the decision to ‘save time/hassle’ vs. saving dollars as we do in other aspects of our lives. This really drove home for me that the debate about ‘rising health care costs’ doesn’t really account for improved patient outcomes in terms of fewer lost days of work/productive living. I am all for comparative effectiveness of various options and knowing what things cost, but it needs to include patient values -- like less pain and getting back to normal faster -- or it may lead to bad unintended consequences. I am more concerned than ever that increased government financing of health will ultimately lead to fewer consumer choices and will stifle future innovation with tangible economic benefits.

I haven’t received the multiple confusing bills and outrageous line items of detail from the hospital stay yet. Nonetheless, when it comes to getting a quality outcome from an advanced surgical procedure, I prefer the current U.S. health system with all its flaws to the alternative future of less consumer choice and innovation.

Empowering Consumers

pnblog — Sat, 26 Sep 2009 20:48:00 GMT

So this week’s question from the Washington Post RX Blog was:

In the Baucus bill, insurers would pay a tax on the value above $8,000 for an individual policy and $21,000 for a family plan. What do you think of Sen. Baucus' proposal to impose a 35 percent tax on "Cadillac" health insurance plans?

My response is below.

We should have faith in consumers to make the right choices for their health -- only then will we reduce costs, expand coverage and drive value.

The motivation driving this tax is that health insurance plans (Cadillac or not) are another form of compensation -- something your employer provides for you with pre-tax dollars versus your paying yourself with after-tax dollars. The employer's ability to use pre-tax dollars creates a misalignment. Rather than tax a small percent of plans, it would seem better to correct the core problem. Until consumers are educated and empowered about how their health-care dollars -- both pre-tax and post-tax -- are spent, real reform won't happen.

One of the big snags in reform conversations is the idea that employment and health insurance are inextricably linked. Health insurance should be portable so that it can be taken from one job to the next and will cover you when you're temporarily unemployed. Labor mobility is one of the underlying strengths of the U.S. economic system, and health benefits connected to employment unnecessarily weakens labor mobility.

Moreover, the concept of health insurance should be more focused on 'major medical' needs like other insurance where you pay into a system to prepare for a catastrophe. But the norm of the current system is first dollar coverage which pays for every routine procedure. The fact that employers can use pre-tax dollars and ostensibly provide greater benefits for each dollar spent has led to this situation. This has driven up total health costs through misaligned incentives, extra administrative costs and limited provider innovation (e.g. packaging of services to meet routine needs). If there were a consumer-driven market, consumers would understand how their dollars are spent and there would be a more innovative insurance market.

The Wyden-Bennett Act provides this foundation. Consumers would receive cash from their employers equivalent to what the employer spends on health insurance. They'd have the option to buy the insurance they considered most appropriate, based upon need and determined by behaviors, through a health insurance exchange, which would be regulated by the government and encourage insurers to compete for their business.

Consumers make health choices every day, so why shouldn't they decide the coverage they need and the amount they will pay for it? People don't need the government to help them pick their car insurance.

Let's give people the right information to make the right decisions.

Lessons from Medicare and Medicaid

pnblog — Fri, 07 Aug 2009 07:34:00 GMT

So this week’s question from the Washington Post RX Blog was:

Do you think that a government-sponsored health insurance option is needed to help control rising costs and "keep insurers honest," as President Obama says?

My response is now live: Lessons from Medicare and Medicaid.

My main points:

· How will another government-managed option be better at building a health system that works for the 21st Century than the one we already have (Medicare and Medicaid)?

· While these programs began with admiral goals and are politically popular, in reality, over the past 40 years, they have done little to control costs or drive innovation.

· What's needed is a new framework to drive innovation, better value, improved outcomes and increased access.

Please feel free to comment with your own thoughts on the public option.

A New Place for Health Care Policy Debate

pnblog — Wed, 22 Jul 2009 20:34:00 GMT

About a month or so ago, the Washington Post launched their new Health Care Rx blog, and I was asked to participate as a panelist. Every Monday, questions are sent out, and a variety of “experts” from across the health care industry respond. It provides a great snapshot of the many different perspectives that exist.

