Swimming pools and supermarkets -- recipe for health

This week's Forbes magazine features a story on Americas Most Sedentary Cities. Translation: which cities in America have the highest levels of obesity, and why?

The answer to "why?" is a complex but understandable interaction between several factors: suburban sprawl, lifestyles of convenience, and some local factors that vary city-by-city.

It turns out that transportation planning and the larger context of urban planning -- or lack thereof -- are contributing mightily to our lack of exercise and communities' 'walkability.' Research is finding that the lack of greenspace and parkland in a community contributes to sedentary lifestyles and, thus, obesity.

The Forbes team researched the 20 most sedentary, and thus most "sloth-y," cities. In spots #1 and #2 are Memphis and New Orleans (I know, I know, I'm a foodie, too...just fantasizing about the wonders of BBQ and Paul Prudhomme as I type the names of those two offending food meccas).

Forbes analyzed 2006 data from the CDC's Behavioral Risk Factor Surveillance System including body mass index (BMI) and physical inactivity. The team married data from Nielsen on the number of hours of TV watched per week by metro area.

While obesity has spread as quickly as urban sprawl -- a major contributor to the epidemic -- the factors that cause obesity can be very specific to a community. Forbes found that in New Orleans after Katrina, a lack of supermarkets has led to citizens relying on small convenience stores for junk food-laden daily fare.

Memphis's combination of southern cuisine and most-watched hours of TV, coupled with a higher proportion of people who don't exercise, has led to its high obesity profile.

The British organization SmarTrans has done a stellar job organizing some of the latest research into the relationship between suburban sprawl and health. Take a look at the article, Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet, in the November 2007 issue of Social Science and Medicine. Mai Stafford and her colleagues found lower levels of obesity in areas with more swimming pools and supermarkets.

Health Populi's Hot Points: City and transportation planning play large, and often unrecognized, roles in supporting public health. These planners set the environmental context for daily living. These functions are generally siloed away from health policy makers. In focusing on the public's health, we should make sure to include all relevant stakeholders at the table who influence and positively promote healthy lifestyles. The case of obesity in the US is a prime example of the complex interactions between lifestyle, local and household economies, and community environment.

CVS Ad Targets Caregiving Women -- Comforting or Condescending?

Women determine the bulk of health spending in American households. Furthermore, caregiving women can be passionate health care consumers. CVS is tapping into this consumer segment through its ad campaign, For All the Ways You Care.

Part of this campaign asks women to share their caregiving stories online. CVS hopes to make this website a viable online community that will support caregivers (and of course, drive traffic into the store).

The TV ad plays the sweet song, "Ordinary Miracle," as a soundtrack to the caregiver's storyline. (This song was part of the recent remake of Charlotte's Web. A bit of music trivia: the lovely song was co-written by Dave Stewart of the Eurhythmics).

Bob Garfield, Advertising Age columnist and media pundit, wrote in a column this week that this ad is a demeaning, Disney-esque and too-saccharine a portrayal of women.

Judge for yourself; here's the video: http://www.forallthewaysyoucare.com/videos/ . Let me know what you think by leaving comments to this post, below.

Health Populi's Hot Points: I'm a woman, I'm a caregiver, I live in the northeastern U.S., I have a post-graduate education, and I like this ad. CVS is speaking to the sandwich generation. Women age 35 and upward are going through the push-and-pull of caregiving, particularly those who work both in- and outside of the home. CVS is tapping into an ache that lots of us feel, at least occasionally. The song plays viscerally on that feeling.

The Importance of Being Iowan; an early snapshot into voter feelings about health care

Iowa gained early-bird status for primary season as it set the date for its caucus as early in the new year as it could: January 3, 2008. A new survey indicates that Iowans are restless about health care.

CodeBlueNow!, a consumer-led health advocacy group, sponsored the Iowa survey as part of its "Pulse" research program.

Iowans believe that (1) health care services should stress disease prevention over high-technology cures, (2) more public accountability is needed in how health care dollars are spent, and, (3) "basic" health services should include access to any licensed health care professional. While the survey results revealed no solid consensus among voters on how to pay for services, they also indicate no strong preferences for either government run health care or personal responsibility, leaning instead for shared responsibility.

In fact, Iowans have little confidence in the very groups that have the power to change the system. Only 22% trust the federal government to fix the system, and only 12% expect that the presidential election will kick off a new vision for health care in the U.S.

When it comes to presidential candidates' proposals, Iowans believe the Democrats have the most meaningful plans (38%). Just 15% say Republican candidates have the best proposals.

Who's trusted to design a new health system? Health care professionals and non-profit organizations are way ahead of business professionals, federal government, and academic institutions. A resounding 65% of Iowans would support a non-partisan, non-profit civic organization composed of regular citizens.

Health Populi Hot Points: Who knows better than those who work in health care, up-close-and-personal, along with patients/consumers and their caregivers, on what's needed to change health care in America for the better? Whether Iowans represent the national opinion, there's clearly major cynicism concerning the federal government's ability and trustworthiness to fix the health system. What is that old saw about voters getting the government they deserve? If that's so, perhaps the 2008 elections will yield a more worthy electorate.

Colds, kids and labels

Over-the-counter medicines (OTC meds) don't cure colds in kids. The FDA has spoken, and said that the kinds of kid-targeted medicines photographed on the right aren't only useless -- they can be dangerous.

The offending incredients are dextromethorphan, used in cough suppressants; pseudoephedrine and phenylephrine, used in decongestants; guaifenesin, an expectorant; and, brompheniramine, chlorpheniramine maleate, or diphenhydramine, used in OTC meds labelled as antihistamines.

If ever there was a time for a parent to get into label-reading, it's now. The good news is that more of us are reading labels, according to the Hartman Group, the food and wellness research group. But Hartman's research is into reading food labels, and not necessarily reading medicine labels.

Hartman says that, "the depth of interrogation increases as consumers become more active in health and wellness lifestyles."

The challenge is that labels for OTC meds can be tough to read. In fact, basic medical instructions are hard for many adults. "Even those who are most proficient at using text and numbers may be compromised in the understanding of health care information when they are challenged by sickness and feelings of vulnerability," according to the Joint Commission in their report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety. When your kid is sick, you as a parent can indeed feel vulnerable.

The savvy consumer goods retailer Target has won awards for its prescription drug label and ergonomically sound packaging. OTC products that are in front of the pharmacy counter don't require the intervention of the pharmacist for dispensing. However, with OTCs, the consumer is on her own. OTC labels should be as consumer-friendly and helpful as Target's Rx labels.

In the meantime, as a mother of a child who will inevitably be getting a cold this season, I like this smart advice from Wegmans, the family-owned grocery chain...

Hugs and Other Non-drug Support
You can help your help your children feel better in other ways, too -- especially making sure they feel loved and cared as only you can:

1. Give them a daily multi-vitamin to support their immune system.
2. Have him or her drink plenty of fluids. This helps to thin mucous, making it easier to expel.
3. Be careful to avoid giving caffeine-containing drinks during a cold or the flu, as the diuretic effect of these can counteract the benefits of fluids.
4. Use a moisturizing nasal spray to ease dry or itchy nasal passages.
5. Remember good old Vick's Vapo-Rub? Rub a little onto the child's chest and let the vapors loosen up the congestion. Soon, your child may be breathing easier, and without so much as one teaspoon of medication introduced into their system.

