Retirement forecast: work longer, see fewer medical specialists, take care of yourself

Older workers will work longer to keep health coverage. But even as they do so, they'll confront a dwindling supply of medical specialists.

Watson Wyatt (WW) found that people over 50 years of age who receive health benefits from employers and don't expect to receive these benefits in retirement are 16.5 percentage points less likely to retire than people who have health coverage from another source (such as a spouse’s health insurance plan, Medicare/Medicaid, COBRA).

In its report, Predictive Factors for Retirement Timing, WW identifies the main factors influencing when Americans will retire, including health and non-health considerations. The key findings are that:

1. Increases in wealth increase the probability of retiring, but don't count out people postponing retirement if their earnings prospects are good at the expected retirement age.

2. People with defined benefit plans are more likely to retire than those with defined contribution plans. DB plans may represent a more secure retirement income.

3. Business cycles influence the probability of retirement. This is a corollary to point #2, where DC plans face risks of stock market fluctuations. If people enrolled in DC plans perceive their 401(k)'s, for example, have declined in value, they are more likely to put off retirement until they feel more 'flush.'

4. Access to health insurance is a big determinant on the timing of retirement, of course.

But even with health insurance, the retiree will face a deficit of health care specialists. A poll from Zogby conducted on behalf of the American System for Advancing Senior Health (ASASH) found that 7 in 8 Baby Boomers believe that specialty training in dealing with geriatrics and aging is important for their physicians, but the Boomers are having a hard time finding this sort of doctor.

Women in particular believe this kind of expertise is critical for their health maintenance, yet only 1 in 4 said they perceive their health has suffered because they did not have access to such a physician.

An intriguing finding is that about half of people 55 and older said they would seek a different health provider to achieve better outcomes. 1 in 2 said they could get better care than they are now receiving.

This challenge was discussed in the IOM report I blogged about here in my post, Home care and garbage collectors.

Health Populi's Hot Points: "We are seeing the Baby Boomers use the Internet to take a much more activist role in almost every aspect of their lives," according to John Zogby, pollster. Zogby points to the Internet playing a key role in educating and empowering people.

One in 3 older Americans said they need more help with their health decisions, and 71% said they want to be able to find more information about their own health care. 9 in 10 older Americans want to be in control of their health decisions.

One-half of older people believe they themselves are in the best position to help improve the quality of their health.

These two polls together paint a picture of an engaged older American, in touch with the fiscal and health realities of retirement in the U.S. Based on these data, it appears that Boomers are not in denial about the tough choices ahead. The motivation to work longer for health may engender motivation to stay well, longer. It's never too late to engage in healthy behaviors. Perhaps this lightbulb moment in Boomers' lives will drive people in the 50s and beyond to get real about work, health, and wellness. There will be opportunity for providers and organizations to support this population in living better, longer, through services, information, and support.

Retail meds: pharmacy update and Wal-Mart price cuts

Wal-Mart continued its first-mover tactics in health by dropping the price of prescriptions again. This time, the target (sorry for the pun) is maintenance meds which Wal-Mart will price at $10 for 90 days' supply.

This move puts Wal-Mart squarely in the pharmacy benefits management (PBM) segment vis-à-vis ExpressScripts, Medco, and the big PBM players. The 3-month mail order med business is the lucrative turf of PBMs. Wal-Mart's first move into this space was in 2006 when the company priced many 30-day scrips at $4, shaking up the industry. I wrote about that market disruption here in January 2008.

Wal-Mart will also offer over 1,000 over-the-counter (OTC) meds for $4 and under. These will all be Wal-Mart's private labels for popular OTC brands.

As the company with the red bulls-eye did the last time Wal-Mart dropped the price of meds, Target responded as fast follower by saying they, too, will match the Wal-Mart prices for 90-day supplies of drugs. Target's program will expand the assortment of $4 Rx drugs and the 90-day supply of these medications for $10 and private-label OTC medications for $4 or less.

While price transparency is what retail pharmacy should be all about, Consumer Reports found that prices across and even within pharmacy chains can significantly vary -- by $100 or more from the same drug, from store to store and within the chain.

Consumer Reports surveyed pharmacies' prices for 3 brand-name meds and one generic drug. The range of retail prices for each drug were:

• Pfizer’s urinary incontinence drug Detrol = $365 to $551
• BMS's and Sanofi-Aventis' blood clot drug Plavix = $382 to $541
• King Pharmaceuticals’ hypothyroid drug Levoxyl = $29 to $85
• Generic Fosamax for osteoporosis (alendronate) = $124 to $306.

Consumer Reports also found that independent pharmacies can be price-competitive, given these price ranges, and can offer a higher level of service -- especially access to pharmacists for personal consults.

In another prescription drug update, a study published in the American Journal of Public Health found that 1 in 4 Americans share or "borrow" prescription drugs from each other. Most common shared drugs include those for categories in allergy, pain (like Darvocet and Oxycontin), and antibiotics.

Women are twice as likely to share prescription drugs as men.