This week’s question:

The Blue Dog Coalition worries the health bill in the House does not address fundamental cost drivers in the system. Is it possible to rein in costs in the current system? How?

My response is now live: It's Not About Costs, It's About Enabling Transformation

My main points -- real change requires:

Figuring out what works (and what doesn't)
Enabling supply-side innovation
Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

To read the full post, click here. Please feel free to comment with your own thoughts on how to rein in costs in the current health care system.

And you can see my responses to previous questions:

Who Pays for Whose Heath Care? [Posted July 14]

The political debate is often framed around covering the uninsured. At the heart of this is the supposition that health care is a moral obligation -- that everyone has a "right" to it. But it's difficult to separate the moral from the economic because there is no other "liberty" that requires payment.

Defusing the Health Care Bomb [Posted June 16]

The "big red wire" that needs to be clipped first is the fee-for-service payment system driven by the government today through Medicare reimbursement decisions. Until that's addressed, the ticking bomb won't be stopped.

Diagnosing and Treating the Health Non-System [Posted June 7]

We do not currently have a health system at all: it is a health non-system.

If you want to follow the conversation, you can add the Health Care Rx blog to your RSS reader here: http://views.washingtonpost.com/healthcarerx/atom.xml, and I will be posting summaries of my responses on this blog.

Before you finalize your Health IT shopping list

pnblog — Mon, 12 Jan 2009 17:23:18 GMT

The mad dash for health reform continues in earnest as stakeholders from all parts of the health ecosystem work to inform, engage and encourage the incoming Administration. The need for reform is obvious and the dialog is positive -- I continue to worry that 'soundbite solutions' will get in the way of a serious discussion of principles, desired outcomes and alternatives to achieve a good return on investment on 'change.'

As a business guy -- one that has worked on startup initiatives over most of my life -- I tried to put into context what it means to invest an 'incremental $50B' in health IT. It sounds like a lot of money -- something on the order of $83k per practicing physician -- we ought to be able to do something spectacular for that kind of money.

There is a new study out by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. I recommend folks read it (full disclosure I was both interviewed and a reviewer). Many folks I talk with in the computer science industry recognize the huge benefits that will be gained in medicine and health outcomes with thoughtful investments in information technology. Many (myself included) are technology optimists and believe that information technology will ultimately disrupt and transform health delivery.

But to achieve this transformation -- we have to acknowledge the reality of the institutions and systems currently in place; we have to invest in the new kinds of architectures and IT systems that will deliver real value over time. This report is bi-partisan and a timely reminder of key principles by experts -- one that I hope informs the health reform spending debate before folks finish their HIT shopping list and count too much on electronic health records as a simplistic cure-all.

The study acknowledges the need for comprehensive patient data, empowerment of consumers/families with personal health information and for flexibility in systems design to enable new advances in biology to be integrated effectively -- among many other principles.

Here are a few of the topline recommendations (pages S-9 and S-10) from the report I chose to highlight because they are so important and often get lost in the 'soundbite solutions' debate:

incentivize clinical performance gains rather than the acquisition of IT, per se
encourage initiatives to empower iterative process improvement and small-scale optimization
develop the necessary data infrastructure for health care improvement by aggregating data regarding people, processes, and outcomes from all sources.
insists that vendors supply IT that permits the separation of data from applications and facilitates data transfers to and from other non-vendor applications in sharable and generally useful formats

If the country is going to invest $50B in incremental health IT -- we all want it to be invested wisely. The question is; what will generate the most benefit and how can we accomplish it? We should be building an asset with this investment - and the asset is not an application per se -- but a health data asset that can be used to improve both individual outcomes and the performance of the institutions and the system overall. Individuals should be encouraged to create and manage their health data asset and to learn how to share it to achieve better outcomes and interactions with the health delivery system. Similarly - health enterprises should invest in building and sharing health data assets that enable them to have a culture of process improvement over time.