Are Americans willing to pay for health reform? It depends how you put it...

There are many surveys that are looking at whether Americans are willing to pay for health reforms: in particular, to cover the uninsured. This is a conceptual question: we don't really know how people will really feel once they are mandated by tax law or other mechanism to reach into their pockets. Still, it's instructive to take a look at the range of possibilities.

The Kaiser Public Opinion Data Note of July 2009 looks at "Footing the Bill" for health reform. KFF examines the plethora of polls' questions on willingness to pay for expanding coverage, from CBS/New York Times, Quinnipiac (the political polling group at Q University), NBC/Wall Street Journal, CNN/Opinon Research Corporation, and KFF's own survey. Across the surveys, except for KFF's, there's roughly a 50/50 split between people willing versus not willing to pay for expanding health coverage to the uninsure.

"Gee, that's helpful," you mock.

Looking under the respective polls' kimonos, there are nuances to note: question wording varies, and poll timing, too.

The more specific the question, KFF finds, the more definitely the public responds. For example, the CBS/NY Times poll asked whether "you approve or disapprove of taxing employer paid health insurance benefits, or are you unsure?" The split? 20% of Americans in favor of taxing, 46% opposed to taxing employer-paid health beneits. But over 1 in 3 (34%) are "unsure."

The one overwhelming majority response to a question across the KFF survey data in the June 2009 poll was whether Americans were in favor of, "increasing income taxes for all who pay income taxes." The responses: 29% favor, 67% -- against.

But increasing taxes on the rich (families with >$250K a year), on smokers and alcohol drinkers? That's all right with 2 in 3 Americans (68%).

Health Populi's Hot Points: At the end of the day, 3 in 5 Americans think it's possible to 'do' health reform without spending any additional funds. "This feeling that change could come without pain likely makes Americans less likely to back anything with a price tag," KFF foresees.

This chart details the just-released data on job losses in June. Note that the downward trend we saw in job losses in May is now reversed - nearly one-half million jobs were lost in June, which will surely lead to the uneasy feeling among American consumers that the recession has not yet hit bottom.

This unease and concern about job security will bolster the KFF forecast that Americans generally would like health reform to be a zero-sum spend. However, there's a countervailing reality that may play against this: that job insecurity roughly equals health insurance insecurity. Many Americans have connected the dots between keeping a job and holding onto insurance. Still, the so-called "jobless recovery" is also a "wageless recovery" as the most recent end-of-recession was, the average American taxpayer won't perceive they're able to pay more out in taxes to cover the uninsured.

"We try to walk you through the thicket of findings" of the polls, KFF introduces the Data Note. "Thicket" indeed!

The Other health reform - cutting through the red tape

There's another, complementary track to take to reform American health care that will streamline workflow, cut down on paperwork and save money: administrative simplification.

While not a sexy phrase, it's a very attractive option that will help to contain costs. The UnitedHealth Center for Health Reform & Modernization (UHC), part of UnitedHealth Group, issued its report into this topic, Health Care Cost Containment - How Technology Can Cut Red Tape and Simplify Health Care Administration.

UHC found $332 billion in medical cost savings through 12 proposals that group into the following themes:

1. For patients, go electronic: use automated cards for patient eligibility and benefits, create a monthly online personalized health statement for patients, eliminate paper checks for electronic funds transfer.

2. For providers, expand use of electronic data interchange (EDI), implement multi-payer transactional capability for practice management systems, and integrating practice management systems with payer systems.

3. Integrating electronic medical records with personal health records to promote coordination of patient care.

4. Improve payment speed and accuracy through using predictive modeling to 'pre-score' claims for better medical management as well as fraud detection.

These approaches are all founded on rapidly deploying and adopting data and transaction standards, and applying what UHC calls "modern management techniques" -- that is first and foremost information technology that can track fraud and flows of money to providers and payers.

Health Populi's Hot Points: "Bending the health cost curve" is the Holy Grail for health reform; if we don't stem the cost increases in health care, the long-term challenge of the U.S. deficit won't get cured.

Administrative simplification has been a target of health reform since the passage of HIPAA. Remember that "HIPAA" is the acronym for "Health Insurance Portability and Accountability Act of 1996." It's the "Accountability" portion of the law that included the administrative simplification components regarding the adoption of electronic data standards as a basis for streamlining bureaucracy and saving costs.

We're still getting 'there,' and it's slow-going. But administrative simplification and the long slog toward building and sustaining an electronic infrastructure in health care is an integral part of reforming U.S. health care and bending the cost curve, as the UnitedHealth report quantifies.

For more on the opportunity to save money through investing in the electronic infrastructure of U.S. health care, visit the U.S. Healthcare Efficiency Index project at http://www.ushealthcareindex.com/.

Health care is local, according to Secretary Sebelius. It's also personal.

Health care is, broadly speaking a local good, just like Senator Tip O'Neill used to say about politics: that "all politics is local." Secretary of Health and Human Kathlees Sebelius launched the website The Heatlh Care Status Quo on the HealthReform.Gov portal, profiling each of the 50 States and their current level of health care and "need for health reform," according to the Secretary.

We learn about a medical bankruptcy case in South Florida through the eyes of Dorothy Carmone, a self-employed cancer patient. Health care for Dorothy, and for all of us, is personal.

Each state profile details level of insured and uninsured, percent of incomes spent on health care, health status (e.g., % obesity), health plan competition, access to care and services, and other metrics.

Based on these data, the "hot point" is summarized in terms of, "Why (Fill-in-the-State-Name) Needs Health Reform."

Health Populi's Hot Points: The DHHS and President Obama's team have entered the Health Reform PR Wars. While for the short-term, Michael Jackson's death and other celebrity news items have filled the airwaves and public mindshare, the lobbying efforts on all sides of health reform will heat up after the Congressional recess. This website is one aspect of the Health Reform Reality Show.

As a data junkie and industry analyst, I love the site. Many health policy wonks will. The level of detail is useful and well-researched. However, I'm not sure it's going to resonate with many health citizens for whom, as Tip said, "health care is local."

Health care is not just local -- it's personal. In the Stakeholder Discussions tab under "Forums," you can find reports from in-person meetings held around the U.S. What would resonate with Real People would be online discussions where people could leave their personal, up-close-and-personal, 360-degree stories about their experiences with the U.S. health system. These stories would together piece the patchwork quilt of Participatory Healthcare: patients' voices from around the nation stating their case, filling in the blanks that policymakers seem blind to. Or constrained by the lobbying fray =--- the fear of the camel's nose -- whatever.

The Health Status Quo is that The American People -- the health citizen, health consumer, caregiver, sick child, young adult with cancer -- still aren't integrated into policy. We won't get to person-centered care that works for all until we're woven into the fabric of policy.

The 99% End-Game: Health Care Is All of Us in 2082

I was reminded by a short story in the Kansas City Star over the weekend about a report from the Congressional Budget Office published in November 2007. In The Long-Term Outlook for Health Care Spending, the CBO forecasts that health spending - including Medicare, Medicaid, and all other spending -- will consume the entire U.S. gross domestic product in 2082 projected health care spending cost continues at historical averages. The chart illustrates this trajectory.

The Obama Administration's focus on cost containment is aiming squarely at this future state. For their part, industry stakeholders have been ante'ing up their bets on how to stem their roles in this inexorable health cost inflation. Take a look at health plans, pharmaceutical manufacturers, and doctors for a snapshot on where they are on cost containment.

The health insurance industry is represented by America's Health Insurance Plans (AHIP), Karen Ignani, AHIP president and CEO, said in a statement that, "Reducing the rate of growth of health care costs is an urgent national priority....Unless bold action is taken, the health care system will be unaffordable and crowd out other critical national priorities – a situation which would be devastating to families, employers and our country as a whole." That's the 99% end-game she's talking about - the crowding out of other national priorities like education, infrastructure, safe food, and defense.

PhRMA, the prescription drug association, committed $80 billion in savings on drugs over 10 years, including selling drugs at half-price to seniors who fall into the Medicare Part D donut hole.