Health Populi's Hot Points: Almost a third of Wal-Mart's nonprescription drugs now sell for $4 or less, luring people also shopping for groceries and clothes. The price of gas is a powerful incentive for consumers to look for one-stop shopping, and Wal-Mart can deliver on this.

That consumers respond to price incentives for prescription drug shopping is in general healthy; it's a rational economic response from the pages of Adam Smith and market theory. That people "share" drugs like OxyContin and antibiotics, however, is a rational economic response; but not sound public health. Here's an example of where market forces can drive bad health behavior.

Employer-based health care erodes U.S. global competition: A New America report

The world is flat, but American manufacturers have known that since before Tom Friedman published the book on the subject. Globalization means American companies compete with foreign trade partners. The New America Foundation calculates that U.S. manufacturers pay an average of $2.38 an hour for health benefits, while trade partners pay only $0.96 an hour.

That's the bottom-line in the Foundation's paper, Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms.

The percent of payroll devoted to health benefits is about 13% for American manufacturers, and 5% for foreign trade partners.

That adds up to one big competitive disadvantage which ultimately results in lost jobs for Americans.

Health Populi's Hot Points: This is everybody's business. Labor is coming together with business and key stakeholder groups to address the impact of health insurance on business and competition. New America points out a few of these important coalitions: Better Health Care Together, uniting Wal-Mart, AT&T, the Service Employees International Union (SEIU), and the Communications Workers of America; Divided We Fail, a coalition of the Business Roundtable, National Federation of Independent Business, the AARP, and the SEIU; the Coalition to Advance Healthcare Reform, a business coalition led by Safeway CEO Steve Burd.

Clearly, one-time adversaries like Big Labor and Big Business can come together. Why can't our legislators breach the same sort of chasm? Let's make 2008 the year to stop demonization of stakeholders and come together for the benefit of all.

A profile of silver surfers: don't discount older web-searchers

There's a growing cadre of older people online, and they're an attractive demographic, according to Focalyst, a joint venture of the AARP and Millward Brown, a market research and branding company. The researchers found that "matures" spend 750,000,000 minutes a day on the Internet (sounds like a song from Rent--the AARP version of 525,600 Minutes).

Focalyst calls the group of people age 62 and over "Matures Online." The Insight Report: April 2008 finds that matures are just as likely to be persuaded by an Internet ad as younger consumers. Is this what Martha would consider a "good thing" or not-so-good? Well, it is what it is.

Regardless of where you sit on that that response, here's a remarkable fact: 1 in 4 Americans over 80 is online.

The table details Focalyst's findings on what older people do online:

- 6 in 10 matures use search engines

- 6 in 10 matures keep in touch online with family and friends

- 1 in 2 matures gathers information

- 2 in 5 look for health information.

Focalyst found "greater purchase intent" when it comes to older people looking at specific categories of online ads, especially pharmaceutical advertising and insurance. This signifies greater engagement in these topics, which is not surprising. However, there is also substantial engagement in categories such as consumer goods, travel, and entertainment -- including movies, TV and games (Scrabulous or Sudoku, anyone?).

Health Populi's Hot Points: TV and print are still the top 2 used media among matures, but the Internet is growing as "media channel of choice," according to Focalyst. By 2011, the number of online uses 62+ will grow 51%.

The data on health conditions and aging is well-known. As boomers age into the mature cohort, they will use the Internet for health and wellness applications. Games will continue to be developed that target health: see Robert Wood Johnson Foundation's excellent ongoing work into games and health. Ignore this trend, marketers, at your peril.

The virtues of virtual visits

There is more evidence that remote health care can improve health outcomes. Say 'hello' to the Virtual Integrated Practice (VIP).

The term was coined by the Rush-Presbyterian Medical Center, where a team has been refining the VIP model for the past four years. The VIP's objective is to improve chronic disease management for older people by deploying an

interdisciplinary team using communications technology.

The main challenges in primary care for VIP's target patient population are:

• Multiple chronic problems
• Polypharmacy
• Physical disability
• Functional impairment, and
• Economic stressors.

The Holy Grail here is that when these patients are optimally-managed, VIP can identify missed opportunities for primary prevention and avoid eventual disability.

As the population ages, more chronic conditions ensue. Traditional institutionally-based care in hospitals and nursing homes is based on synchronous, face-to-face care. VIP disrupts that institutional model, instead embracing a team-based, asynchronous co-located model. Clinicians on the patients' team interact in the medical record and enhance ongoing team communication about the patient's progress.

The VIP team consists of a nurse, a social worker/case manager, a physician, a pharmacist, and a physical therapist. Here's the 'co-located' part: they're in different settings, and they relate to the patient at different times. But they're coordinated via information technology -- the electronic patient record.

One of the most important lessons the team learned in its four-year study is that patients expect the professionals on care teams to communicate with each other. This is typically not a streamlined, efficient or effective process in traditional primary care.

Toolkits are available here for several health issues: diabetes, nutrition, urinary incontinence/overactive bladder.

