Disruptive Women Archelle Georgiou was interviewed for the blog below, originally posted on August 21st on Big Think.  In order to be a patient advocate you need to be well informed of the issues, this post reminds us of that:

You may want to think twice before your next visit to the doctor’s office. According to Dr. Barbara Starfield’s now-famous study, iatrogenic deaths (those resulting from treatment by physicians or surgeons) are the third leading cause of mortality in the United States, resulting in the loss of 225,000 lives per year. Of that total, nosocomial (hospital-acquired) infections kill 80,000, physician errors claim 27,000, and unnecessary surgery results in 12,000 deaths.  

But iatrogenic errors aren’t the only reason people should avoid hospitals, says physician and health care administrator Archelle Georgiou. She tells Big Think that relying on doctors may actually shorten your lifespan. Georgiou bases this idea on her studies of the earth’s so-called “blue zones,” isolated communities around the world whose inhabitants live longer and healthier lives than the greater populace.

In the Greek blue zone, the island of Ikaria, inhabitants are more than 4 times more likely to live to age 90 than Americans are—yet there is virtually no health care infrastructure. Georgiou tells us: “There are no hospitals or major surgery capabilities…. People needing emergency care are transported by helicopter to Samos (a neighboring island), and all elective surgery is done in Athens.”

A procedure like an arthroscopy or a hysterectomy that would take 3-5 days in the U.S. consumes 3-5 weeks for Ikarians, who must relocate to Athens for the procedure and convalescence. Therefore, “their threshold for elective surgery is significantly higher than ours,” Georgiou says. The result is that people depend on themselves rather than doctors for non-life threatening ailments. And, knowing that health care is so inconvenient, Ikarians take greater care not to get sick—they eat a healthy diet rich in vegetables and exercise daily.

Our greater access to health care (discounting, of course, the millions of uninsured Americans) might make us more likely to live unhealthfully. “U.S. culture is steeped with a ‘find it and fix it’ mentality,” Georgiou tells us. Rather than try to prevent illnesses, we rely on our doctor’s ability to fix what ails us. And the result is that “we spend significantly more on health care than any other nation but without the benefit of improved outcomes or longevity.” In the U.S., our life expectancy is only 78, yet we spend 2.5 times more money per capita than Japan, the country with the highest life expectancy (82.6 years). One-half to one-third of the $2.2 trillion per year America spends on health care is simply unnecessary, says former AMA chairman Raymond Scalettar. (more…)

Our series on Patient Advocacy kicks off with today’s post.  Over the next week, we will hear from a variety of women about their personal journeys and professional experiences.  Early in September we will compile these posts, along with our August Man of the Month’s and blog talk radio interviews, into an e-book.  As always, we look forward to your comments.

By Stephanie Mensh. When my husband, Paul Berger suffered his stroke, we were both in our 30′s, established in our careers, and planning for the future. We wanted to continue our active lifestyle, which meant overcoming Paul’s disabilities and pulling services out of many different organizations, each with their own roadblocks. I became Paul’s advocate. Here are my tips for successful advocacy to get what your survivor needs from the system.

There are three types of advocacy: (1) personal advocacy by individuals, family members, friends or others to obtain benefits and services from public or private service providers; (2) legal advocacy by a lawyer to navigate legal processes; and (3) political or policy advocacy by lobbyists and concerned citizens to change government systems.

Personal Advocacy

Most caregivers learn to be personal advocates by “on-the-job” training, usually starting with hospital, medical, and therapy providers, then health insurance. Here are some tips to help you improve your personal advocacy:

• Make a written list of your needs and questions, and go after the most important first.
• Research as much as possible from insurance policies, medical brochures, treatment plans, and other sources.
• Talk to other caregivers and ask for advice, especially for the names and phone numbers and emails of people who were helpful to them.
• Call and ask for the person or department that specifically handles the services or questions you need answered. Ask for the exact spelling of that person’s name.
• Write down the date, time, person’s name, and topic discussed in any phone calls. Keep this in a file with your other materials and research.
• Be persistent. This may mean calling every day. This may also mean asking another family member or friend to call on your behalf.
• If you feel that your questions are not being answered, or you are not getting the appropriate services, find an outside professional, agency or organization that can intervene on your behalf.