The American Medical Association (which represents fewer than 50% of physicians) says it's committed to "making private insurance more affordable," along with principles of "pluralism, freedom of choice, freedom of practice and universal access for patients." When it comes to cost containment, the AMA hasn't offered a lot of concrete suggestions except for a need for malpractice caps.

Health Populi's Hot Points: Clearly, the microeconomy of health care is a core component of the U.S. macroeconomy. Getting to "yes" on health reform and cost-containment might not be so difficult if we take the advice of Uwe Reinhardt and David Riemer that they offered in a New York Times op-ed on June 25th 2009. In their best of all possible worlds (in our health politics-constrained world), a health insurance exchange could be built on choice, competition and incentives thus meeting critics on all sides somewhere in the middle.

What Michael Jackson can teach us about health

Having grown up outside of Detroit, Berry Gordy and Hitsville, U.S.A., aka Motown Records, plays the core beat in the soundtrack of my younger life, and still to this day. The Jackson 5's hits are woven into that musical quilt, and Michael Jackson's work with Quincy Jones even more: in particular, Off the Wall and Thriller.

This brilliant force in our lives had much to teach us in life: Be a lifelong learner, and grow every day in your craft - whatever that might be. Reach beyond your grasp. Delight in what you do for a living. Give to the causes you believe in.

His death can give us lessons, as well, about health.

Dr. Deepak Chopra, a trained cardiologist and integrative medicine guru, told CNN talking heads on the day after Michael died this longtime friend came to the doctor in 2005 asking for a prescription for narcotics.

It was then that Dr. Chopra realized that his young friend was wrestling with prescription drug addiction. Dr. Chopra said to CNN, "There's a plethora of doctors in Hollywood that are drug peddlers, they are drug pushers....They just happen to have a medical license."

He spoke of Hollywood's, "huge problem with celebrity doctors who not only initiate people into the drug experience but then they perpetuate it so that people become dependent on them. I think this is something that really should be investigated because it's a disease."

Dr. Chopra called prescription drug addiction, "the number-one cause of drug addiction in the world, and particularly in the United States." Not street drugs, Dr. Chopra has observed, but medical prescriptions given legally by physicians.

In a bittersweet eulogy to her ex-husband, Lisa Marie Presley spoke on her MySpace blog of Michael's concerns about dying like her father, Elvis.

"Years ago Michael and I were having a deep conversation about life in general. I can’t recall the exact subject matter but he may have been questioning me about the circumstances of my Father’s Death. At some point he paused, he stared at me very intensely and he stated with an almost calm certainty, 'I am afraid that I am going to end up like him, the way he did.' I promptly tried to deter him from the idea, at which point he just shrugged his shoulders and nodded almost matter of fact as if to let me know, he knew what he knew and that was kind of that."

Health Populi's Hot Points: Since Michael's death, which occurred on my birthday, I've been wrestling with what we can learn from this tragedy. We lose yet another young, creative spirit to what could turn out to be a preventable cause.

Last night, we watched La Vie en Rose, the life story of Edith Piaf. This just happened to be one of the 3 DVDs that Netflix sent us this week. The timing was ironic; Edith received shots and consumed innumerable cocktails of drugs throughout her life, snuffed too-early like Michael's and Judy's and Elvis's and Heath's and countless other creative spirits.

It really does take a village when it comes to health. Enablers and sycophants: be gone.

All I can say is: We Are The World.

P4P4P - paying patients to be healthy, and the best cos. for health

A powerful, simple, nudge has been discovered by researchers at Wharton's Leonard Davis Institute -- it's directly paying people to be healthy.

Readers of Health Populi should already know about P4P, pay-for-performance, being adopted in Medicare and by other payers to incent health providers to provide health care that demonstrates health outcomes.

In this health citizen-facing version, call it "pay-for-performance-for-patients," P4P4P.

Kevin Volpp is the Wharton professor who's been studying how to move health consumers toward healthier behaviors. He's written articles for journals like, "Asymmetric Paternalism to Improve Health Behaviors" in JAMA. His logic trail follows the Sunstein and Thaler Nudge principles of libertarian paternalism.

His research has found the following:

• 9.4% of smokers who were offered $750 in incentives to quit smoking were able to remain smoke free for 18 months, compared with just 3.6% of smokers who tried to quit without financial incentive


• Dieters who could earn money by loosing weight lost more pounds more quickly than those who weren't offered a monetary reward


• Patients who regularly forget to take their medication and have the chance to win an average of $3 per day in a daily lottery pushes many of them to remember to take their daily doses.

Volpp has uncovered some nuances across different populations, which are discussed in more detail in Wharton's June 24, 2009, publication of Knowledge at Wharton.

Health Populi's Hot Points: I've been doing a lot of speaking with large health plans, employer coalitions, and life sciences companies these past few months, and the Nudge concept is getting a lot of traction in those quarters as well as in the Obama Administration, where Cass Sunstein is now employed in a health regulatory capacity.

This week, The National Business Group on Health recognized 63 of the 2009 Best Employers for Healthy Lifestyles. These firms, NBGH says, "create healthy workplaces and help employees and their families make wise choices about their health and well being."

These Best Health-Cos include several retailers (Hannaford, Walmart, Meijer and Target), health companies (Boehringer-Ingelheim, CVS Caremark and Cardinal Health), and General Mills.

It's heartening to see smarter health plan design targeting wellness and productivity, along with the refinement in the Art of Nudging, gaining traction among employers. Here's one targeted, strategic way to lower health costs in an era where employers are facing between 9 and 11% cost increases for the 2010 health planning horizon.

Getting people to use health-y tools

Here's the recipe for making a health-oriented consumer-facing health decision tool that gets traction: the secrets in the sauce that get health citizens to use self-care tools are trust, usability, and branding.

It also takes luck in timing and, by the way, helps to come from outside of the health industry.

For sustained success, the tools must reach a national audience and the developer should continue to invest in, innovate and market the tool.

That's it. Now you can bake that health decision-support cake.

The Center for Advancing Health (CFAH) has done an important service in publishing the paper, Getting Tools Used: Lessons for Health Care from Successful Consumer Decision Aids. By diving deep into consumer-beloved shopping tools such as Consumer Reports Car Buying Guide, eBay, the FDA Nutrition Facts Panels, and US News & World Report Best Colleges guide, CFAH identifies what works best based on these well-embraced examples.

The project was funded and supported by the Changes in Health Care Financing and Organization program office of the Robert Wood Johnson Foundation, the California Health Care Foundation, and the Foundation for Informed Medical Decision Making.

Health Populi's Hot Points: We are past the point of assuming that, If We Build It, Health Consumers Will Come. After years and dollars and blood-sweat-and-teary energy spent on health report card and quality projects, CFAH points out the critical success factors that can help achieve adoption by real people in the real-world markets.

It helps, they say, to be an 'outsider.' What does that mean? As in so many venues in health care market dysfunction these days, it means to get past the legacy systems and views of U.S. health care and learn from other industries. Be entertaining, engaging, user-centric. Like Gretzky, be where the puck is -- that is, in the words of CFAH, "meet a ready audience."

Note the wise inclusion of the FDA nutrition label, shown here. This template can provide tasty food-for-thought for developers of consumer-facing decision tools.

Our bodies, our health information, ourselves - A Declaration of Health Data Rights

There are a million stories in the naked city when it comes to personal health information...many of which end up very badly.

At the very point in our lives when when we're fighting for our life, or for the life or 'good death' of our loved one, we too-often find ourselves also fighting to access our health data. This absurd, appalling scenario steals a basic right away from health citizens: our ability to fully participate in our own health decisions and care.

A Declaration of Health Data Rights has been launched on four simple, elegant, personal precepts: that We the People...

• Have the right to our own health data.
• Have the right to know the source of each health data element.
• Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form.
• Have the right to share our health data with others as we see fit.

This effort came about through a convergence of events, writings, and social network interactions -- all driven by the context of the erosion of personal health data rights and access, and growing personal health crises. As the Health Data Rights' FAQ states, "The Internet, social networking, and most lately the agenda for change put forth by President Obama’s Administration has brought the power of the idea to a meme that is much bigger than any individual’s contribution."