Health Populi's Hot Points: Slow down and ready the label. As The Hartman Group recognizes, consumers' interest in label-reading increases with their level of engagement in healthy living. When it comes to caring for kids, there are no good excuses for parents not getting engaged.

Declining income, declining health care

Health and wealth are intimately related. This week's (October 24/31 2007) Journal of the American Medical Association (JAMA) is devoted to poverty and human development. Another important publication this week highlights the relationship between income and health: EBRI has just published its the 2007 Health Confidence Survey, the Institute's tenth annual report on how Americans perceive the US health system. Together, these two documents shine a light on the health/wealth relationship. This relationship holds true whether we're talking about rural India, Zambia, Beijing, east LA or Ames, Iowa.

In JAMA, take a look at Dr. Steven Woolf's commentary, Future Health Consequences of Current Decline in US Household Income. Dr. Woolf wants to alert health professionals about three income-related realities in the US that will impact the US health system and individuals' health status: increasing poverty rates, decreasing household income, and widening income equality (that is, the gap between rich and poor). Dr. Woolf notes that, "even modest reductions in income among more affluent persons can also influence health." He goes on: "It would be easy to succumb to the misconception that this threat endangers only a small, highly disadvantaged segment of the US population." Ultimately, the decline in income is likely to "intensify demands on the health care system," Woolf predicts. In particular, Woolf notes that obesity is more prevalent among those with lower incomes, so the ripple effects on the health system will be very significant in the future. Woolf concludes that, instead of expanding health system capacity and government intervening in job growth, investing in education may be the most important strategy for addressing poverty's impact on health in America.

EBRI's report presents data on health cost increases negatively impacting Americans' household finances. Specifically, higher health costs have caused Americans to decrease contributions to retirement investments and other savings plans. We know millions of Americans have been "dissaving" since 2000; see my blog post earlier this week on Plastic's Growing Role in Health Care. The best way to save for retirement is to put away consistently, year after year.

"Never underestimate the power of compounding and saving consistently," Constanza Low, Vice President of Knickerbocker Advisors, advises. "The impact of diverting money from your savings is huge in the long run. Save just $5,000 less per year and 20 years later you will have shortchanged your own retirement by over $250,000 (assuming an average annual investment return of 9%). Save $10,000 less a year and you will have shortchanged yourself by over half a million dollars!"

Health Populi's Hot Points: Health security is about every American, not 'just' 12.3% of Americans who live below the poverty level. Dissaving will do a disservice to health care for our children and ourselves in retirement. We must boldly invest now for the future. This isn't socialist planning. This is survival time.

The theme of health and poverty is featured in over 200 science and health journals this week. Thanks to Larry Stillman of the Applied Statistics Laboratory in Ann Arbor for the heads-up.

The heart of marketing? DTC and stents

No one doubts whether Johnson & Johnson is a crackerjack consumer health marketer; can this expertise inform how well the company does going direct-to-consumer (DTC) with medical devices?

Now that DTC advertising has matured for the pharmaceutical industry, the medical device industry has begun to stick its toe in those promotional waters. Earlier this week, I saw an ad for a medical device -- one of the first I can recall.

The specific ad was for a stent. This is intriguing because stents have come under tremendous scrutiny since the FDA began re-examining the safety of drug eluting stents in 2006.

In the past year, there have been several peer-reviewed papers published, pro- and con-, on the safety of stents. So it's with some chutzpah that Cordis, the J&J unit that markets Cypher stents, has launched a direct-to-consumer promotional campaign to bolster sales of the stent. No doubt, the consumer strategy is aimed at reversing the declining sales of Cypher; the company reported this week that Cypher sales fell 44% in the third quarter '07 versus one year ago, and sales were down 12% from second to third quarter this year.

To complement the campaign to consumers, a paper supporting drug-eluting stents (DES) was presented this week at the annual conference of Transcatheter Cardiovascular Therapeutics 2007. The paper demonstrated that the introduction of DES was associated with reduced health care costs while providing improved clinical outcomes vs. the "pre-DES era."

The researchers calculated that even though DES procedures are initially higher cost, total spending for patients fell by over $1,900 per patient by avoiding surgery downstream. Note that this study was funded by Cordis.

Health Populi's Hot Points: It is early days for DTC and medical devices. Promoting devices to consumers that require a surgeon's or specialist's intervention doesn't have a clear-cut ROI. The Cypher promotion assumes that consumers will request the device by name in the same way they might ask a doc for a particular statin or allergy drug. The stent, though, is another step removed from the consumer's ultimate consumption. Furthermore, as an investment, the cost of national ads for a procedure that applies to about 700,000 Americans annually seems like a very inefficient, poorly targeted, expensive per-patient spend. But the market for DES was valued at $5 billion in 2006, and so perhaps an aggressive campaign is justified in the eyes of J&J.

Plastic's growing role in health care

There are many forms of plastic in health care. No, I'm not talking about new polymers used for medical implants. I'm talking about financial services.

A new card from Humana and Republic Bank illustrates the continuing integration of consumer personal finance and health care. The new VISA card, private labelled as the HumanaAdvance card, will be offered to Humana's employer groups for enrollees to use at hospitals, doctor and dentist offices, drugstores and other locations providing health-related products and services.

Of course, as with all plastic, this card comes with its own fine print: 0% interest rate (APR) on purchases paid over six months. What happens after six months, the press release doesn't say. The card can be used in conjunction with health savings accounts. Republic's press release empathizes, "We understand that consumers need to bridge the gap on their healthcare expenses and believe our Card is a perfect solution that allows consumers to better budget for their healthcare costs while more easily paying for them over time." For Humana's enrollees who regularly fund their HSA and track expenses, this will be helpful.

But the use of plastic isn't always healthy, at least financially speaking. There's a growing use of plastic in health care. As plastic's role in health grows, so does medical bankruptcy. Comptroller General David Walker told a meeting of the Federation of American Hospitals in March that, "If there's one thing that can bankrupt America, it's health care." Credit cards are enabling medical bankruptcy.

About one-fifth of low- and middle-income households with credit card balances cited significant medical expenses as a reason according to Demos and The Access Project, who conducted a study into medical bankruptcy earlier this year.

A growing number of Americans, most notably seniors, use credit cards and lines of home equity to pay for medical care in the U.S. Among households ages 65 and older, the average amount of credit card debt more than doubled between 1992 and 2004 to $4,907. Bankruptcy filings in recent years have increased among seniors at a higher rate than among any other age group. Seniors 65 and older represent the fastest-growing group seeking bankruptcy protection, though they made up only 5% of all bankruptcy filers as of 2001.

In their study, Demos and The Access Project said the number of patients using credit cards to pay their medical bills is expected to rise as employers increasingly shift insurance expenses to workers who already face larger insurance copayments and higher deductibles for medicine and treatment.

"The healthcare safety net is made of plastic -- its called 'credit cards' for many people," said Mark Rukavina , director of Access Project, which is affiliated with Brandeis University. "It's a pretty frightening prospect."