The study is funded by the John Hartford Foundation of New York.

Health Populi's Hot Points: The critical success factor with VIP is that the patient is at the center of the process. The team emphasizes self-management training in all interactions, and establishes monitor-able goals throughout the encounters. Messages are triggered to team members and to adjacent professionals as needed, which may include a nutritionist, an ophthalmology, or a podiatrist, for example. With the patient as an integral member of the virtual team, outcomes are improved. It's not about the technology per se -- which clearly enables this concept -- it's the process: the right caregiver at the right time using the right technology.

Health Plan Illiteracy, or how not to benefit from the Benefit

Health plan illiteracy is alive and well, according to J.D. Power and Associates. The consumer market research firm's 2008 National Health Insurance Plan Study finds that 1 in two plan members don't understand their plan.

In this second year of the survey, J.D. Power notes that, as consumers understand the benefits of their Benefit, their satisfaction with the plan increases. Thus, there is a virtuous cycle that happens between a plan and an enrollee when communication is clear and understood.

J.D. Power looked at member satisfaction in 107 health plans throughout the U.S. in terms of 7 key metrics: coverage and benefits; choice of doctors, hospitals and pharmacies; information and communication; approval processes; claims processing; insurance statements; and customer service.

The survey was conducted in November and December 2007.

Last year, Abt Associates found that most insured workers don't understand simple health plan language. I abstracted some of Abt's findings in this chart that I use in many of my presentations. Health plan illiteracy goes beyond general health illiteracy -- this is people blessed with benefits who don't 'get' them.

Health Populi's Hot Points: Having access to a health plan at the workplace is a Major Blessing these days. It is also an eroding benefit, as we learned earlier this week from the Robert Wood Johnson Foundation's paper, Squeezed: How Costs for Insuring Families are Outpacing Income. It's all about customer engagement. For employers to get their fully bang-for-health-buck, they need to pressure plans to adopt the consumer goods marketing hat and take a page out of the books of beloved brands and market segmentation gurus.

Not only would plans bolster their consumer satisfaction ratings -- they could become beloved consumer brands in health care and build more trusted relationships in their communities. This could, ultimately, improve healthy communities...at least among the insured citizens.

American voters believe that health care is a matter of human dignity

American voters are overwhelmingly paying attention to presidential candidates' positions on health care, according to a poll published by the Catholic Health Association of the United States (CHA).

CHA released the survey as part of the Robert Wood Johnson Foundation's Cover The Uninsured Week, in which CHA has participated since the effort's inception.

After the big issue of national security -- terrorism, Iraq -- voters point to jobs and the economy (40%) and health insurance (21%) as the top two domestic issues of highest priority for the next president. This prioritization is consistent with that reported out of the Kaiser Family Foundation poll I wrote about earlier this week.

79% of voters say the candidate's position on health care will affect his/her decision to vote for that candidate.

And nearly 9 in 10 believe that health care is a matter of human dignity and should be available to all based on moral and ethical reasons.

Health care for all is a mission for CHA. The organization is supporting Catholic health care facilities in organizing roundtable discussions in local communities to build consensus for health reform.

CHA recently released its Vision for U.S. Health Care, which outlines values and principles for a reformed system. The document is available online at www.OurHealthCareValues.org.

The survey was conducted among 800 likely voters between March 31 and April 2, 2008.

Health Populi's Hot Points: People want a national dialogue about health care. It's clear during this Cover the Uninsured Week and the latest economic news that the number of uninsured people will increase in 2008. People are job- and health-insecure. And as the CHA poll demonstrates, health insurance coverage is a matter of human dignity to most people. Politicians who don't get real about Americans' visceral and emotional feelings about health care won't fare well this election year. Dignity is not based in a market.

Is the Health Index a Misery Index?

It's a 50/50 America again. This time, half of us are thriving, and half of us are struggling.

News of that Great American Chasm is brought to you by the Gallup-Healthways Wellbeing Index.

I wrote about The Gallup-Healthways Wellbeing Index in March here when the project was first announced. The profile of the collective American mind-body-spirit was unveiled yesterday based on the poll's first 100,000 interviews.

It's not a pretty picture.

According to the survey's definition, people who are thriving:

• having basic needs met (food, clothing, shelter)
• earn higher incomes
• have lower burdens of disease
• report fewer sick days
• enjoy better working environments.

More of those who thrive are now struggling. The proportion of Americans thriving was 60% in 2006; this year, it is down to 49%.

Those people who are struggling are growing in numbers, from 37% of the population two years ago, to nearly half (47%) in 2008.

The health impacts of misery are profound. The survey results support the fact that misery underpins a cycle of chronic disease. The data illustrates this reality:

• Nearly two-thirds are obese or overweight (25 percent obese, 40 percent overweight)
• Two-thirds report one or more chronic diseases or recurring conditions
• More than 20 percent report they are not able to perform their usual activities on one or more days last month due to illness; this group was out sick from work 6 days in the last 30
• Workers with one to three diseases and/or conditions report they cannot carry out their usual activities on 13.5 days each year.