Health Populi's Hot Points: Without immediate, full access to our personal health information, we cannot realize our full health potential...or manage end-of-life decisions with the fullest grace and dignity which is the right of every health citizen.

Please visit the healthdatarights.org website and read the FAQ. If you are so inclined, endorse the Declaration. Think about your family, your friends, your self.

My homeboy Benjamin Franklin wrote, "In this world nothing can be said to be certain, except death and taxes."

After Taxes but before Death, the great equalizing certainty in life is that we will all find ourselves at a moment-of-truth confronting a diagnosis of cancer or HIV or Parkinson's or heart failure or other threat to our life or health. Whether you will have access to all of your health information to Get Smart Fast is not so certain.

Economic pressures facing average Americans are increasing pressure for health reform

55% of Americans have taken at least one action to delay medical care because of cost in the past year, according to the June 2009 Kaiser Health Tracking Poll.

Most prevalent strategies for health cost avoidance include relying on home remedies and over-the-counter drugs instead of seeing a doctor, skipping dental care, postponing getting health care people think they need, skipping a recommended test or treatment, and not filling a prescription -- all shown in the chart.

A steady 61% of Americans believe it is "more important than ever to take on health care reform now," about the same percentage of Americans believing that since October 2008. While this sentiment splits along party affiliation, with 74% of Democrats feeling this way, most Republicans believe we can't afford to take on health care reform now.

One of the few areas where Americans tend to agree across party lines is in their willingness to pay for more Americans to be insured. In December 2008, 49% of Americans said they would not be willing to pay more to reduce the number of uninsured; by June, the number unwilling to pay to increase access rose to 54%. There is bipartisan agreement that health reform can be accomplished without spending more money.

Health Populi's Hot Points: The economy is driving consensus among American health citizens, a majority of whom want to see health reform. The fact that over one-half of Americans have done "something" to manage their household health costs bolsters the public's pro-health reform position.

Americans are open to a variety of strategies that would increase health insurance coverage, such as individual and/or employer mandates and the use of tax credits to fund increased access, However, their positions still appear quite changeable based on KFF's polling data.

This leaves room for competing health stakeholders to make their arguments to the public-at-large through traditional and, I predict, non-traditional means. Watch for social networks, tweets, and YouTube-style videos to virally "inform" and populate the public discussion. There will be a lot of clutter: the most compelling and creative messages and messaging styles will be able to break through the same-old, same-old public relations and advocacy.

Advertising and retail health - ad clutter expands its footprint

"Advertising carried on blood pressure monitors at 20,000 stores reaches more than 1 million users a day," a press release from Lifeclinic International boasted this week.

According to the Lifeclinic website, "the blood pressure monitor is free for consumers to use. So it’s no surprise that our blood pressure monitors are a recognized consumer destination, attracting customers and building store traffic daily by offering shoppers an important service. Lifeclinic said that because 52 customers per store use its Health Stations every day."

Let's hearken back to the sage words of economist Milton Friedman: there is no such thing as a free lunch.

Nor a blood pressure reading, apparently.

Health Populi's Hot Points: The growth of new channels and milieus for health-oriented advertising is inevitable. As print and traditional broadcast avenues decline in effectiveness (and thus lose favor among ad space buyers), it's a sort of whack-a-mole phenomenon: health ads will show up elsewhere to motivate sales of products aimed at health care consumers.

Thus, the volume of ad messages will expand in retail and mobile health (mHealth) channels as part of the ever-morphing health care consumer-facing environment. As Wayne Gretzky brilliantly demonstrated on the ice, you've got to go where the puck is going to be.

Is there anything wrong with this picture? The answer is not simple. Before the consumer takes his blood pressure, is there an opportunity to opt-in to an advertising message? Is opt-in even a relevant question in this scenario?

On the other hand, a consumer's experience of an ad at the point-of-health-care-service (in this case, blood pressure screening) can bolster a positive health message -- in this case, for example, "Did you know that a high salt intake in your diet increases your risk of high blood pressure?"). On the other hand, messages that are more brand/product specific could be subject to greater regulatory scrutiny.

In either case, inevitably, watch the ad space of retail and mobile health channels to clutter. It's a naturally occurring phenomenon in the consumer-facing health market.

One-third of Americans have lost confidence in their health system

Most Americans believe that in fixing health care, we'll be addressing the economy. This, according to a new Index of American health citizens' confidence in the health economy.

The Robert Wood Johnson Foundation joins forces with the Center for Social Research at the University of Michigan (SRC) to bring this innovative measurement tool to policymakers and health citizens during this long, intense season of health reform. The SRC will include questions regarding health care, health insurance and the impact on families’ economic situations in its ongoing Surveys of Consumers. The SRC is well-known for its Index of Consumer Sentiment.

A key finding in the April-May 2009 survey is big differences in confidence between people who are insured versus those without insurance.

The health consumer confidence index measures Americans' experiences with health care access in the past year:

• Delaying seeing a doctor when it was necessary due to cost.
• Skipping a recommended medical test, treatment, or follow up due to cost.
• Not filling a prescription due to cost.
• Having difficulty paying medical bills.

Furthermore, the Index asks health consumers to look into the future -- that is, even if they're able to afford health care 'today,' what do they see in terms of their ability to pay for health care in the future?

Health Populi's Hot Points: Well over 1 in 3 Americans lacks confidence in the health system, and nearly 2 in 3 are concerned about future costs. These numbers grow in direct proportion to whether someone has health insurance, their age and feeling of vulnerability.

One of the biggest overall findings in terms of sheer percentage is that 86% of Americans believe that President Obama should address health reform as a macroeconomic issue. Whether insured or not, this large majority speaks collectively about a growing lack of confidence about the future health system -- and in particular, health citizens' ability to access and pay for health services tomorrow, next month, or next year.

As RWJF and the SRC track these sentiments over time, we'll have a credible picture of how Americans' personal perceptions of their health system vulnerability improve...or not.

Health care costs for dummies: some costs you might not have thought about

This week, a report from the Congressional Budget Office tells us that if Senator Kennedy's health care plan were to be implemented, 16 million Americans might still be uninsured even after the nation spent $1 trillion for a package meant to deliver universal coverage.

CBO budget director Douglas Elmendorf told USA Today, "It's going to be a long, hard slog" to find savings in U.S. health delivery without "harming health."

Here are some areas to consider...without harming health...

1. Administrative waste costs. Estimates for the cost of paper and inefficiency reach as high as 30% of U.S. health costs. Check out the U.S. Health Efficiency Index to learn more about this wasteful spending. Here's an area where real savings can be achieved to be re-allocated to health care and away from unhealthy paper. I wrote a lot more about this cost in Health Populi in How to find $150 billion for health care in February 2009.

2. Unstandardized, and often too much, care. Can you spell "D-A-R-T-M-O-U-T-H?" The Dartmouth Atlas of Health Care has shown in brilliant detail, for over two decades, the expensive phenomenon of regional variation in U.S. health care. Move Americans to evidence-based care. Get people the right care at the right time -- but just enough of it. Read Shannon Brownlee's book Overtreated to learn more about how we supersize health care portions in the U.S. -- to the detriment of quality and human outcomes.

3. Launch a national war on diabetes. If we attack diabetes as a national threat to the economy, we could make a dent in the $218 billion spend on the disease each year. There are real savings to be had in laser-focusing on this epidemic, which is growing in very young Americans and poorly managed in the middle aged and older. The death rate from diabetes is on the rise. That's a cost that's too dear.

Health Populi's Hot Points: Costs are clearly in the eye of the beholder/health stakeholder. But the larger cost of not moving on health reform will jeopardize the financial health of the nation sooner rather than later -- which will further deteriorate the nation's global competitive position for business, and quality of life for citizens.

A long slog is surely ahead of us. Those stakeholders who keep their eye on the long-term goal of universal coverage, cost containment, and evidence-based care will be the heroes of health reform.