About half (48%) of adults in middle-income families ($35,000 to $50,000 annual income) reported serious problems paying for health care and health insurance. In fact, health care costs are now stretching budgets even for those with higher incomes.

One-third of adults with family incomes between $50,000 and $75,000 a year, and one-fifth with incomes over $75,000 report serious medical bill problems, according to PNC Wealth Management. Wealthy people increasingly believe paying for health care will eat through their assets. Forty-three percent of individuals with at least $500,000 in assets said that health care costs will consume a major portion of their wealth, up from 37 percent in late 2005, according to PNC.

Health Populi's Hot Points: The graph on the right dramatically illustrates the drastic decline in personal saving rates in the US. Note that in recent years there was "dissaving" -- economists' phrase when spending is greater than income. In dissaving, money can come from personal savings such as money in a savings account, or it can be borrowed. Such borrowing can take the form of credit card spending when the balance isn't paid off in 30 days. Expect more dissaving, and personal bankruptcy, as Americans age and haven't saved enough to pay for medical expenses that won't be covered by health plans.

Zagat comes to health care

Love the doctor's exam room manner, hate the wait in the anteroom? Know the customer experience before you visit your doctor once the first round of Zagat's ratings for WellPoint physicians get published in March 2008.

Zagat is a well-known brand for reporting consumers' reviews of restaurants, hotels, and spas. The famous report card publisher now comes to health care, specifically to WellPoint, the largest member of the Blue Cross and Blue Shield Association.

Instead of ratings on decor, food, service and pricing, Zagat will review WellPoint physicians on availability, communication, trust and office environment.

Like the Zagat guides on hospitality, the WellPoint physician reports will include anecdotal quotes from patients. And just like the city-based series of reports for foodies and travelers, all data in the Zagat's WellPoint reviews will be consumer-generated.

Based on the fact that the data will be based only on patient-generated surveys, Zagat says that their reports will not include information about "medical expertise" (would that mean quality and outcomes?) or malpractice settlements.

WellPoint covers 34 million Americans in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin.

Health Populi's Health Points: Thumbs-up on the first phase of the Zagat-WellPoint concept. However, what consumers really want to know about is price and outcomes. This project is a good start with a trusted consumer brand. In v.2.0, more robust data on pricing and "performance" (specifically, medical mistakes and quality measurements) can and should be integrated in the reporting system.

The Future of Retail - Implications for Health

I've been looking at health care through a retail lens for some time. Perhaps it's that I'm a rag trader's daughter, or that I've been known to like shopping, that I have clients in consumer goods, or that I understand how tiered drug pricing impacts the consumption of medicines (answer: it's all of the above).

I've just reviewed the latest trend report from PricewaterhouseCoopers and TNS Retail Forward on the future of retailing. My mind is connecting the dots between the future of retail and the American health care consumer. Four future retail trends are already embedding in health care @ retail: In Control, Glocalization, Pervasive Technology, and Consumer-as-Cocreator.

In Control. PWC and TNS forecast that consumers will be increasingly good at controlling the ways in which they interact with others. According to PWC and TNS, consumer control will come from clout (where consumers exercise collective strength with others), context (when consumers time- and place-shift where and when they interact with marketers) and contacts (enabling consumers, through the use of filtering mechanisms, to grant access only to those with whom they desire to interact). We already see the influence of consumer clout today with patient advocacy; we're in the Pink Month of October, for example, where the clout of many people has come together to raise awareness for breast cancer. Context control means that consumers will be time- and place-shifting where and when they want to interact. An example would be a patient emailing her physician in the evening after business hours and receiving a response when she looks at her email in the morning.

Glocalization. While we tend to think of health care as a local good, the boundaries around that are changing. We see the growth and legitimacy of medical tourism to the point where The Joint Commission on Accreditation now audits hospitals in Thailand and India frequented by Americans in search of less costly care. Radiology networks are forming to cover digital reading on a 24x7 basis. And all sorts of health information is, of course, accessible by anyone online, anywhere.

Pervasive technology. Health (especially health care) is no stranger to technology. But the pervasiveness of technology in health is upon us. Wireless networks and miniaturization are enabling continuous monitoring for chronic disease management, and standardization is accelerating the development of more pervasive technology in health. Smart agents will play a significant role here.

Consumer as co-creator. Consumers are helping to design new products; see P&G's approach to new product development involving consumers for more on that future, today. In health care, consumers can be co-creators of health. Yet several external forces often constrain an individual's ability to co-create health. Among these, third-party insurance coverage and the traditional physician-patient relationship with its asymmetry of information have prevented consumers from realizing their full potential as co-creators of their own health. Those constraints are loosening. In co-creating health, consumers will use whatever channels and tools they find useful -- customizable and personalizable. Consumers diagnosed with a new illness may find themselves involved in R&D with a biopharmaceutical or other research organization -- many do now when they consent to be part of clinical trials. These activities will become ever more targeted, personalized and transparent.

Health Populi's Hot Points: The new retail environment for consumer products has direct implications for consumers in health care. Control, co-creation, technology, globalization...these forces are, together, shaping some consumers' approach to health in the current market. By 2015, these forces will be part of the health landscape in which providers and marketers will compete, and where patients will behave more like...consumers.

Disappearing docs, and the new house call

By 2010, nearly 50% of doctors between 50 and 65 years of age will be cutting down on doctoring – choosing to retire, work in non-clinical jobs, go part-time, or close their doors to new patients.

The loss of this wise cadre of clinicians to the physician supply could exacerbate a forecasted shortage of doctors in the U.S.

Overall, 24% of the older physicians will opt out of patient care within one to three years, and 14% will completely retire.

These sobering results were published in the 14th annual survey of Merritt Hawkins & Associates, a physician recruiting firm, in the 2007 Review of Physician Recruiting Incentives.

Younger docs, those under 50, are making different work/life balance choices. Older docs, according to Merritt Hawkins, see their younger colleagues as less dedicated/less hard charging than they were at the same age.

The bottom line is that most older docs would not recommend medicine as a career to young people today.

Health Populi's Hot Points: The AMA, the Council on Graduate Medical Education (COGME), and the Association of American Medical Colleges (AAMC) have predicted medical shortages. But their forecasts have not anticipated the level and momentum of physician exodus that Merritt Hawkins has found. Younger physicians are indeed searching for more balance in their lives. This is translating into several marketplace phenomena: motivation to join group practices and hospital-based employment; segues into non-clinical employment or jobs in the health care industry that don't require front-line patient care; and, entry into concierge-style practices that give the physician direct patient access without the 'intrusion' of third-party insurance in the practice of medicine on a daily basis. Whether this model can sustain a practice with middle-income patients (especially the uninsured) remains to be seen. For now, the concierge practice is firmly focused on well-heeled clientele.

Who Are Uninsured People?

Where you live, who you work for, and what color you were born are predictors of whether you have health insurance in America.

New data from those hard-working, non-partisan researchers at the Employee Benefits Research Institute (EBRI) have published their latest portrait of insured, and uninsured, Americans. The report is based on data from the March 2007 Current Population Survey of the U.S. census. For the details, see EBRI Issue Brief No. 310, October 2007.