Health Populi's Hot Points: At yesterday's public launch of the Index, Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention (the CDC), spoke about the massive public health implications of the survey. Dr. James Harter, Gallup's chief scientist for workplace management and well-being, said, "Just as the U.S is not No. 1 when it comes to health measures, it also is not No. 1 in well-being."

People are struggling. Those of us who work and live in the real world are well aware of these connections. But to have them codified and aggregated in the way that this project is doing could provide the visual and empirical proof that will motivate policymakers and employers to address the health crisis in America. As important, citizens should be moved and motivated by these findings to act on both their personal health and to demand protection of the collective public's health. All the public's health.

The new health insurance math: every 1% rise in unemployment adds 1.1 million uninsured

I had an unsettling conversation yesterday with someone in-the-know about consumer credit markets. Consumer credit covers everything from credit cards to auto and home equity loans. The expert expects that a deepening consumer credit crisis will loom until late in 2010.

Food and credit card debt are seen as a "serious problem" by 18% of Americans.

Just before this consumer-credit realization, I read the latest poll, Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses, from the Kaiser Family Foundation which finds that, for every 1 percent increase in unemployment, there is a 1.1 million person rise in the number of uninsured Americans.

KFF forecasts that this would result in 1 million more people enrolling in Medicaid, including 600,000 children and 400,000 adults. This would increase states' Medicaid spending by $1.4 billion -- at the same time that tax revenues would fall by 3 to 4 percent due to declining workforce participation and worker tax payments.

The exacerbating economy for Everyday Man and Woman is already forcing hard choices for many. Look at the news that Costco is rationing rice (and other staple foodstuffs) based on the exponentially increasing cost of basic food. The worsening economy is hitting the kitchen table.

It's being called the New Consumer Credit Paradigm, or the new standard of consumer frugality.

Health Populi's Hot Points: What are the implications for personal health? I thought I'd take a stab at the New Consumer View on microeconomics in health, the analog to Budget Savvy Magazine's table at the top of this post.

The rest of the world is girding up for the U.S. recession.

Health stakeholders in the U.S. must do the same.

Health plans vs. banks? Who's trusted more with health information?

People trust health insurance companies to hold their health spending information more than they trust banks, according to a survey from Medavante.

In Cure the Confusion: The Consumer Experience of Online Healthcare, Medavante found that consumers perceived that health plans have less bias than financial institutions. Yet, 80 million Americans bank online.

Still, trust in online banking is eroding. Earlier this month, Bankrate's survey asserted that Americans are very concerned about identity theft. This is beginning to impact their online behavior with banks.

This is a new finding. Other data sources assert that consumers lack trust in health plans when it comes to data. Forrester's recent research discovered that consumers don't necessarily trust health plans to keep personal health information private. Furthermore, Bruce Temkin's excellent Customer Experience Index work at Forrester found that health plans rank in last place in customer experiences.

With the growing role consumers are playing in personal health financing, banks are launching an initiative to play a major role in managing personal health information. The Medical Banking Project (MBP) was founded in 2001 as a rallying point for financial services institutions who were carving out a role in health care. Since then, the MBP has grown its membership and mission beyond driving paper out of health care. Its sights are set on "medical banking convergence:" the integration of medical information with health financial data.

But will consumers slow this convergence given their potential concerns about banks managing health information found by Medavante?

Health Populi's Hot Points: It is possible that consumer trust has eroded in banks' handling of personal information given more press and concern about identity theft, privacy gaffes, and potentially, the impact of the sub-prime mortgage crisis on the consumer psyche. At the same time, Medavante's poll shows that consumers may have more trust in health plans -- which would be big news for the industry.

If Medavante's findings are right, health plans have an opportunity to capitalize on consumer trust. this is a fragile phenomenon: the industry should move carefully, with transparency, and in full consultation with consumers.

As economic worries grow, people plan to spend less on health care; a look at Lasik

• 
  The demand for health care appears to be somewhat elastic....in economic terms. We economists define a good or service as elastic when the quantity demanded changes with a change in the price.

This is happening to demand for Lasik surgery, a topic covered in the 24 April 08 New York Times.

Data demonstrating the phenomenon of the elasticity of demand in health care comes from a fascinating, short poll conducted by QualityHealth, called the Health Opin III Survey. QualityHealth is a consumer health portal which is part of the larger company, MTS, which does interactive marketing.

Overall, 73% of Americans say they are taking preventative measures to remain healthy. Among these, the most popular self-health measures are:

• Eating healthier, with 60% of people saying they do so;
• Taking vitamins, done by 48% of people;
• Exercising more, by 46% of people; and,
• Visiting the doctor more, done by 25% of people.

While these are all useful tactics for managing health on a daily basis, nearly one-half of Americans (48%) say that given the current economy, they feel they have to cut back on the amount they spend on health care.

The table shown above lists the areas where people expect they will cut back -- going to the doctor, visiting the dentist, and filling prescriptions.