But the difficult journey will be longer and more painful if we don't address the long-term threat of health costs to American citizens during this current window of opportunity.

WaPo hosts diverse panel of health reform pundits...including me

What newspaper is better positioned than the Washington Post to host a bunch of people who observe health to respond to Big Questions facing health reformers and citizens in 2009?

It's the Washington Post's Healthcare Rx series. On a weekly basis, you can read what these people have to stay about a broad range of health reform issues with which President Obama, Congress, and health citizens are wrestling:

Angela Glover Blackwell, CEO and Founder of PolicyLink

Ceci Connolly, WaPo's own national health policy analyst.

Chisara N. Asomugha, a pediatrician and Robert Wood Johnson Clinical Scholar at Yale University

Chris T. Pernell, a doctor and clergywoman in New Jersey

Colleen Conway-Welch, dean of Vanderbilt University’s School of Nursing
David Brennan, CEO of AstraZeneca
Doug Ulman, cancer survivor and president of the Lance Armstrong Foundation

Georges Benjamin, ER physician and executive director of the American Public Health Association

Dr. Howard Forman, a professor at at Yale University
Jeff Emerson, president of NorthEnd Group, a medical technology expert

Jeffrey Korsmo, executive director of the Mayo Clinic Health Policy Center

John Agwunobi, SVP and president of health and wellness for Wal-Mart
Kathy-Ellen Kups, breast cancer blogger for Everydayhealth.com
Maggie Mahar, the health care journalist

Mark Kelley, CEO of the Henry Ford Medical Group in Detroit

Michael Critelli, health innovator at Pitney Bowes where he was CEO

Nancy LeaMond, EVP at AARP and director of Divided We Fail

Newt Gingrich, founder of the Center for Health Transformation and former speaker of the House

Peter Neupert, who leads Microsoft's Health Solutions Group
Raymond J. Zastrow, president of QuadMed
Raymond Martins, CMO of Whitman-Walker Clinic

Dr. Scott Young of the Permanente Federation in California
Shannon Brownlee, author of the seminal book, Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer and fellow at New America Foundation
Sue Falkner Wood, blogger on EverydayHealth.com of Life with Chronic Pain: A How-to Guide...

and....me.

Health Populi's Hot Points: As you can tell from the roster of contributors, we represent every stakeholder group in health care, to WaPo's credit. Central is the consumer-citizen health angle, as well as technology, provider, pharma, physician, payer-employer, and policymaker.

Our first question was, "What should Congress tackle first," to which I replied, in summary, "attack chronic conditions through info-tainment." Others tackled waste, aligning payment with performance, universal coverage, equity, and cost containment.

This week, we're all reacting to President Obama's speech to the AMA on health reform delivered on June 15, 2009. Please visit each week as my fellow panelists and I build the broad range of perspectives on health reform in America.

Confidence in the U.S. health system decreases as Americans look to the future

Most Americans are confident that their employers will continue to offer health benefits. Whether people will be able to afford to purchase them on their own is an entirely different matter.

The blue and the red bars graphically tell this story: the blue 'confidence' bars say people have faith that employers and unions will probably offer health insurance in the future. The red bars say that if Americans are given cash by employers or unions to purchase health coverage on their own, they're not confident they'll be able to do so.

This story is told by the Employee Benefit Research Institute (EBRI), whose 12th annual Health Confidence Survey is out for 2009. According to EBRI's survey, most Americans support insurance market reform and a public plan option.

Between 68% and 88% of Americans support health reform options including national plans, a public plan option, guaranteed issue, expansion of Medicare and Medicaid, and mandates on employers and individuals.

About 80% of people with greater out-of-pocket costs are pushing people to choose generic drugs where available; about 1 in four of those with higher OOP costs say they did not fill an Rx or they skipped doses of their prescribed meds due to higher costs.

67% of insured Americans say they're talking to their doctors more carefully about treatment options and costs; this number was 58% in 2004. 64% of Americans are also going to the doctor only for more serous conditions of symptoms (according to their perceptions of 'seriousness').

The future isn't clear when Americans imaging the US health system. While 57% of Americans are confident about their ability to get the treatments they need today, only 35% are confident about their ability to get needed treatments during the next 10 years. Only 22% are confident
they'll get necessary treatments once they're Medicare-eligible.

Health Populi's Hot Points: For the health-insured population, it's the costs, stupid. People aren't confident about the future viability of American health care in terms of whether they'll be able to access and afford necessary treatment.

Their current proxy for this is self-rationing prescription drugs and visits to doctors when deemed 'necessary.'

That's what's certain in today's health economic climate. What will also be certain, but difficult to quantify today, is that many of these people are sacrificing their future health outcomes based on tight personal health finances today.

Infection prevention is a casualty of the recession

U.S. hospital finances are so stretched in the current recession, infection prevention efforts have begun to be curtailed.

32% of health facilities say that reductions in staffing and infection prevention (IP) departments have reduced their capacity to deal with IP in their institutions.

The Association for Professionals in Infection Control & Epidemiology (APIC) has released the 2009 APIC Economic Survey - The Economic Downturn and Infection Prevention, published in June 2009.

41% of APIC's polled members reported budget cutbacks for infection prevention in the past 18 months, due to the economic downturn.

Among several areas negatively impacted that touch on IP, a decrease in IP oversight (34%) and surveillance (24%) are cited as specific impacts due to financial cutbacks in budgets. Surveillance involves detecting, tracking and managing healthcare-associated infections.

Health Populi's Hot Points: Healthcare-associated infections cost hospitals and the economy money. Preventing infections not only enhances a hospital's profitability, they also save costs to payers and promote patient and public health. As private and public payers (Medicare and Medicaid) seek to ratchet down hospital payments, this is not the time to ration infection prevention budgets.

IP is an area of health facilities that's understaffed and underfinanced. Yet the public health implications for preventing infections, and funding the infrastructure for pandemic preparations, must be squarely faced.

"Spreading knowledge. Preventing infection" is APIC's tagline. APIC is spreading some important knowledge about the sad state of hospital IP financing with this survey. Whether APIC's members can get back to the full-time job of preventing infection is an entirely different, and fiscally short-changed, matter.

Health information is social, and is everywhere

Like the Grateful Dead and global warming, health information is everywhere. The proliferating platforms, online and mobile, and the multiplying volume of content and opinions, drive the very social life of health information.

Susannah Fox's latest research on behalf of the Pew Internet & American Life Project, in collaboration with the California HealthCare Foundation, illustrates this phenomenon through many fascinating lenses. The Social Life of Health Information is a deep dive into the phenomenon of Americans' online searches of health by information category and demographics.

Fox has a long-view on Americans' use of information, on- and off-line. She's been studying this space for years and is arguably the brand-name guress in the field.

The first Big Difference I note this time around since her last study in 2006 is the increasing penetration of broadband and wireless, and their impact on e-patients. E-patients who have wireless and/or have access to broadband are more engaged with health information.

Among those going online for health information, Fox finds that many people are looking for a "just-in-time someone-like-me" to help inform personal health decisions. This finding confirms recent research from the Edelman Health Engagement Barometer covered in Health Populi on health engagement and patient activation.

One in 3 American adults access social media for health reasons. That's 60% of online users. Wikipedia is a go-to source among 1 in 2 e-patients. Twitter and other social networks like Facebook -- not so much, but they're still used along with lots of other (non-social but still online) sources.

Overall search for health information about a specific medical problem was relatively flat between 2002 (63%) and 2008 (66%). However, four areas of health search grew and are worth noting:

Prescription drug information. 45% of online adults looked for information about prescription or over-the-counter drugs in 2008, up from 34% in 2002. Rx/OTC is one of the largest growth areas for online health search, perhaps due to consumers' increasing co-pays for prescription drugs, the growing array of alternatives going off-patent as generics, and Rx switch to OTC for categories such as GI and allergy. In addition, the advent of Medicare Part D has incentivized older Americans to seek pricing and alternative information for prescription drugs to manage their 'doughnut holes.'