Geography is destiny as a factor for being insured. The highest level of uninsurance is in the south central US, where about 20% of the population lacked health insurance in 2006. EBRI points out that in many of these states, lower average income and higher unemployment rates contribute to uninsurance. States with the highest percentage of uninsured include Arizona, Florida, Oklahoma, New Mexico, and Texas.

Race and ethnicity are factors in uninsurance. White people are more likely to receive employment-based health insurance than people of other races. EBRI notes, “Even after controlling for poverty status, whites nearly across the board were more likely to have employment-based coverage than other races/ethnicities.”

Occupation type determines whether you’ll have health insurance. Uninsured workers were most likely to be employed in the wholesale and retail trade or service industries, which collectively account for 55% of jobs in the U.S.

Size (of employer) matters. If your employer is large, you’ll more likely get offered health insurance than if your employer is small. Large employers can provide health benefits at a lower cost than small employers because they cover the health risks of more people – and thus, are subject to less adverse selection. The costs of plan administration and marketing are also lower for larger companies.

Self-employment is a precursor to being uninsured. Nearly two-thirds of uninsured workers are self-employed or in small companies with fewer than 100 employees.

Health Populi's Hot Points: New job formation tends to be among smaller companies, and smaller companies don't tend to offer health insurance due to the "size matters" metric. Those of us who bravely start new businesses on our own, the self-employed cadre of which I've been a member for 15 years, are at a lonely and financially draining disadvantage when it comes to finding and funding health insurance on our own. And the continuing challenge of health disparities between white Americans vis-à-vis non-white Americans is alive and unwell in this sad saga of uninsurance in America.

My home, my hearth, my health

Yesterday was one of those days you want to bottle: perfect, crisp-as-an-apple autumn temperature, long walks through New York City between meetings, meaningful discussions, on-time trains.

I spent most of the day talking and thinking about home and hearth and health. I savored lunch at the delectable and health-ful Josie's East restaurant in Murray Hill, NYC, with a client/colleague who values home, hearth and health as much as I do.

On the train ride home, I delved into the latest (November/December 2007) issue of Blueprint, part of Martha Stewart Living Omnimedia. The magazine's tagline is Design Your Life. While I had mentally placed this magazine in the category of home decor and cocooning, I realized between the fine print that the "Design Your Life" mission includes furniture, cooking, and...health.

I was surprised, then delighted, to encounter an article authored by a Murray Hill-based (!) physician, Dr. Amy Bleyer, suggesting ten little things we can do to improve our health. These range from drinking a cup of tea in the morning (her choice, Tetley; mine, Mighty Leaf Green Tea Passion) to taking your vitamins. All, small movements, micro choices.

And, of course, smart food choices. To bolster the theme of Home/Hearth/Health, go read the September issue of the Journal of Nutrition and Education Behavior. The focus of the issue is "eating competence." The article by Shira Feldman, et. al., on watching TV during family meals is illuminating: "Adolescents watching television were found to have lower intakes of vegetables, dark green/yellow vegetables, calcium-rich food, and grains and higher intakes of soft drinks compared to adolescents not watching television during meals. However, watching television during family meals was associated with a more healthful diet than not eating regular family meals."

We come full circle, then: health is, ultimately, a function of home and hearth.

Health Populi's Hot Points: Our health doesn't just come from the calories stocked in your larder. It comes from the many small choices we make each day. Look at your night table, your medicine cabinet, your commute, your morning beverage. Is your dinner table one focus of your family life? Connect the dots between these small moments-of-truth. Small changes can translate into big improvements.

To learn more about the health benefits of tea, see this article in USA Today.

Beyond tooth whitening: the decline of oral health

For 50 years, the oral health of Americans had been improving. By 2004, the trend reversed.

The state of oral health in the US is on the decline, with 100 million people lacking dental insurance and cavities going unfilled. This, while so many millions are spending on tooth whitening and breath freshening.

Oral health is an integral part of a person's overall health. According to the Academy of General Dentistry, there is a relationship between gum (periodontal) disease and heart disease. A recent study on periodontal disease and atherosclerosis confirmed this finding. flossing showed evidence to support flossing to fight disease. Over 90% of systemic diseases (those that involve many organs or the whole body) show up in the mouth cavity first: dry mouth, mouth ulcers, swollen gums.

This is serious business: systemic diseases include cancer, diabetes, heart disease, kidney disease, and leukemia.

While we've seen a degradation in the state of American oral health, we've also witnessed dramatic growth in consumer-facing oral health retail categories: a proliferation of new toothpaste flavors, from vanilla to cinnamon and citrus; and, the emerging category of "mobile" oral health, products for taking care of teeth on-the-go such as Oral-B Brush-Ups, and my personal favorite, Listerine PocketPaks breath strips, based on that great dissolving strip technology.
And don't forget the growth category of home whitening systems, which now exceeds a $1 billion market.

Yet while many of us have been whitening and brightening, millions of Americans aren't spending much on oral health. The chart on the right comes from a New York Times analysis based on just-released data from the CDC. It indicates that after improvements in oral health, a growing number of kids and adults are going with untreated cavities.

Poverty is directly correlated with poor dental health. See this study from the Journal of Epidemiology and Community Health from February 2007 for more on that relationship.

The Times pointed out an example of what happens when people don't attend to oral care: "A child in Mississippi and another in Maryland died this year from infections caused by decayed teeth."

This is a public health issue that we all pay for in the form of much higher costs in emergency room visits, systemic disease and lost human lives.

Health Populi's Hot Points: Access, my friends, access, is the point. Because dental care is a health care service that is paid for by millions of people 100% out-of-pocket, those people with lower incomes often go without primary dental screening and simple procedures such as cavity-filling. While we're increasing spending on tooth whitening and citrus-infused breath mints, these are not equal to sound primary oral care. People with lower incomes could access dental care if there were practitioners available to serve them at a relatively reasonable price point. With a dentist shortage predicted, it's time to open up the professional dental market to new practitioners, much as we've begun to see occur with nurse practitioners operating in retail health clinics. The Robert Wood Johnson Foundation wrote about this in 2002; it's five years since they made their recommendations. More than time enough to know we must welcome and train a new mid-level dental practitioner akin to a nurse practitioner or physician’s assistant.

A Broad Vision of Health 2.0: an invitation to dialogue!

/Health20%2010-12.ppt

Before you start reading, download the document above. It's a single PowerPoint slide that's animated to build. Go into presentation mode, then read along with the narrative below.

A Broad Vision of Health 2.0
Reformulating Data for Transparency, Decision Support & Revitalized Health Care Markets

Brian Klepper and Jane Sarasohn-Kahn

The term Health 2.0 refers to the concept, described by O’Reilly, of Web-based platforms that allow users to reformulate data for their own purposes. The Health 2.0 movement is rapidly gaining steam and traction, propelled by established and startup firms. The efforts displayed at the recent Health 2.0 meeting in San Francisco, convened by Matthew Holt and Indu Sabaiya, were both wide-ranging and narrowly focused. Even so, several end-of-day panelists noted that, at this early stage, Health 2.0’s definitions and translations into practice remain murky and fragmented.