(more…)

By Archelle Georgiou. Celebrity chef, Andrew Zimmern, said it well in a recent article, “Headlines be damned. Greece is still open for business.”

Well, sort of. . .

My family and I recently returned from a month long trip to Greece. Indeed, it was glorious, and it would be fun to write about the exquisite meals, the inspiring history, and the experience of “moving in” to Lahania, the small village (population: 50) where my father was born. But, that’s not what I’m writing about because, frankly,  I expected that we would have a wonderful vacation. What I wasn’t expecting is that I would get an insider’s view of the Greek economic crisis.

It started the moment we arrived. The plan for our first full day in Athens was to visit the New Acropolis Museum that opened to rave reviews in  2009. It cost $200 million and sits near the base of the Acropolis with a direct view of the Parthenon. BUT….we were promptly informed that the museum was closed. In fact, all of the historical sites were closed due to a 1-day national strike. Two and half million public and private sector workers in Greece were on strike in Athens and other major cities protesting the European Union-International Monetary Fund austerity measures.  This particular strike was scheduled on the same day that the Parliament was voting on a bill to increase the retirement age to 65 and decrease early pensions for workers. FYI…the Greek government has policies that promise early retirement (age 50 for women and 55 for men) to 700,000 people. Warning: Don’t get in between a Greek and their “syntaxi”—their retirement check.

No problem…we decided to spend the day in Varkiza, one of the lovely beaches just outside of the city.
Interestingly, despite the palpable anger and frustration (with their own government, not the EU or IMF), we didn’t see any picket lines or strikers. The beach, however, was packed with locals who were thrilled to have a day off. Little did we know that this was the 5th national strike since February with the sixth strike scheduled for July 25.

Over the course of the next four weeks, we had many conversations about the financial crisis, and there were two consistent themes regarding the root cause: overspending and fraud.

Overspending

There are many reports that suggest that the 2004 Olympic Games put the country into a downward spiral, and this issue came up frequently in our discussions. Costing $11 billion dollars, in addition to infrastructure costs, this was 50% over budget and clearly more than the country could afford.  In our conversations, however, the prevailing perspective was that it was the government’s fault.

Maybe so, but there is a long history of overspending, in the form of entitlements, that the country cannot afford to continue but, yet, the people don’t want to give up.   Did you know:

• As a way to stimulate population growth, women who have three or more more children are given a lifetime stipend. One family that we were with has four sons. All are adults, and the mother continues to receives 200 euros per month…forever.
• As a way to stimulate tourism, the government established incentives for entrepreneurs to build hotels and open restaurants. And, what a deal! The government gifted–yes, paid for…60% of the development costs for new projects. This helps explains why the islands are lined with large, luxurious hotels with a 57% average hotel occupancy rate.  
• All employees receive two  bonuses a year: a Christmas bonus equal to  one month of salary and an Easter bonus equal to two weeks of salary. So, employers are obligated to pay 13.5 months of wages for 12 months of work. Can anyone say pay for performance? Management discretion? Nah..

(more…)

Did you miss Disruptive Women bloggers Indu Subaiya, Jane Sarasohn-Kahn, Trisha Torrey, and Regina Holliday this week on the Real Women on Health! Radio series? Or did you hear them, but want to listen again? If so, you can listen to the podcasts now available.

By Archelle Georgiou. “Dr G. Any ideas on the best way to lose weight?” “What do you think about (name the supplement) for losing weight?”

Diet and nutrition questions are some of the most common that I get on Fox. My response always begins with the calorie speech—”In order to lose weight, calories consumed must be less than calories expended.” I consistently take a hard stance on the physics of weight loss which makes some people bristle, especially those who believe that their weight issues are hormonal, genetic, or “their metabolism.” I emphasized this very black and white perspective in my February blog, Weight Loss 101: Count Your Calories, where I explained, mathematically, how my own 2-1/2 pound weight loss was fully explained by the energy expenditure of some increased physical activity.