Exercise and fitness. Among Internet users, the percentage of those seeking fitness information has jumped from 36% in the year 2002 to 52% now – one of the biggest growths since 2002 out of all health searches. Younger adults are more engaged in exercise/fitness search online than older health citizens.

Mental health. 21% of American adults, or 28% of Internet users, now report that they have looked online for information about depression, anxiety, stress or mental health issues, compared with 12% of adults, or 21% of Internet users, in 2002. This category is particularly used by women, who account for much of the growth in online research of mental health since 2002. 35% of online women search for information about mental health issues vs. 22% of men.

Information on alternative treatments. 26% of American adults, or 35% of Internet users, now report that they have looked online for information about alternative treatments or medicines, compared with 16% of adults, or 28% of Internet users, in 2002.

Health Populi's Hot Points: The Pew's work on consumers' growing use of various platforms in the communications ecosystem is very salient for health - especially for opportunities to address the complex challenge of chronic care management. Read more about the communications ecosystem in the Pew's work on the new media ecology.

As Fox found in 2006, people with chronic conditions tend to go online for health information more than those with no chronic conditions, as the chart details.

There is opportunity to engage people to manage chronic conditions on a 24x7 basis given their increasing adoption of wireless, mobile technologies. Mobility enhances peoples' ability to intensively, intimately engage in their health and health care.

Fox has previously pointed out that, "Mobile could be a game-changer" for health. "But only for those who get in the game." While the upside for mHealth is huge, access to and engagement with the communications platforms, programs and tools will be barriers to mass adoption of Participatory Health in the short term.

Health Care Costs Will Increase at Double-Digit Rates in 2010

Peter Orszag, the Director of the Office of Management and Budget, believes that health costs are the #1 driver of America's long-term deficit. The inexorable increase of health costs are plaguing the Federal budget, Governors' state budgets, employers' bottom-lines and ability to compete globally, and household budgets.

Things are looking up for next year when it comes to health costs in 2010 - they'll continue to grow at double-digit rates, according to Buck Consultants, the employer benefits consultancy.

Buck's 2009 National Health Care Trend Survey finds that costs for all flavors of health plans - including PPOs, POS, HMO and consumer-driven/high-deductible - will increase between 10.2% and 11.0% into 2010.

The rate of increase has declined very slightly across-the-plans, from 0.1% to 0.3%.

The growth in the cost of prescription drug trends among health plans is projected to decline 0.6%, but still increasing at a 10.8% trend.

Buck surveyed over 100 insurers, HMOs and TPAs covering about 95 million enrollees.

Health Populi's Hot Points: The rise of health costs, especially in the current recession, is the front-burner issue in health reform. While universal coverage continues to be a priority for most Americans, that issue is sharply split across party lines. Getting health cost increases under control is something most Americans and policymakers can agree on in 2009.

Expect this issue to be front-and-center in health reform discussions this year, as double-digit cost increases are in reformers' collective crystal ball.

The mortality risks of talking on cell-phones and driving = 2,600 deaths a year

Health risks are part of our daily lives. The World Health Organization's (WHO) 2002 Annual Report focused on Reducing Risks, Promoting Health Lives.

According to WHO, risk is defined as a probability of an adverse health outcome, or a factor that raises this probability.

The probability is that more people will die in car accidents caused by talking on cell phones and driving-while-texting.

The latest Harris Poll, Large Majority of Drivers Who Own Cell Phones Use Them While Driving, Even Though They Know This Is Dangerous, finds that 9 in 10 cell phone users know that using cell phones while driving is dangerous, but they do so anyway.

According to the Poll, 27% of cell phone users surveyed -- all adults over 18 -- text while driving, sometimes (22%) or "all of the time" (5%).

The National Safety Council says that talking on a cell phone puts drivers at a four-times greater risk of a car crash. NSC data demonstrates that cell phone use contributes to 6% of all car crashes. In total, this leads to 330,000 injuries, 12,000 serious injuries and 2,600 deaths each year.

Beyond 'just' talking on the phone while driving, welcome to the next cell phone-phenomenon: Driving While Texting - "DWT" for those of you who need the acronym.

According to Vlingo, who develops speech recognition technology for wireless phones, over 26% of cell phone users in the U.S. text while driving. This varies by state: Tennessee has the most active DWTers, at 42% of cell phone users.

This Harris Poll was conducted online in May 2009 among 2,681 adults 18 and over.

Health Populi's Hot Points: Using cell phones while driving is clearly a health risk - a major one. DWT'ing probably yields an even greater health risk than talking.

RIP, DWTers. Pity the people on the road with you - whether passengers in your car, or sharing the same route at the same time.

Most health citizens search on illness, but Microsoft finds people are open to tech-enabled health coaching

Health engagement helps to bolster health citizens' positive health outcomes. Microsoft has released the 2009 Health Engagement Survey, focusing on health plan enrollees' online behaviors and perceptions of the U.S. health system.

Microsoft found that 1 in 2 Americans view the U.S. health system as 'fragmented,' which creates challenges in helping people manage their health care and health behaviors.

These people tend more to look online for health information, versus turning to health professionals or health plans.

Furthermore, when seeking health information online, people make more reactive than proactive decisions. As the chart illustrates, 2/3 of people search topics on specific diseases they have been diagnosed with. Fewer people search online on topics regarding wellness and whole health.

On the positive side, Microsoft points out that health citizens welcome health coaching support that technology enables. For example, 2 in 3 Americans are interested in receiving health-related encouragement or reminder e-mails from health plans. 52% would be willing to receive e-mails that provide them with feedback on their health progress.

62% health citizens said they believed that personal health records are valuable.

Health Populi's Hot Points: As consumers use online tools to manage their lives' tasks, more are open to using online tools for health. Microsoft learned that people would generally welcome email messages as conduits for health messaging and support.

Microsoft's lens on this survey was health plans. I would point you to the Edelman Health Engagement Barometer, published in October 2008, to a key data point which found that American health info-entials (the most highly engaged health citizens) tend to trust personal and health expert channels compared to other sources of health information. Health plans have a ways to go to earn the health public's trust for health engagement.

The cost of sleeplessness = $42 billion

Two categories of prescription drugs are growing faster than most others in this second quarter of 2009: anti-depressants and sleep aids, according to IMS Health.

Can you spell "R-E-C-E-S-S-I-O-N?"

Sleeplessness is up in 2009, and people are kept up with anxiety about the economy along with other factors driving the prescription drug market for sleep.

The cost of insomnia is $42 billion annually in the U.S. The numbers on sleeplessness are epidemic: some 70 million Americans have some sort of insomnia.

About 1 in 3 American adults use some form of sleep aid at least a few nights a week, to the 2009 Sleep in America Poll from the National Sleep Foundation. Sleep aids including relaxation techniques (15%), prescription meds (8%), alcohol/beer/wine (7%), OTCs (7%), and alternative therapies such as Valerian and Melatonin.

According to Meir Kryger, MD, Director of Research and Education at Gaylord Sleep Services, insomniacs can suffer worse from chronic conditions. "Sleep disorders are often associated with other chronic diseases, like diabetes and hypertension, and they can add complexity and even accelerate each other if untreated.”

Waking Up to the Insomnia Crisis: How Insomnia is Costing American More Than $42 Billion a Year and What We Can Do About It was funded by Sanofi-aventis US, the pharmaceutical manufacturer, in collaboration with the Center for Medicine in the Public Interest (CMPI), an advocacy organization.

Sanofi-aventis held the patent on zolpidem, brand name Ambien, until April 23, 2007, when the FDA approved 13 generic versions of zolpidem tartrate.

Health Populi's Hot Points: According to Meir Kryger, MD, a sleep guru at Gaylord Sleep Services in New Haven, lack of sleep is a risk factor for chronic disease. "Sleep disorders are often associated with other chronic diseases, like diabetes and hypertension, and they can add complexity and even accelerate each other if untreated,” Dr. Kryger told the National Sleep Foundation.

Chronic insomnia is bad for the economy. Insomniacs miss over 3 days more work each year compared to people who sleep well. Insomnia costs employers 4.4 days of wages per untreated individuals over six months -- in addition to the direct costs of treating insomnia, and the indirect costs such as lost productivity.