We thought it might be useful to try to develop an image of how Health 2.0 MIGHT develop: what its working parts were, what kinds of information it would receive and generate, who its users would be and what its impacts might be. The image that has resulted is simplistic; it doesn't try to explore any of the underlying mechanisms necessary to pull this off. But it does try to convey a vision of how innovators might come together to aggregate and reformulate large data sets from disparate sources to create tremendous new utility in the marketplace for patients, clinicians and purchasers of all types.

We are posting this image on the various sites where we write – others are welcome to post it as well – as an exercise. Where is the structure wrong? What are we missing? How can this be made clearer, stronger, more faithful to our best hopes for where health information management might take us? Let us hear from you, and we'll update the image as we collectively think through the issues involved.

One caveat. Please note that we have not included back-office operational functions in this chart. While it is entirely possible that these too will ultimately be managed through Web-based processes, they are by definition the most proprietary business management tools and therefore the least susceptible to sharing.

Thanks much for working with us on this.

Now let's look at what we have so far. Open the PowerPoint file and go into presentation mode. At the top you should see the title, "A Broad Vision of Health 2.0," and the subtitle "Reformulating Data for Transparency, Decision Support & Revitalized Health Care Markets." Our names are listed at the bottom left.

Now click once (or you can hit the space bar or the right arrow), and the first element should appear. These are:

The Data Sources - claims, clinical encounter data, drug, lab, image - that can be captured and mapped to a common format, like ASTM’s Continuity of Care Record (CCR). (click)

A Centralized Data Repository (CDR), which is designed to receive, aggregate and securely house large data sets. (click)

Above the CDR are several Tools, each focused on a different health care stakeholder. We've listed four big ones here, in descending order from the center of the system (that is, the consumer/patient) downward. First is a Vendor Management tool to help purchasers manage vendors. The term "vendor” is used very broadly here, because, in the continuum of care, nearly everyone is a purchaser, vendor, or both. Employers buy health benefits from health plans that in turn contract with doctors, hospitals and other care providers. Doctors and hospitals buy drugs, devices, supplies and many other products and services, and so on. One of health care's most vexing problems has been that most purchasers have had very little information to help them decide which products and services offer the best value. As Health 2.0 creates greater pricing and performance transparency for products and services, as well as decision support tools that can help purchasers make sense of complex information, these forces may go far to help health care work as a functioning market, driving tremendous new efficiencies and smarter purchasing decisions.

Individualized data flow from the CDR to the Electronic Health Record (provider-oriented) and Patient Health Record (consumer/patient-facing). Once analyzed, individualized and de-identified data flow from the CDR to the appropriate tools. (See below.) (click)

Next are the Health Management tools that will be used by health care professionals who manage patient care outside clinical settings. These might include the staffs in demand, case, disease and wellness management operations, whose interventions are focused on (1) monitoring health status and the vectors that impact it, (2) cultivating positive behavioral change and, (3) coordinating the care delivered by constellations of clinical providers. (click)

The Electronic Health Record (EHR) is the hub of patient management within the clinical setting, and should be understood here to be not only an expansive repository of patient information (ultimately with room for gene maps, family histories and information about alternative care maps), but a complex of tools that includes clinical decision support, health plan rules, product/service pricing, and so on.(click)

The Patient Health Record (PHR) is a lay reflection of the more robust EHR, with linkage to tools that are aimed at the consumer’s self-management, including guidance on when to seek professional expertise. (click)

Analytics are applied to the data in the CDR to reveal patterns, to evaluate patients’ health status, and to identify the desirability of different clinical and vendor choices. For example, the:

o Relative pricing and performance within and across regions of physicians by specialty, and hospitals by services,
o Relative pricing and performance of drugs and devices within class and by vendor.
o Identification of patients with specific risks.
o Identification of more or less effective diagnostic and treatment pathways.

There are several well-accepted, widely-used analytical classification and risk adjustment tools in the market, e.g.: ETGs, CRGs and DxCGs. These algorithms permit unbiased comparisons among providers, patients and treatments and facilitate identification of patients at risk, as well continuous updating of clinical and administrative best practice.

These tools allow decision-makers of all types to evaluate professionals, organizations, products and services in the marketplace. So it is critical that all health care stakeholders find the analytical processes trustworthy, credible and open to scrutiny. This is why it is so important that the methods used to achieve transparency be transparent as well. (click)

Now comes the first result of the analyses, Identifying Patients At Risk. These might be patients identified with chronic conditions; they could also be patients with signs or symptoms predicting genetic anomalies or acute conditions. Information about the patients identified during this process would be forwarded to their EHRs and PHRs, as well as to the Health Management tool, so they can be contacted and, possibly, receive health interventions. (click)

By receiving a continuous flow of data, by constantly watching for best clinical and financial outcomes for specific conditions and purchasing processes, and by working “backwards” to identify the common pathways that led to those outcomes, the analytical tools could presumably Identify Best Practice Guidelines. These, in turn, could be passed along to and embedded in the EHRs, Health Management and Vendor Management tools, each in formats that make sense to the tools' different users. This becomes a continuous improvement process. (click)

The third major result of the analytics, Pricing/Performance Transparency compares the relative pricing and performance of four major health care product/service classes: Providers, Payers, Products (Drugs, Devices, Equipment and Supplies), and Interventions/Treatments. (click)

The information produced by the Pricing/Performance Transparency functions are distributed into two ways. First, they become readily available to stakeholders of all types through Public Reports, distributed by the host or by any other public or private group, and made available through the tools to purchasers, health managers, clinicians and patients. Again, to be credible, public reporters must be scrupulous and transparent in their evaluation methodologies. (click)

The findings of the various Pricing/Performance analytics can also flow into constantly updated Decision-Support Tools, which are adapted to the needs of purchasers, health managers, clinicians and patients. (click)

Decision Support is also informed by input from Expert Content – e.g., current knowledge on efficacy and value from the health care literature, medical encyclopedias, and best practice guidelines. (click)

Finally, the PHR and patient decision-making are enhanced by User-Generated Content, guidance from patients and caregivers who have dealt with the condition in question, information about health or treatments that might not be contained in the current record, individualized search results, and other relevant information.

It is not difficult to imagine that, as these various functions come together and are integrated into continuously refined applications, the impacts on the health care marketplace could be profound. The inability to see and know the results of health care processes has created an opportunistic culture that pervades every part of the continuum. The unprecedented transparency that will result from these, as well as the decision-support capabilities for patients, clinicians, health managers and purchasers, should go far in finally helping health care begin to adhere to the same rules that govern other markets. When stakeholders can make informed decisions, based on solid data, the impacts on cost and quality could be transformational.

Some key questions remain. Does this model represent what is possible and likely to occur? Can the organizations working to integrate these functionalities access the data required, and will they be capable of developing or acquiring the various processing elements incrementally? Will certain stakeholders, knowingly or tacitly, work against the ultimate objectives of this model?

We’re optimistic, but time will tell.

The cost of health illiteracy = 47 million uninsured

The annual financial burden of health illiteracy costs between $106 and $238 billion. This is enough money to cover the 47 million uninsured people in America.

That metric, and many other insights, were published this week in an important new report called, Low Health Literacy: Implications for National Health Policy.