After 7 months, I’ve lost a total of 7 pounds and the thermogenic reality is a 24,500 calorie deficit. The bigger achievement, however, is the insight into my personal relationship with food.

Hunger does not necessarily mean that my body needs to eat. Emotional-eating has been a way of life for me. I just accepted this behavior as one of my (many) flaws until I learned about the physiologic effects of two hormones that have a powerful influence on the urge to eat—or not. Ghrelin is produced mainly by the stomach and pancreas. Levels are normally high before meals and make us feel hungry. Leptin, its counterpart, is produced by fat cells and causes feelings of satiety and reduces sugar cravings. When leptin levels increase after meals, the brain signals us to stop eating. Here’s the problem: These appetite-controlling hormones are not simply regulated by the body’s nutritional status. Ghrelin (or should I say, gremlin!) levels increase with sleep deprivation. (Maybe this is why I was at my heaviest during my residency?) And, leptin levels, or the body’s sensitivity to it, may diminish in the presence of emotional stress. Just educating myself was enough to give me the willpower to—PAUSE–before reaching for an extra helping or sneaking a second dessert. If I can objectively convince myself that I am calorie-deficient…fine. Open mouth, insert food. However, if I am tired, frustrated, angry or brewing with Greek emotional drama, then instead of using food as a Band-Aid, I try to address the root cause by sleeping, meditating, taking a walk, ….whatever it takes. (more…)

By Robin Strongin. This was a busy week in women’s health—an issue of global importance. On June 7th, Women Deliver 2010, the largest meeting on global maternal health in the last ten years, kicked off in Washington, DC. UN Secretary-General Ban Ki-moon delivered opening remarks and US Secretary of State Hillary Rodham Clinton addressed participants via video. The conference offered an opportunity to take stock of progress that has been made in improving global maternal health while assessing the challenges that remain.

Women Deliver 2010 highlighted achievements in reducing maternal mortality, breakthroughs in reproductive technology, the role of women’s health in development, and remaining obstacles to improving maternal health around the world. The conference’s 3,000 participants, including heads of state, ministers of health and leading maternal health advocates, called on governments, donors, and multi-lateral organizations to increase their financial commitments to women and girls. For more information on Women Deliver, visit: www.womendeliver.org and to watch replays of the presentations, click here: www.womendeliver.org/webcast.

During the conference, Population Action International launched a new documentary, Empty Handed: Responding to the Demand for Contraceptives. WATCH THE TRAILER

Empty Handed Advocacy Short from Population Action International on Vimeo.

Around the world, more than 215 million women lack access to basic contraception. Empty Handed tells the story of women’s lack of access to reproductive health supplies (contraceptives and condoms) in sub-Saharan Africa, and its impact on their lives. The film documents the challenges at each level of the reproductive health supply chain and identifies key areas of improvement.

Empty Handed was shot in Uganda in March 2010 by PAI filmmaker Nathan Golon with support from the Reproductive Health Supplies Coalition.

By Glenna Crooks. During my years in the Administration I was sometimes directed to draft responses the President would send in reply to letters he’d received from individual citizens.

Sometimes, rather than drafting the letter for him, I’d be directed to reply on the President’s behalf. Such was the case when the White House directed I write to a young boy from Texas.

His father – a young, healthy man – collapsed and died suddenly during an after-work run on the local high school track. Later, at the funeral home, the director complimented the boy’s Mother about her generosity in having donated her husband’s corneas. But there was a problem: it had not been her decision. In fact, until that moment she had not even know her husband’s corneas were removed.

The ‘donation’ was made under Texas law that provides for the ‘presumed consent’ on the part of deceased individuals. A medical examiner was allowed to remove corneas from a deceased person if the examiner was not aware of the relatives’ objections. The law did not require that the medical examiner ask the family before doing so, however. In other words, every one is ‘opted in’ to organ donation unless they ‘opt out’ and the medical examiner knows about their ‘opting out.’ This family, like most in Texas, had never been asked. The wife had never been given the opportunity to ‘opt out’ for her husband.