Compared to those who sleep better, people who don't get enough sleep are less likely to exercise, engage in leisure activities, eat healthy, and have sex. The sleepless are also more likely to be not completely satisfied in their relationships.

The health risk factors of insomnia are a substantial, growing -- and often invisible -- part of the US health economy.

Learning about social networks and health in Omaha

There's a groundswell driving social media in health care in America, from Silicon Valley to Boston, Miami to...Omaha?

Booz Allen and the Center for Health Transformation convened a roundtable discussion in Omaha, Nebraska, in March 2009 following up a discussion Booz Allen had in 2008 with stakeholders in diabetes. In that meeting, the opportunities generated by social media in the field of diabetes were explored, with respect to improving peoples' access to information for health and wellness, as well as how to use social media to influence policy and positive health behaviors.

As I pointed out in my report for the California HealthCare Foundation published in 2008, The Wisdom of Patients: Health Meets Online Social Media, social media can positively impact health in innumerable ways. The Omaha group identified a few important opportunities that leverage social media for health:

• To provide low-cost, highly targeted, highly engaging tools to increase awareness of community health initiatives.


• To reach and engage younger people through communities they're already participating in.


• To build trust and engagement between citizens and organizations/business beyond traditional "information push" by these organizations.


• To promote patient-centered medicine by empowering patients to do their own research.

Health Populi's Hot Points: Since the publication of The Wisdom of Patients in April 2008, I've been tracking the continued adoption of social networks in health. With the publication of Groundswell from Josh Bernoff and Clay Shirkey's Here Comes Everybody, there is no doubt that social networks in health are 'here,' and are already changing the relationships between patients who are finding colleagues in-sickness-and-in-health, physicians in communities with other physicians, and researchers collaborating in new and facile ways.

In this emerging era of participatory health, I expect we'll be seeing (early-adopting) physicians co-creating health in social networks with patients and caregivers sooner rather than later. It's important to note that on Facebook, the fastest growing segment of users is older women -- kids, teens, and millenials are already fully absorbed in there.

The groundswell of patient-centered medicine is upon us. This is being driven, as Bernoff, Shirkey and I agree, from the ground up -- by the people, for the people.

The world is flat when it comes to health care consumerism

The recession around the world is having a negative impact on health citizens' purchases of over-the-counter drugs.

The economy is changing the way they will use non-prescription drugs, as well as the kind of drugs they will use. To the first point, OTC consumption will decline for some; for people who continue to demand OTC meds, they will increasingly seek lower-priced products.

Globally, 46% of the world's citizens believe that economic decline will have an impact on their demand for over-the-counter drugs. The chart illustrates that, from China (CN) down to Belgium and the US, the world's citizens feel negatively impacted by economic decline -- and this will negatively impact their demand for over-the-counter drugs.

You can sift through many countries' 'scores' on OTC demand. For example, nearly 8 in 10 respondents from China said their consumption of non-prescription meds would be impacted by the economy; in the Philippines, about 75% of citizens feel their demand for OTCs would be impacted due to the economy. At the bottom end of this negative impact are the Scandinavian citizens of Norway, Finland, and Sweden, along with Denmark, the Netherlands, and Switzerland.

Underneath this macro impact, though, citizens in different parts of the world will behave differently vis-à-vis OTCs. For example, in the US, the response will be roughly equally split between cutting back on non-prescription meds and seeking cheaper alternatives (32% and 29%, respectively).

In contrast, in Europe, adopting traditional and natural remedies will beat shopping on the basis of price.

Eyeballing the chart, you will notice the orange bars -- adoption of alternative and natural remedies -- are far larger in other parts of the world compared to North America.

Nielsen's Global Online Consumer Survey was conducted in March 2009 among over 25,000 Internet users in 50 markets from Europe, Asia Pacific, North and Latin America and the Middle East.

Health Populi's Hot Points: Americans are clearly more price-driven than the world's other health citizens. In the U.S., there is much greater choice in over-the-counter products, which are also "open-shelved." Except for a very few non-prescriptions meds, Americans can walk in to the drugstore on the corner (inevitably a chain, grocer or superstore) and choose from scores headache meds (with variations from migraine to sinus), cold meds, and pain meds.

That choice is increasingly driven by price, with Nielsen finding 30% of American consumers saying that price is such an important factor in product choice they will buy cheaper products. Generics and stores' private label brands will replace branded products in this scenario.

As Americans' out-of-pocket costs continue to increase for 'prescribed' health care goods and services, from surgical procedures to specialty drugs, health citizens will shop around. The greater transparency and access, the better decisions the health consumer will be able to make. That is, (1) if alternatives exist, (2) if the substitutes are efficacious and safe, and (3) if the consumer's household dollar will be able to stretch far enough to accommodate the health spending. Here as in all personal spending, value will be in the eye of the beholder.

Workers appreciate health benefits more than ever - but for how long?

Two reports come at the issue of workplace benefits with different perspectives. Together, they combine to find that workers value benefits in 2009 more than they have in the past -- and especially as the economic pressures on workers' households is increasing.

Workscape's Annual Benefits Study for 2009 illustrates several impacts of the economy on health benefits.

3 in 4 human resources professionals see employees' having a heightened appreciation of benefits. The declining economy clearly has increased awareness and appreciation of workplace benefits.

With respect to health benefits, roughly one-half of small and mid-size employers now offer employees at least one consumer-driven (CDHP) or high-deductible health plan (HDHP). Two in 3 large employers do so. These numbers increased between 9 and 11 percentage points since 2008 depending on organization size.

Three-quarters of organizations' respondents say that the economy is having an impact on their organization, most likely in the form of employees working hard and being more productive. Within the large employer segment, the harder-working employee is seen in healthcare, manufacturing and financial services sectors; not so much, though, in the government segment, based on the survey's findings.

Workspace collaborated on the survey with Workforce Management. The poll was conducted among the journal's subscriber base in May 2009. This duet conducted a similar study in 2008, which allows year-on-year comparisons between some of the datapoints. In total, 787 human resource professionals and CEOs were surveyed from small (<1000>5,000) companies.

Another report issued this week complements Workscape's and Workforce Management's findings.

Trends In Underinsurance And The Affordability Of Employer Coverage, 2004-2007 is published in the policy journal Health Affairs online, exploring the tug-of-war between covered employees' eroding coverage, and employee benefit consultants' proposals for health consumers to get more "skin in the game."

Jon Gabel et. al. found that, "if you are sick and earn a modest income, then you are probably underinsured--even if you have employer-based health coverage." Underinsurance increased between 2004 and 2007, while the value of employer-based health insurance slightly fell. The authors identified the big change in health benefit design in that period was the growth of plans with deductibles along with increases in the average deductible levels. These include CDHPs and HDHPs -- the kinds of plans Workscape's report shows have grown roughly 10 percentage points between 2008 and 2009.

Health Populi's Hot Points: Gable and team point out that 2004-2007 was a period of economic expansion. Yet during that time, when the U.S. felt 'richer,' health financial protection eroded.

The team notes that after the 1991 and 2001 instances of economic decline, patient cost-sharing increased. In this recession of 2009, it is rational to expect cost-sharing will increase for American health citizens with employer-sponsored coverage.

It's clear these most Americans who receive health benefits appreciate the value of these benefits more now than ever - even as people ante up more skin-in-the-game. Their level of appreciation may toggle over to financial frustration depending on whether their fiscal contribution deepens from epidermis to dermis in the personal health economic skin-game.

Transparency and credit cards: how doctors can talk to patients about money

In the emerging era of participatory health, fanned by the fiscal flames of the recession and increasing out-of-pocket costs, there's an important communications component to consider: participatory health economics.

The chart illustrates why. Out-of-pocket health costs are steadily increasing for households. Thus, it is reasonable for health citizens to want to know how much health goods and services will cost them before they partake of the service -- whether a prescription drug, a stay in rehab, a surgical procedure, or a course of chemo.