The report was written by Dr. John Vernon, a professor of finance at the University of Connecticut, and three colleagues from the University of Central Florida, George Washington University, and an executive from Pfizer. This research was sponsored by Pfizer, which has been promoting health literacy as part of the "Ask Me Three" campaign, a program of the Partnership for Clear Health Communication at the National Patient Safety Foundation.

Health literacy isn't the same as literacy, per se; health literacy is the ability to read and comprehend literature that is health related. Thus, many more people are health illiterate than simply illiterate.

The report offers two broad health policy recommendations.

1. Eliminate disparities in health insurance coverage.
2. Improve how health plans and providers interact with patients.

Health Populi's Hot Points: Health literacy is a profound driver of escalating costs in US health care. The Ask Me Three campaign offers actionable suggestions on how patients can more engagingly and effectively interact with health providers and plans; the three key questions for a patient to ask are,

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

Providers (especially physicians) can download patient-friendly materials from the Askmethree.com website to share with their patients. Plans can join the movement and get smarter about helping their enrollees to become better, more enlightened health care consumers.

Cobbling together a new plan for financing national health reform without attending to this basic, uber-health issue won't solve the problem of getting consumers to be able to better manage their health care, outcomes, or costs.

The grocery store as health destination

We love new food products, as evidenced by the ever-growing array and permutation of new goodies at our grocery stores. Among those who say new food products are important to them, the top reason why they buy new food products is health.

Open your eyes when you're next grocery shopping and look around you -- your favorite grocer is morhping into a health destination. Whole Foods has launched its Whole Body store-within-a-store concept. Wegmans offers their Eat Well Live Well program. Even Wal-Mart, home of the $4 generic drug price-point, has begun to offer organic food based on demand according to location.

But health isn't marketed only in the health-and-beauty aisles.

Hartman Group's Consumer Interest in New Products in Supermarkets survey was just released, and it's chock full of insights into consumers' relationships with food shopping. Three-quarters of people who try new food products tend to try new food and beverage products due to health concerns.

In fact, according to Hartman, health has become a very strong driver that is influencing consumers more than brand -- although saving money through coupons trumps even health by a factor of 2:1!

To capitalize on the expanding intersection of health and food, IMS Health, the leader in providing prescription medicine data to the industry, has allied with IRI, a major provider of similar data for the consumer packaged goods and retail sectors.

IRI reports this week that grocery stores' "center of the store" numbers are growing as spending on fresh foods (the outer ring of the stores) continues to be strong. They say that, "...consumers are really repsonding to the emphasis on healthy new products in the center aisle, whether it's lighter and lower-calorie versions or enhanced nutritional benefits." Younger shoppers are also drawn to exploding categories like energy drinks, trail mixes, and ready-to-drink teas.

The IMS/IRI alliance is so important for health because typical data repositories in health care are populated by health claims data -- from reference laboratories, imaging centers, hospitals, physicians offices and, yes, pharmacies. But those are only health care sources and don't count the substantial consumer out-of-pocket spending that's, well, totally consumer-driven. By integrating retail data which details a consumer's use of over-the-counter medicines, vitamins/minerals/supplements, food (healthy and otherwise, organic and non-), and other consumer products, the IMS/IRI analysts could eventually create a 360=degree view into a consumer's health-style. These would be used for marketers in developing and targeting advertising as well as for new product development.

Health Populi's Hot Points: The fastest-growing segment of pharmacies are those located within grocery and chain stores. Those pharmacies drive very profitable consumer traffic to the rest of the store, creating very profitable customers. At the same time, grocery chains are recognizing the opportunity that health in the food aisle represents. Organics, healthy snacks, teas, whole grains and "good fats" are seen by a growing proportion of consumers as health-ful purchases. My hope is that it won't only be only the advertisers, marketers, and retailers who have access to the kind of data that IMS/IRI are developing. If consumers can gain access to the information that can help them view themselves full-on in front of the 360-degree mirror -- now, there would be some powerful health information on which to act.

The value of medicine: from Beijing to London

Consider, a definition of value: Worth in usefulness or importance to the possessor; utility or merit: as in, the value of an education.

Hey Mr. Webster, how about, “the value of health?”

This week, the ground beneath Philadelphia and Research Triangle Park moved as the announcement of Andrew Witty’s nomination to the post of CEO of GlaxoSmithKline shook the headquarter offices of the second biggest pharmaceutical company in the world. Among his American colleagues, Witty was generally not considered to be the front-runner in the triple-threat horse race launched by J-P Garnier, current honcho, to head the company.

Among the 3 contenders for the top job, though, Witty has a key competence the other 2 American-based executives do not: invaluable experience working with the drug price-regulated markets in Europe and, at the same time, turning a profit. Witty openly talks the talk about the value of medicines. He’s also not adverse to the concept of risk-sharing and charging less for me-too drugs while pricing the truly innovative stuff at a premium. Such value-based pricing would be walking the talk.

Now, let’s shift geographic gears and shine the spotlight over China: as $12 billion of drugs have lost patent protection this year, another $20 billion will lose protection in 2008. This summer, a small Chinese generics manufacturer received permission from the FDA to make and export a drug that treats AIDS. This was the first time a Chinese company got approval to send a finished pill to the United States.

Expect more Chinese generics makers to export meds to the US, even in the midst of greater scrutiny on safety over the country's exported toys, food and toothpaste. The country is the #1 producer of raw materials for prescription drugs. China is already the source for 85% of the vitamin C that Americans consume.

How do we value, value? If the pharmacoeconomic equation doesn’t encompass health outcomes, safety and quality, it’s not delivering value. In this post-Vioxx, post-deadly-pet food, post-pink-box-toy environment, cheap does not necessarily equal good value. Think Target, not dollar store, when it comes to pharma and value. I am hopeful that Witty will bring that sense to the pharma landscape.

Health Populi’s Hot Points: Getting the true sense of value into the pharmaceutical equation is sensible and necessary. The next generation of pharmaceutical products must truly innovate, and deliver outcomes packaged up in a culture of safety. The lack of innovation in pharma isn’t good news for anyone…including generics companies, who depend on having new drugs to copy.

ePatients are Passionate! says Pew

The population of adults living with a disability or chronic disease comprises a relatively higher proportion of people over age 50 and people who do not use a computer on a regular basis.

New insights from the great researchers at the Pew Internet & American Life Project find that adults living with a disability or chronic illness are less likely than others to go online. However, once they go online, these people become what the Pew calls, "avid health consumers."

Their latest health report, E-patients With a Disability or Chronic Disease, offers a lot of data into this overlooked group of e-patients. Here's a list of the most popular health applications online for people with chronic illness and disabilities:

Sites with specific disease or medical problem, used by 73%
Certain medical treatment or procedure, used by 64%
Diet, nutrition, vitamins, supplements, used by 53%
Prescription or OTC drugs, used by 51%
Exercise or fitness, used by 46%
Alternative treatments or medicines, used by 42%.