Of particular concern to me is the number of people saying a family member has been laid off in the past year -- 20%, or 1 in 5. This doesn't mesh necessarily with the unemployment labor statistics coming out of the Bush administration, but it's possible that survey respondents' defined "family member" quite broadly, to include the broadest extent of "extended family."

Now, for some methodological caveats to the data. This survey polled over 10,000 adults over 18, so it is a large base of respondents. The survey was fielded between March 29 and April 3, 2008. Note that nearly 9 in 10 survey respondents were women (I don't know why this was the case, but it will surely skew the data in some way). The age cohorts weigh more heavily to younger people -- most respondents were between 35 and 64 years of age. People over 65 aren't hardly represented; that's the age group that uses more health care services than any other. However, since this population is generally covered by Medicare, health care is paid for by generous Uncle Sam (that would be the American taxpayers). Thus, the issue of elasticity of demand isn't as germane...at least until Medicare levies more out-of-pocket costs onto enrollees.

Health Populi's Hot Points: We can't be naive to the relationship between health care cost increases and individual demand for health services when they are paid out-of-pocket. Proponents of the consumer-directed health movement have often pointed to Lasik surgery as the stellar example for such plans. However, the New York Times writes that we are headed for a "Lasik recession." The declining demand -- that is, consumers' willingness to pay -- for other procedures include Botox, skin treatments, and breast implants. So much for demand for elective procedures with good price transparency. What will happen with peoples' willingness-to-pay for "must-have" health services such as visiting physicians for preventive or early-stage care, or needed prescription drugs? The QualityHealth survey tells us to expect the elasticity of demand to kick in for more necessary care, as well.

The Wisdom of Patients - social media in health care

People -- citizens, patients, caregivers, "consumers" -- are early adopters of social media in health, compared to other industry stakeholders including providers, plans, payers, and suppliers such as pharmas and medical equipment companies.

This is but one of many findings in my report, The Wisdom of Patients, which was published yesterday by the California HealthCare Foundation.

The report covers the origins of social media in the morphing of Web 1.0 to 2.0; the current state of social media in health; business models, opportunities and obstacles; a glimpse into the fuzzy future of Health 2.0; and, profiles several of the most pioneering figures in health/social media including Amy Tenderich of DiabetesMine; Matthew Zachary of the I'm Too Young For This! Foundation; Jack Barrette, founder of WEGO Health and formerly with Yahoo! Health; Neal Sofian of Resolution Health; Dan Hoch, MD, of the Harvard Medical School; and, Ben Heywood, CEO of PatientsLikeMe.

Health Populi's Hot Points: So many people informed this report. I interviewed over 30 people to listen to a broad range of perspectives, and benefited from the peer review of people like Matthew Holt, Scott Shreeve, and Dmitriy Kruglyak. I thank them all. I am fortunate to have had the California HealthCare Foundation sponsor this research. They are a visionary organization that supports and celebrates new thinking in health, particular in the area of patient self-care and technology.

I look forward to learning from Health Populi readers' own perspectives on this topic. Please comment on this blog and we can have ongoing dialogue here on the present and future of social media in health.

Americans' eroding confidence in the FDA: whom do you trust?

Confidence in the FDA has hit bottom. The latest survey on trust in the FDA comes from HarrisInteractive, who regularly surveys the public's faith in the regulator.

Consumers see the FDA's #1 job as "ensuring the safety and efficacy of new prescription drugs," cited by 61% of the public; however, 58% of people have a negative view of the FDA's role in this job, compared to only 35% who think positively about the FDA's performance in this key role.

This latest drop in confidence in the FDA is driven by the Heparin scare, blogged about here in Health Populi back in November 2007.

Other factors eroding confidence in the FDA include toy safety, food safety, the recent toothpaste scare, and perceived lags in approving necessary drugs.

Health Populi's Hot Points: Lack of trust in our institutions is driving people toward nodes of positive trust: first and foremost, to "people like me." I continue to refer to the Edelman Trust Barometer on this issue, a source the I trust.

People have lived with risk in daily life since Adam and Eve were tempted in the Garden of Eden. There is a rising wave of risks, at least as we perceive them, in our daily lives. The sub-prime mortgage crisis leads us to mistrust financial services companies. The rising price of gas drives us to mistrust oil companies. Health insurance denials for care and increasing health costs compel us to mistrust insurance companies and those who supply products to the industry.

Risk management requires us to seek information that helps us manage those risks on a daily basis. Increasingly, people are looking for trustworthy sources in new places, offline and online. But in the case of the FDA, which is charged with protecting the public's health, where else can we turn? Whether it's to assess E. coli or new meds or that new toy, we need a vigilant, productive, and effective FDA in our corner. And, for now, 2 in 3 Americans is frustrated with the agency that's supposed to protect them.

What's on voters' minds: the Economy-War-Health Trifecta

I just returned from voting in the State of Pennsylvania primary. My husband and I decided to go when the polls opened at 7 am, and the line was out the door of our local fire company, our polling place. We expect record voter turnout in Pennsylvania, which is a good thing.