For some time, providers have had a difficult time effectively fulfilling this role. Thanks to the Patient Friendly Billing Project developed by the Healthcare Financial Management Association (HFMA), providers have some guidance. The HFMA launched the Patient Friendly Billing Project eight years ago to help providers with revenue cycle management.

HFMA has written a statement that targets patients' rights for early, transparent financial communications. HFMA's objective is for patients to, "understand and prepare for their financial obligation at the earliest point possible in the care experience."

Simply put, people want to know how much they're expected to pay for health care before they incur the costs. By being transparent from the get-go, health citizens can sort out whether there is available financial assistance to care from Medicaid, non-profit organizations, drug companies, physicians (who may help structure a payment plan), among other sources of support for health care.

That sort of transparency benefits both patient and provider since both can plan for the payment stream - whatever the fiscal outcome.

People can also shop around for alternatives once they know the cost of a service.

Health Populi's Hot Points: One of the constraints preventing some health citizens from paying providers is that one-third of physician practices do not accept credit cards as a source of payment, according to The Physician Office Credit-Card Acceptance Survey from SK&A Information Services conducted in April 2009.

SK&A suggests that a growing number of doctors is not accepting credit card payments because patients are adversely affected by high interest rates, maxed-out credit limits and a more challenging ability to qualify for credit.

The providers who are most likely to accept credit cards are plastic surgeons, 91% of whom take the cards, along with opthalmologists, bariatrics specialists, otolaryngologists, and dermatologists.

The least likely providers to accept credit cards include dialysis, geriatric medicine, nuclear medicine, and critical-care medicine.

It's VISA and Mastercard that are most accepted in physician practices.

The personal health economics reality is that out-of-pocket costs are going up. Until Americans have access to a different sort of health system, this is reality for anyone receiving health services in the U.S. This scenario is accompanied by a picture of many Americans going bankrupt paying for health services.

Not to mention the precursor to bankruptcy: growing credit card debt for medical expenses, as discussed here in Health Populi in September 2008.

Meaningful USe - or, whose health is it, anyway?

When I Googled "meaningful use" this morning just before writing this post, the search yielded over 10 million results. Googling "meaningful use and patient" gets you over 1 million results.

Dr. Ted Eytan wrote a post on his blog, Ted Eytan, MD, on May 28, 2009, which captures the core of meaning of "meaningful use." He titled the post, "Is It Meaningful If Patients Can't Use It?"

The bottom line: it's not meaningful, Dr. Ted says, if patients can't see everything.

Dr. Ted met with a group of healthy thinkers in Washington DC this week to discuss patient empowerment in health; these thought leaders included Susannah Fox of the Pew Internet & American Life Project (@susannahfox); Claudio Luis Vera of Studio:Module (@modulist); Cindy Throop of the Center for Information Therapy (@cindythroop); Christine Kraft, the Founder of the e-Health Workshop (@christinekraft); and, Regina Holliday (@reginaholliday) who shared her personal healthstory.

Regina talked about her husband Fred's recent kidney cancer diagnosis and theatre-of-the-absurd encounter with the health system. Read the details here on her blog. See the photo: this is Fred's paper-based medical record, painstakingly (emphasis on the pain) accumulated by Regina @ $.73 a page...per her HIPAA rights.

Now that Fred is more comfortable in hospice, Regina has taken on a parallel project beyond being a caregiving loved one: she's creating a mural based on the USDA-approved nutrition label which diagrams a patient's personal kidney cancer profile.

In her words:

Today I had an epiphany. You might have seen my mural work on the side of the American City Diner. I painted all those famous stars from the 30's through the 50's about six years ago. I also painted the mural of the children reading at Child's Play. I painted the St. Jude's Hospital Thanks and Giving mural on the old Hecht's Building about five years ago. I would like to do a new mural series. I want to do a Medical Advocacy series. I am doing a design based on the food packaging Nutrition Facts label. Instead of Nutrition Facts it will be Medical Facts. I want do a simple anatomy drawing that highlights the patient's illness. To the side of this will be an easy to reference list of all pertinent info. This will be done in such a way to mimic a nutrition label. I think this will be very eye-catching. I want senators and congressmen, bus drivers, and waitresses to drive by this, and I want this kind of clarity and transparency for themselves.

There is no greater illustration of Participatory Health than this story of Regina and Fred's.

Health Populi's Hot Points: Dr. Ted tweeted about a patient-centric meaning of meaningful use for EHRs around April 22, 2009. Since then, countless thought leaders have expressed similar ideas; a few of these include:

Peter Neupert of Microsoft on Neupert on Health
Dr. David Kibbe and Dr. Brian Klepper on The Health Care Blog
The Markle Foundation in Achieving the Health IT Objectives of the American Recovery and Reinvestment Act
Gilles Frydman, Founder of ACOR, on e-Patients
Josh Seidman from the Center for Information Therapy
Dr. Steve Beller in TrustedMD
John Moore of Chilmark Research
Dave DeBronkart on e-Patients

I was gratified to be invited to give testimony at a hearing of the National Center for Vital and Health Statistics (NCVHS) in Washington, DC, on May 20. On my panel sat Bob Coffield, a prominent health lawyer who also writes the Health Care Law Blog, and Daniel Weitzner of MIT's Computer Science and Artificial Intelligence Laboratory. Here is the agenda for the 2 days of testimony.

As we were the first panel kicking off the two days of testimony, Bob and I set forth a context of person-centric and participatory health. By the end of Day 2's proceedings, the NCVHS panel remarked they couldn't remember a hearing where "the patient" was discussed more. You can download the broadcasts here.

Our testimony will be followed on June 9 with more insights from the health citizen - including input from Susannah Fox of the Pew Internet & American Life Project and Dave DeBronkart, who has reached a kind of celebrity status in HIT circles as e-Patient Dave based on the misadventures of his personal health information interactions with the U.S. health system.

Dave is now joined by Regina. We know there are millions of Dave's and Regina's. They are Us.

So Regina's breaking down the walls, the silos, the closed files, fighting through the un-transparent world that is health care in America. I will make my own pilgrimage to the Pumpernickels Deli in Washington DC, where Regina's health empowering murals will be featured, very soon.

Meaningful use is about US.

More workers are engaging in healthier lifestyles in the recession, says NBGH

Insured workers in the U.S. are cost-sensitive to health care. The recession has been negatively impacting workers' health: physically, emotionally, financially.

However, there may be a silver lining here: that workers are making health improvement a greater priority than they did in 2008.

The National Business Group on Health's report on The Recession's Toll on Employees' Health presents results of a survey among workers age 22 to 64, finding good news amidst the not-so-good: that while some employees choose not to receive health treatment to save money on out-of-pocket costs, large percentages of workers are trying to lose weight and live healthier lifestyles to improve their health bottom lines.

And, 2/3 of people are saving more in 2009, which can help tame personal financial stress. This is an important response because 40% of workers told NBGH that mental health - including stress and anxiety - is worse since the economic downturn. Among those, 40% said they've taken action to improve their mental states.

Several of the most important findings in the survey are:

- 52% of workers say cost has the most influence when choosing a health plan - with people earning less than $75K indicating cost as a larger influence

- 25% of workers who switched health plans did so to reduce their annual premium

- 3 in 4 employees say they've become more aware of the total cost of health care in the past year

- 58% of people are surprised at their out-of-pocket costs

- 68% of employees say having access to health benefits is a key reason for staying in their job

- 2 in 3 workers whose employees offer financial incentives say it's motivated them to try healthier lifestyles

- 58% believe smokers should pay higher premiums

- 46% believe obese people should pay higher premiums.

Health Populi's Hot Points: NBGH points to two key areas where employers can help workers better manage health in the midst of the recession: exercise (which the Group calls the "silver bullet" to control costs) and mental health.

This report reveals the important link between the fiscal and the physical which is one of the philosophical underpinnings of Health Populi. NBGH's recommendation for employers to promote an enterprise-wide culture of health and to get more targeted in communicating and 'nudging' workers to healthier lifestyles would surely benefit the Health of the People.