It's interesting to compare the net difference between the percent of people with chronic illness and disabilities versus the percent of people without, and how each group uses health information online. Here are the largest marked net differences, by online health feature:

Specific disease or medical problem 11%
Certain medical treatment or procedure 15%
Prescription or over-the-counter drugs 16%
Alternative treatments or medicines 17%
Depression, anxiety, stress, or mental health issues 9%
Experimental treatments or medicines 13%
Medicare or Medicaid 13%

Thus, e-patients managing chronic illness and disabilities are more interested in alternative treatments, medications and procedures (mainstream and experimental), and information on payment (Medicare and Medicaid).

Equal percentages of people -- ill and well -- search for sexual health information and information on drugs or alcohol. Sex, drugs, alcohol: these are health issues facing all of us, chronically ill, disabled, and the so-called "well."

Here's what's so powerful about health care search in the unwell population: 3/4 of e-patients say the information they found in their last search affected a decision about how to treat an illness or condition (vs. 55% of the well); and 69% of e-patients with chronic conditions say the information led them to ask a doctor new questions or to get a second opinion from another doctor (vs. 52% of other e-patients). That's informed-empowerment.

Health Populi's Hot Points: The Pew researchers tell us that a lower percentage of people managing chronic illness and disabilities use the Internet for health search than people without disabilities. However, once people with chronic illness and disabilities begin to use the Internet for health search, they become "avid users." The challenge, then: how to drive more people with chronic illness and disabilities to the Internet for information, support, and all of the other great experiences available to them online? Physicians (particularly specialists) can help by providing patients with useful websites germane to patients' conditions. Information therapy drives toward this objective. Sites themselves can attract patients by channeling through patient advocacy, health associations. and other trusted third parties. Site content must be accessible, credible, and highly relevant so that e-patients can act on the information. Then word-of-mouth, patient-to-patient, friend-to-friend, goes to work.

A Majority Wants All Americans to Have Adequate Health Coverage

Covering the uninsured tops Americans’ health care priorities for presidential candidates. That’s the #1 health issue for Democrats and Independents; managing health care costs is the top health policy concern for Republicans. This, according to the latest Wall Street Journal Online/Harris Interactive poll published on October 4, 2007.

Health care coverage is emerging as a front-burner for the American middle class. 61% of Americans said that health care ‘works’ better for the very poor and the rich versus the middle class. Furthermore, nearly 2/3 of Americans believe that health care in the U.S. works just fine if you are healthy – but not if you are sick.

Two-thirds of Americans see it as the government’s job to ensure that all Americans have adequate healthcare coverage. Most adults -- across party lines -- also believe that the U.S. healthcare system could be improved by creating an insurance program that is not linked to individuals' employers (62%).

The poll examines how much Americans trust each of the presidential candidates' policies for "improving and reforming the U.S. healthcare system." Senator Clinton comes out on top, as follows:

Candidate and % trusting a great deal/to some extent
Senator Clinton 38%
Senator Obama 36%
Senator Edwards 34%
Mayor Giuliani 31%
Senator McCain 26%
Former Senator Thompson 24%
Governor Romney 18%
Governor Richardson 12%

While Senator Clinton marginally wins the health reform trust contest, the poll shows that she polarizes America on health care. She is both most and least trusted when it comes to health care reform in the U.S. – in nearly equal parts (38% to 32%).

Health Populi’s Hot Points: Consensus is building among the American middle class to ensure that all Americans without health care coverage get it. Furthermore, most Americans believe it is government’s job to ensure that happens. Most Americans also believe that health insurance should be de-coupled from employment. The complex web of health insurance and the tax code under which employers have operated for decades would have to be untangled. Do employers want to be untangled from providing health insurance? We know that some indeed do; I wrote about the autos’ desperate wish to divest themselves of future health care liabilities in Health Populi on the 13th and 26th of September. We’ve also heard from small business on the subject; a new Wells Fargo/Gallup Small Business Index poll demonstrates that small business supports the idea of a taxpayer-funded national health insurance program. So how do larger employers feel? In the months approaching the 2008 elections, watch for policy statements to emerge from the U.S. Chamber of Commerce and regional business groups on health.

The Health Data Vault, circa 1999

Today, October 4, Microsoft unveiled its long-awaited electronic health records system, Health Vault.

In a white paper called, Concepts of the Health Data Vault, the author discusses the value of an individual's "health data bitstream." The author goes on to say that,

"The value of this bitstream is based on its organization and communication within an individual's context. This value is not necessarily reflected in specific dollars and cents savings, but rather in the individual's health, trust in the healthcare system, and community. It has the potential to radically shift the balance of power in today’s health care system."

This is not a representative from Microsoft talking; it was written by Tom Munnecke when he worked with SAIC alongside the Veterans Health Administration...in 1999.

During his long career, Tom was hands-on involved with two of the world's largest hospital information systems: the VA's program that we now know as VistA, and with the Department of Defense's Composite Health Care System.

He knows what he's talking about. He's also one of the Good Guys. He's spending this next part of his career to do what his blog calls, "the simplest thing I can do to have maximum uplift for humanity."

As Microsoft continues down the path of developing, marketing, and operating Health Vault, the company would be wise to follow some of Tom's tenets developed in his 1999 paper:

• Trust
• Owner controls
• The patient at the center
• Knowledge access
• Discussions in the collaborative space.
  

Kudos to the company for giving privacy a front-burner spot in today's presentation and toward the top of the Health Vault. The project even received a quasi-endorsement from Dr. Deborah Peel, the founder of the consumer advocacy group Patient Privacy Rights.

Peter Neupert, the head of Microsoft's Health Solutions Group, told the press today that, "To make a difference in health care, it is going to take time and scale. And Microsoft has both."

Time and scale, indeed. But I hope they also stay true to Tom's tenets. That would make some difference indeed.

Health Populi's Hot Points: After forecasting and refining the S-curve of personal health record adoption for the past 12 years, I welcome this development. Microsoft, with prodigious "time and scale," is positioned to take a leadership position in personal health records. Additional health records projects will come on line in the next 12-18 months from the likes of Google, Revolution Health, and the Dossia project, among others. Which will consumers use? Will one emerge as a standard in the way Microsoft drove the PC market? Trust will be the killer app. Tom Munnecke has some insights into this from his 1999 paper: "Individuals must feel that they can provide information...as part of a trusted community of interest." That trust must be earned, and that is the wild card that will play out as consumers pick and choose among the growing array of personal health records systems.

The Unbearable Heaviness of Chronic Disease = $1 Trillion

It is no surprise that chronic disease costs, but the burden of chronic disease is staggering: pegged at $1 trillion, according to the Milken Institute's latest report, An Unhealthy America: the Economic Burden of Chronic Disease. This report highlights the sobering statistics about this critical cost driver in our system.

The chronic diseases most burdensome to the economy including pulmonary conditions, hypertension, mental disorders, heart disease, diabetes, and cancer.

What factors are contributing to America's heavy chronic disease burden? The Milken team identifies them as:

> Air quality

> Alcohol

> Cholesterol

> Illicit drug use

> Obesity (BMI ≥ 30)

> Overweight (BMI between 25 and 30)

> Physicial activity (lack thereof), and

> Smoking.