I've been analyzing the latest Kaiser Health Tracking Poll: Election 2008. Health care as the top 1 or 2 issue among voters has fallen to #3 after the Economy and Iraq. This is a big shift since Kaiser conducted its poll in December 2007, when the Economy ranked #3: then, 23% of American voters selected the economy as one of the top two issues for the 2008 presidential election; by February, that percentage nearly doubled to 45% of voters who cited the economy as a top-two issue for the November election. The Economy is now ranked #1 in the KFF poll.

In that time, two major economic events hit the American pocketbook: the sub-prime mortgage crisis and Bear Stearns bailout; and, the price of gas per gallon, which rose to an average of $3.50 this week. On April 8, The Energy Information Administration forecasted that the price of gas will increase an average of 55 cents this year over 2007. That's a 20% increase over the average $2.81 price of 2007. The image on the left is from a Chicago Tribune blog post from 2006, showing real prescience on the part of that paper!

I wrote in the inaugural post of Health Populi in September 2007, Health Care is the #1 Line Item in Our National Economy, about the relationship of the price of petrol and costs of health care in our larger macroeconomy.

Health Populi's Hot Points: What's in that bailiwick, The Economy, anyway? The KFF poll mentions include Jobs (most cited by 31% of voters), Housing (that mortgage crisis being top-of-mind), Recession, National Debt, and Inflation. Gas prices were cited by 5% of the population along with Taxes.

This poll was taken in February. By now, gas prices are even higher than they were in February, so I would expect that petrol sticker shock will result in an even greater impact in the KFF poll findings when it soon returns to the field.

Recall that The War was begun on the pretext of weapons of mass destruction, but in the backrooms of the White House plans were drawn up to overtake oil fields. The trifecta issues of the Economy-War-and-Health are inextricably linked in the voters' minds. Let's hope the next President understands this intimate relationship.

I see this morning that sales of hybrid autos are way up. The voters get it!

The legacy of Dr. Jerome Grossman

We've lost a major force for good in health care. Dr. Jerome Grossman, once CEO of Tufts-New England Medical Center, passed away yesterday. He was only 68, an example of another good-man-dying-too-young.

Dr. Grossman's ideas made big impacts on American health care for decades. He chaired many Institute of Medicine (IOM) panels and wrote countless pieces in peer-reviewed journals (including the seminal Crossing the Quality Chasm report). He was one of the earliest proponents of analyzing quality and medical outcomes in health care. He was an early champion and adopter of information technology in health care. Listen to a podcast of him talking about aligning IT in health care for quality here from an IOM meeting held in 2000.

Most recently, at Harvard, he had been was the founder of the Center for Business & Government's Health Care Delivery Policy Program, which he directed during the past seven years.

He had been co-authoring a book on innovative disruptions in health care with Clayton Christensen, a fellow colleague at Harvard. It will be published by the end of the year, and I can't wait to hear Dr. Grossman's voice again through his writing.

Health Populi's Hot Points: Dr. Grossman leaves behind a legacy of great writing on health care and reform. Add the following to your portfolio of must-reads in health...

The "Genome" of Health Care Delivery Innovation: Productivity

http://www.hks.harvard.edu/m-rcbg/hcdp/readings/productivity_11-2.pdf

Thoughts on "Crossing the Quality Chasm"

http://www.pbgh.org/roundtable/jerome_grossman_presentation.pdf

Beyond Employer-Sponsored Insurance, for Brookings

http://www.brookings.edu/events/2007/0502health-care.aspx

Using System Engineering to Improve Health Care, for the Robert Wood Johnson Foundation

http://www.rwjf.org/pr/product.jsp?id=20980&topicid=1048

Sixty minutes of health reform education: Frontline is required watching

Here's an effective, efficient and efficacious Rx for understanding options for health reform: watch the PBS presentation of Frontline's Sick Around the World. You can watch the video or download a podcast. Here's the transcript from a roundtable hosted by Kaiser Family Foundation featuring TR Reid, the producer of the program, along with Uwe Reinhardt and Tsung-Mei Cheng as respondents to the documentary.

TR Reid of the Washington Post has been a Kaiser Fellow over the past year. He's created what hasn't been seen before: in a short sixty minutes, an engaging, informative comparison of health systems that's clear and thought-provoking without being preachy.

Reid visits five countries whose health financing is based on universal health care. We travel through the health systems of Germany, Japan, Switzerland, Taiwan and the United Kingdom, and learn that costs of covering their nations en toto are lower than those in the U.S. -- with better quality and outcomes.

No system is perfect, and you'll hear a bit about the warts in each of the systems.

Health Populi's Hot Points: Reid has shown that universal health care does not have to mean socialized medicine. Reid's research found that there are a few building blocks crucial to universal coverage in these systems: mandatory coverage, meaning that all citizens must be covered by the plan(s) and fixed prices to health providers are among the factors shared by these health systems.