As yesterday's post asserted, Americans may be thinking healthy but not acting healthy, it's all about health engagement. Awareness of total costs and benefits of health behaviors -- communicated in ways that personally touch people -- can help to focus and motivate the consumers of health services.

Americans may be thinking healthy, but not acting healthy

Thinking healthy isn't the same as acting healthy. The gap between what lifestyle behaviors people perceive build health, versus what actually contributes to health, can lead to less than optimal health outcomes.

Based on Yankelovich's 2009 Health & Wellness Segmentation Study, only one-half of people believe that taking medicines as prescribed is "very important" to maintaining health. Only six in 10 believe that exercising regularly is very important to health. One in six people also believe that getting regular physicals and eating a well-balanced diet are very important to maintaining health.

Yankelovich found that people identified other lifestyle behaviors as very important to maintaining health: personal hygiene and cleanliness (cited by 77%), maintaining a positive attitude (74%), staying 'active' (70%), having a sense of purpose in life (70%), and good family relationships (68%).

According to AdWeek, two-thirds of people interviewed for this study in February 2009 were overweight or obese. However, based on Yankelovich's survey data, only 54% were actively trying to lose weight.


Health Populi's Hot Points: Maintaining a strong social network and keeping positive frames of mind are undoubtedly important factors for whole-health.

However, to address the most prevalent chronic conditions facing the world -- heart disease, metabolic syndrome (including diabetes and obesity), and some cancers -- lifestyle changes are a major part of the prescription for health.

Take the epidemic of metabolic syndrome, which impacts about 1 in 5 people in 2009. Risk factors for metabolic syndrome include overweight and obesity, a sedentary lifestyle, aging, diabetes, coronary heart disease, and elevated triglycerides (a high LDL [bad] cholesterol and a low HDL [good] cholesterol level).

Increasing adoption of the first four activities in the chart above would move the needle on diabesity around the world.

In the Harris Poll of May 21, 2009, Americans say the second most important issue for government to address is health care (separate from Medicare).

Americans have cited health care in the top 3 issues for government to address for most of the past decade, as detailed in the chart at left.


While American adults look to government for solving the health care crisis in the nation, based on the Yankelovich data, more should look to themselves to play a central role in managing personal health.

It's easy to point to other stakeholders to take responsibility for 'our' health, whether drug companies, insurance plans, or government agencies; but as Pogo told us many years ago, the enemy is also 'us.'

To delay is deadly - no progress 10 years since "To Err is Human"

Ten years later, a million lives lost, billions of dollars wasted, is the tag line of a report looking back at the decade since IOM's seminal report, To Err is Human, was published in November 1999.

Consumers Union has asked, what progress has been made since IOM calculated that 98,000 lives are lost each year due to medical errors committed in the U.S. health system?

CU's finding: To Err is Human - To Delay is Deadly -- the title of the report.

In the report, CU asserts that preventable medical harm still accounts for over 100,000 deaths a year in the U.S., and a total of over 1 million American lives in the past decade. What factors continue to cause these fatal errors?

1. Few hospitals have adopted computerized prescribing and dispensing systems which, when effectively deployed, prevent errors.

2. There continues to be a lack of transparency in error-reporting by hospitals -- notwithstanding the fact that this was a recommendation published in the the IOM report.

3. There is no national organization tracking patient safety or progress in reducing medical errors. CU believes that the AHRQ falls short of fully tracking progress.

The bottom line: clinicians are no more competent in managing patient safety in 2009 than they were in 1999.

CU recommends that mandatory, validated and public reporting of preventable health care acquired infections and medical errors would create the sort of transparency that could empower health citizens to make sound decisions about quality care. Furthermore, demanding a national body to be responsible for comprehensively tracking medical errors would go a long way, CU says, to de-fragment the current piecemeal process. The way medical errors are currently tracked and addressed, CU concludes, "is practicing 21st century medicine with 19th century oversight."

Health Populi's Hot Ponits: There have been countless task forces, conferences, and recommendations formed, held and issued since November 1999 - I repeat, November 1999! - responding to medical errors since IOM wrote its landmark report. What to do?

CU says we need a Patients' Call to Action to make sure that:

• The FDA, pharma manufacturers, providers and clinicians effectively prevent medication errors.


• Transparency rules through mandatory, validated and public reporting of medical harm and health acquired infections.


• More effective and current training is implemented for clinicians.

Ten years and a million lives later, we're worse off in ways we cannot get our arms around: a million lives lost to preventable causes? Unfathomable.

CU's Safe Patient Project has a petition and more information on this critical issue facing American health care. Go learn more and get activated about medical errors.

While the adoption of ePrescribing and EHRs could help to reduce these errors by 2019, the open disclosure of errors must be an integral part of the solution. Mandating that will focus providers' minds to finally putting the effective systems in place that prevent these errors.

The elongating path to universal coverage

The road to universal coverage will be paved more slowly as the Obama administration comes to terms with the impact of the recession on the general economy, the national deficit, and RealHealthPolitik.

An interview with Peter Orszag in this morning's Financial Times (London's daily business newspaper) featured a sentence that gave me a double take; it was,

"The president has said he wants a path to universal coverage."

A path is not an end-game or an outcome: it is a process, a journey. I believe that Orszag, the head budgeteer and Director at the Office of Management and Budget, carefully chose the word "path" for the interview with the FT.

The context for this is the deficit. When he was a Fellow at the Brookings Institution, Orszag told the City Club of Cleveland in a speech nearly five years ago in July 2004 that Medicare costs were the most significant driver of the long-term fiscal ill-health in the U.S.

Five years later, he tells the FT, "We have been very clear that a deficit-increasing health-care reform is neither practical nor desirable."

Health Populi's Hot Points: While Orszag said in his interview, "There are different ways of putting us on a path to universal coverage," the uber-force isn't universal coverage -- it's slowing down costs, or dare I say, "cost control?"

Orszag (and Obama, since Orszag speaks about these issues on the President's behalf) is transparent about this reality. Embracing this priority can help stakeholder organizations in U.S. health care focus on plans that rationalize services and technologies, optimize cost-effectiveness, and deliver quality outcomes to as wide a population as practical. Health plan-service-product planners and marketers should adopt this lens on innovation for current projects in the pipeline and, especially, for new-new market introductions.

Recession economics of the family physician

1 in 2 family physicians is seeing fewer patients since the recession began in January 2008.

At the same time, 3 in 4 physicians have seen an increase in the number of uninsured patients.

Patients who are covered by employer-sponsored insurance and private health plans are in short supply.

Welcome to the new health economics for family physicians, where there are more patients without health insurance, more Medicaid patients, and more Medicare patients.

As a result, patients are:

- Telling family physicians about concerns over ability to pay for health care
- Cutting prescription dosages
- Cancelling appointments
- Forgoing needed preventive care.

These unhappy, unhealthy findings come out of a survey by the American Academy of Family Physicians, Patient Care During the 2008-2009 Recession, published in May 2009.



Health Populi's Hot Points: The financial bottom-line for family physicians in that more doctors are providing care that's unpaid.

In this recession, 71% of doctors are providing more uncompensated health care.

As a result, 44% of these doctors are forced to cut, or consider cutting, services for patients as well as reducing staff.

In a time when primary care must be bolstered, encouraged, enhanced, and nurtured, this is the worst possible reality. The Primary Care Medical Home is seen by many of us as an important model for driving more effective, cost-efficient patient-centered care. But without aligning payment and performance, the primary care supply of physicians will erode.

The Preserving Patient Access to Primary Care Act, introduced by Rep. Allyson Schwartz in September 2008, would go a long way to addressed the primary care shortage. Passing this bill would help to balance one of the legs of this very shaky stool.

There's an important essay in the May 20th 2009 issue of the New England Journal of Medicine, Achieving Health Care Reform — How Physicians Can Help, by Fisher, Berwick and Davis, that asks physicians to be front-and-center in practical health reform. One solution would be for providers to link up in accountable care organizations that integrates health care, aligns incentives and uses new payment models for patient care. Such population-based payment models put primary care at the center of patient care--exactly where it belongs.