To divert ourselves from the current path -- which would be a dramatic increase in chronic disease by 2023 -- there are two immediate actions we can take to reduce the human and economic cost of chronic disease in America:

• To institute more incentives to promote prevention and early intervention; and,

• To commit ourselves as a nation to achieve healthy body weight.

Here's the math according to the Milken Institute:

United States Economic Impact 2003 Annual Costs in Billions

Treatment Expenditures $277.0B
Lost Productivity $1,046.7B
Total Costs $1,323.7B

The lost productivity number should prove a compelling argument to employers for providing strong incentives to employees for weight reduction, smoking cessation, and exercise programs.

Obesity is the prime culprit among all of the risk factors. A decline in obesity rates could avoid tens of billions of dollars in treatment costs and increased productivity into the hundreds of billions of dollars.

The study breaks down the data by each of the 50 states, which yields some fascinating insights useful for state public health departments to use for strategic planning and budget allocation. Here is a map based on the report data. Note the red region which runs roughly from Maine southwest to Oklahoma. That's the cluster of states with the highest rates of the seven common chronic diseases. Take West Virginia, in last place at #50: the level of heart disease in the state is nearly 50% greater than the U.S. average. Massachusetts has a dramatically higher rate of mental disorders, and in Kentucky, the rate of pulmonary conditions is 42% higher than the national average.

This study was jointly sponsored by The Milken Institute and The Partnership to Fight Chronic Disease, a coalition of patients, providers, community organizations, business and labor groups, and health policy experts. The study was funded by a grant from PhRMA, the Pharmaceutical Research Manufacturers of America (the prescription drug lobby).

Health Populi's Hot Points: A bulk of America's health care costs are attributable to conditions that are largely preventable and manageable. What can be done: more effective primary care, prevention and early diagnosis; lifestyle changes; and, access to prescription drugs, a bulk of which, with the exception of cancer, are available in generic form today (note: Wal-Mart, among other pharmacies, is selling many of these generics @ $4 a script). In the words of that great political philosopher, Pogo, "We have met the enemy and he is us." Getting obesity rates down is Job 1. Quitting smoking is Job 1A. Staying on therapeutic drug regimens is 1B. Embracing and appreciating the blessing that is Health is Job 0.

The Value of Medical Innovation - personal, global, fiscal

One of the key drivers of the medical cost spiral in the U.S. is technology. But it's also one of the brilliant aspects of our national and state economies, and one of the few positive line items in our balance of trade (exports minus imports). The U.S. is still a leader in med tech innovation. But how do we fund medical innovation as we aim to wring costs out of our system?

This week, medical technology is meeting in Washington DC for the annual AdvaMed conference to wrestle with the key issues challenging the industry. Costs and access to care are the over-arching concerns. Medicare is a focus, as clinicians and hospitals aren't paid on the basis of health outcomes.

AdvaMed represents medical device manufacturers of every type -- from "tongue depressors and band-aids" to robotic surgical technologies -- inside the beltway and, as important, globally through work the advocacy group does with foreign countries in promoting global trade and open markets.

AdvaMed's latest PR campaign is themed, "Progress you can see." These print ads are meant to communicate the value of medical technology in our daily lives.

The value of medical innovation: this is the major theme of the meeting this year.



The U.S. is the world's #1 producer of medical technology, producing more than half of the $175 billion in health care technology products purchased worldwide each year. And this sector generates a trade surplus: $62 billion over the last 10 years, and 6 percent annual growth.


Yesterday, a panel at the meeting discussed the value of medical technology -- subtitled, "Innovation, Patients, Society." The panel featured several of the most visible health economists and innovators on the scene.

"Society is really looking to your industry to help solve this cost problem," Uwe Reinhardt, Princeton health economist, told the conference (Dr. Reinhardt also sits on the board of Boston Scientific, a device manufacturer).

While the impact on the trade surplus is positive, it is axiomatic that med tech plays a significant role in local economies in the U.S. A report released by The Lewin Group at the AdvaMed Meeting details the economic contributions of the sector at the state level. The report notes that in 2006, the med tech industry employed 357,700 workers -- and created an additional 4.5 jobs for every med tech job. Put another way, Lewin calculates, each dollar of medical technology sales generates another $0.90 in sales in that state.

States with the biggest med tech economies include California, Massachusetts, Florida, Minnesota, New Jersey and Pennsylvania. Furthermore, several smaller states have high concentrations of med tech jobs, such as Utah and Delaware, along with Nebraska, New Hampshire and South Dakota.

Health Populi's Hot Points: When used appropriately, the benefits of medical technology to us as individuals is a net positive. The value of medical technology goes beyond the individual -- spillover effects to the community are significant in terms of employment and state economic development. And on a national level, med tech contributes to fiscal health. As we grapple with health reform models and cost containment, we must incorporate the value of med tech into the scenarios for reform.

Insecurity vs. equity: what's driving health reform in the U.S. (and post-script on class and health)

While we Americans might personify a kinder, gentler nation if we believed in health equity, it's really health insecurity that's driving current health reform efforts in the U.S.

The lead op-ed in the 1st October Financial Times (FT) editorial page forecasts, "Reform is coming to US healthcare." The column discusses last week's Congressional vote on the state children's health insurance program (S-CHIP). The FT editors then talk about how all of the Democratic presidential candidates have plans for, at a minimum, near-universal health care, an issue that was "considered toxic for the (Democratic) party" just a few years ago.

Although the paper is published across the Pond, they have captured the essence of the current American gut-feelings about health reform: it's the health insecurity, stupid! To quote the FT:

"Insecurity more than equity in the ordinary sense is the issue."

Spot-on, FT editors!

Now here's where I nearly fell out of my chair. I've been a regular FT reader since living in London in the mid-1980s. I realize that the salmon pink-hued paper, emanating since 1888 from the City of London's financial center, is no proponent of public sector programs or entitlements. However, the FT has crossed over to the other side when it asserts, "Universal coverage is feasible, desirable and overdue."

The op-ed goes on to correctly mention (but not solve the problem of) the big C: costs. They also say that our employer-sponsored system continues to perpetuate the illusion that, for the majority of Americans, health care is cheap.

Of course, health care isn't cheap. If universal coverage is to be sustainable, the focus must be on how to achieve coverage for all Americans through a basic benefit plan while making consumers fiscally accountable above that basic level. Equity plus fiscal responsibility (coupled with taking better care of ourselves as a nation through prevention and health promotion) is a practical guiding equation.

Health Populi's Hot Points: The FT plays the role of one of the publishing world's fiscally conservative thought leaders. When this global "stockbroker's Bible" waxes lyrically on the merits of universal healthcare in the U.S., it's a sign that Big Business has begun to embrace the universal health care concept. That isn't to say that U.S.-based conservative think tanks are embracing the concept of universal health care. But the FT, which provides global thought leadership, well comprehends that employer-based health insurance creates an intractable, burdensome global disadvantage for American business. And it's freely moving markets that the FT really loves most.

HP Post-script: After posting this blog, I read Maggie Mahar's analysis of Dr. Stephen Schroeder's commentary in New England Journal of Medicine which focuses on class and health. It is posted today on Merrill Goozner's blog. It is well worth your time to consider. Here's a snippet of Dr. Schroeder's analysis: "One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism,” Schroeder notes. “Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer.”