Reinhardt sums it up well: "So you need very good government regulation but you should use private market forces and they all do. Germany has a reform doing exactly that right now. Don’t succumb to clichés which are your thinking apparatus when it comes to health policy. Don’t confuse social insurance with social, socialized medicine. They’re two different things."

Health ads online: IAC and HealthCentral join forces

Media magnate Barry Diller's got his eyes on health advertising. His media portfolio company IAC has entered into a deal with the HealthCentral network for a new advertising network which aims to be the #2 site-of-choice for health ad placement after WebMD (with about 40 million monthly visitors). HealthCentral will be IAC's exclusive channel for pharmaceutical ads. IAC will be HealthCentral's channel for consumer health products (e.g., OTCs and wellness goods).

HealthCentral operates 35 health sites and 10 million visitors each month.

IAC operates Evite, Match.com, Ticketmaster, Ask.com, Citysearch, and HSN (Home Shopping Network), among other consumer sites. IAC's sites attract about 45 million users per month. The company became a minority investor in HealthCentral earlier this year.

Of particular note is that Evite's users are primarily women age 25-49 years of age. This is a key demographic for health ad targeting -- especially Mothers (to understand the salience of this demographic cohort, read my post on Mother-Power Online).

Health Populi's Hot Points: While the pharma industry has lagged behind other sectors in the Web 2.0 world, pharma companies are expected to spend $2.2 billion online by 2011 according to eMarketer.

Health consumers who want to opt-in to ad networks will do so based on transparency and trust. Those who seek information on managing chronic conditions (whether patients themselves or their caregivers) can find trustworthy communities of fellow citizens online. Whether these ad networks gain traction -- in the form of click-throughs and, ultimately, increased prescriptions filled and adhered-to -- remains to be seen.

Peter Kruger of Wireless Healthcare points out that ad-based revenue models in health may not pan out the way other consumer product categories do. He writes, "Advertising and healthcare do not mix well and this issue is already proving to be controversial. I am sure that regulators would be unhappy if banner advertisements started to appear on a patient's online medical record or diagnosis."

The modus operandi for health ad networks must be opt-in and transparency. Consumers are looking for engagement in health: on their own terms.

Home care and garbage collectors: who's worth more to us when we age? Reflections on the IOM study

The U.S. health system is poorly structured to meet the needs of aging Americans, especially the millions of Boomers who are beginning to turn 65 years of age.

The IOM's Committee on the Future Health Care Workforce for Older Americans looked at the health needs of Americans over 65 years of age. They conclude that the health care workforce includes everyone involved in a patient's care: beyond the traditional definition of workers such as health professionals and "direct care workers" (such as nurse aides, home health aides, and personal care aides), the IOM add informal caregivers -- that would be family and friends -- and the patients themselves.

The IOM prescribes that all of these "health workers," both formal and informal, need to have tools, knowledge, and data to care for a patient. The 3 recommendations are to:

1. Enhance the geriatric competence of workers, as part of licensure, certification, and standards, and training for informal caregivers;

2. Increase recruitment and retention of geriatric specialists and caregivers, through financial incentives and programs to provide loan forgiveness for professionals who undergo extra geriatric training; and,

3. Improve care delivery to older people, specifically through disseminating proven models of care that have been shown to be effective and efficient for older adults.

The IOM also recommends that agencies provide support for technology advancements that improve care for older patients, including assistive and home monitoring technologies. My blog on consumers' embracing such technologies bolsters this IOM recommendation.

Health Populi's Hot Points: As you can see from the chart, meter readers and trash collectors earn more on an hourly basis than home care workers do. As the nature of the family unit morphs into smaller clusters with fewer children, single-heads, and children fleeing the coop for education, jobs, and greener pastures, aging Boomers will increasingly depend on other caregivers outside of the family to help them age at home. Assistive technologies will surely help those who understand their value and can afford to pay for them. For those who do not or cannot, funding agencies will find that with some education, people will be able to do more for themselves at home with these technologies. Many will be labor-saving. Still, technologies in and of themselves will not fill the huge gap of caregiving labor that the IOM forecasts. Here's another instance of us having a clear crystal ball view onto the future. The IOM's work on medical errors has led to some real action addressing patient safety. Let this report do the same for re-engineering and financing care for an aging America.

Excessive costs in the American health care wasteland

In the land that innovated Supersizing, the U.S. has also mastered the art of wasteful health spending served up in a mega-portion of $1.2 trillion (yes, trillion). That's over 50% of health spending. Half. About 8% of Gross Domestic Product.

This Big News is brought to you by those hardworking researchers at PricewaterhouseCoopers' Health Research Institute (PwC) in their report, The Price of Excess: identifying waste in healthcare spending.

The topline finding is: "Eliminating waste in one sector may actually increase it in another."

Here's why: while individual health care organizations try their best to rationalize costs and achieve efficiencies, PwC says, it's the fragmented nature of American health delivery that's to blame. That fragmentation leads to a kind of synergistic waste effect that can't be battled by individual providers or payers. They're fighting a macro battle on a micro field. It just doesn't compute, PwC argues.

Why can't we eliminate costs system-wide? PwC points to American health care's lack of care coordination, misaligned incentives, politics, medical culture.

PwC allocates wasteful spending into 3 categories: Behavioral, Operational, and Clinical. Annually, the top 3 areas of spending waste are:

• Clinical, such as defensive medicine and unnecessary ER visits = $312 billion
• Operational, including inefficient claims processing and ineffective use of health IT = $126-315 billion
• Behavioral, such as spending on preventable conditions related to obesity = $303-493 billion.

Health Populi's Hot Points: Consumers see themselves, government, and the industry at fault for wasteful spending. Perhaps this can be leveraged as a hopeful Pogo effect, that we are all the enemy and can all be the solution. The solution, PwC concludes, is that "Solving inefficiencies means developing system-wide incentives to encourage partnerships and networks that work toward shared value." What will drive us to finally work together to solve this crisis of waste? Ponder that today, Tax Day, as you put your hard-earned dollars into the post box and send them off into the wasteful oblivion.

Medical privacy: the balancing challenge of behavioral ad targeting in health

The latest piece in the medical privacy jigsaw puzzle is online behavioral advertising (OBA). Last week, the Federal Trade Commission (FTC) received comments from the Network Advertising Initiative (NAI) on the agency's proposed principles for OBA. As part of this filing, the NAI has published in draft its own approach to behavioral ad targeting in health, included in the NAI's Self-Regulatory Code of Conduct for Online Behavioral Advertising.

Online behavioral advertising (OBA) is the process whereby the online consumer's search behavior is analyzed across multiple websites and then categorized for use in advertising online.

NAI's members are reputed to cover 95% of the online advertising market. The NAI's membership includes 24/7 Real Media, Acerno, Advertising.com (an AOL company), AlmondNet, Atlas (a Microsoft company), BlueLithium (a Yahoo! Company), Doubleclick (a Google company), Media6degrees, Mindset Media, Revenue Science, Safecount, Specific Media, Tacoda (an AOL company), [X+1], and Yahoo!. Furthermore, NAI is processing membership applications from Undertone Networks, Google and Microsoft.

Toward the end of the NAI's Code you will find a section called, "The need for common understanding by industry," in which the NAI lists the "minimum restricted and sensitive consumer segments" that online advertisers should avoid targeting. The list includes:

1. Certain medical/health conditions–
A. HIV/ AIDS status
B. Sexually-related conditions (e.g., sexually transmitted diseases, erectile dysfunction)
C. Psychiatric conditions
D. Cancer status
E. Abortion-related.

2. Certain personal life information–
A. Sexual behavior/orientation/identity (i.e., Lesbian/Gay/Bisexual/Transgender)
B. Criminal victim status (e.g., rape victim status).

The NAI goes on to list other "potentially restrictive or sensitive" areas such as addictions, disability, and philosophical beliefs, among personal characteristics.

The NAI offers the value proposition for behavioral ad targeting as follows:

Advertising is fundamental to the accessibility, affordability and dynamism of the Internet. Online advertising underwrites the rich variety of online content choices available to consumers at no cost or at a far lower cost than would otherwise be possible – similar to what we see in television and radio. More relevant advertising creates a win-win for both consumers and companies, because consumers find more of what interests them and companies spend less on ineffective advertising.

Health Populi's Hot Points: The NAI recognizes in its self-policing guidelines that, with respect to behavioral ad targeting, health is something different than, say, information on autos, fashion, or coin collecting. The organization concedes that, "self imposed constraints help achieve the balance needed to preserve consumer confidence...Even where there is reduced privacy impact in use of anonymous or anonymized data, the NAI recognizes that consumers will only trust and continue to engage with advertisers online when there is appropriate deference shown to consumers’ concerns about the privacy of their web-surfing experience."

Some health care citizens will want to opt-in to receive relevant ads and information; some won't. Some of these citizens who choose to opt-in will be people managing HIV and AIDS and depression and breast cancer; some will be caregivers. People are already taking advantage of Web 2.0 tools, on their own terms, in managing their and their loved ones' health.

However, our own terms are predicated on transparency and trust and a comprehensive approach. The NAI's list of sensitive and restricted medical areas reads fragmented and ripe for parsing.

A useful model for data protection and search engines was adopted by the European Union on 4 April 2008 which could be a useful model for the FTC to consider.

The NAI is calling for comments to their draft principles. You can review details and leave comments for the NAI here.

The Future of Telehealth, according to Philips

While fiscal, billing and back office technologies universally proliferate home care, only 17% of agencies use some type of telehealth systems. However, 32% of agencies with over $6mm in annual revenue provide telehealth services. Thus, size matters when it comes to home health adopting telehealth technologies.

These are just a couple of many important benchmarks published in the National Study on the Future of Technology and Telehealth in Home Care,

Billed as the largest telehealth study in the history of home care, Philips unveiled this report in conjunction with the 1