The boy wanted the President’s help to change the law. He was distressed that his Father was now in heaven and, without corneas, could not see God. He wanted others spared a similar tragedy. I can’t recall what I wrote to this boy in response; I do recall it was a hard letter to write and I doubt my reply did justice to the pain of his loss and his grief over his Father’s blindness in heaven.

That experience came to mind when I saw an AP report that a New York Assemblyman, whose daughter had been helped by two kidney transplants, intended to pass legislation to ‘presume consent’ for not just corneas, but for donations of all organs in the state. If he succeeds, New York won’t be the first state to try, but will be the first state to succeed in enacting that type of legislation.

More than 6,000 people die each year in this country awaiting donor organs. Improvements in surgical techniques and post-transplant medications offer hope to people who only a few decades ago would have had none.  I have seen lives transformed by organ transplants and we need more donated organs, that’s for sure. But can it possibly be a donation if the person or their loved ones are never asked? Is ‘presumed consent’ donation, or is it just plain ‘taking,’ in this case endorsed by legislators?

I think it is ‘taking’ and for that reason, I oppose it.

I can’t stop thinking about that 10 year old boy and his distress. Like him, I don’t want other families to suffer that fate. The joy of one family for the life of a loved one saved by a transplant does not justify the pain inflicted on another family whose loved one’s organs are taken without consent.

I have always been a bit fascinated by people who make a living telling people what they want to hear.  To be perfectly honest, I actually think it is because I envy them. How nice is that for generating income: making people perky, reassuring them, telling them everything is fine, promising them they are right about everything, helping them keep their denial systems intact?

My envy stems from my irritation with myself for choosing a different path. I have spent most of my life telling people what they need to hear, hence often what they don’t want to hear. I try for balance, noting all the “good stuff”, then offering the counterbalance.  I find one unwelcome message can drown out all the affirmative messages. People home in on that “bad” stuff with an inerrant tenacity.

The differences between these two approaches are instructive.

 Feeling good is quite popular. Creating the conditions for feeling good can lead to fame and fortune. We want to hear from these purveyors of endless good news and reassurance. There is all that amazing research on happiness, the blossoming theories and practices of appreciative inquiry, the neuroscience data on endorphins: you cannot ignore this compelling information.  The reassurance that one is right about everything can make for intense feelings of joy, hope, and optimism. The person who triggers the feelings is brilliant, constructive, right.

In contrast, mentioning the elephants in the room can lead to all manner of irritable behavior, judgments that are hard to absorb. I am too negative, a prig, a moralist, a mean person, a downer. I make people feel bad. Why do I have to bring all that stuff up?

It has taken me several decades to understand that wisdom lies in the middle ground, so I persist. It is in that spirit that I mention an important health care elephant.

• 27 to 30 percent of Medicare payments cover the cost of care for people in the last year of life.
• 40 percent of Medicare dollars cover care for people in the last month.
• 12 percent of Medicare spending covers people who are in the last two months.

We need to have a conversation pretty soon about longevity. Longer life spans are supposed to be the stuff of a success story, not a promise of immortality. We are going to die, eventually.

Exactly how long are we supposed to live, and how much money are we going to spend on dramatic efforts to extend the life of an elderly person for another month or week?  What are we going to do about all these studies that say that the lion’s share of health care costs occur in the last year of life?

How do we as a nation start a constructive discussion about death and how to let go of those we love without insisting that we spend a few large chunks of change on them while we struggle with their inevitable demise? How are we going to help families have this conversation without triggering the “death panel anxiety syndrome”?

Who will lead us in this effort? Theoretically, health care professionals would, however many are ill equipped to do so. They were educated to sustain life at any cost, literally. For many of them, success is not tied to a good death but the ability to not let death happen.  Their job is to save us. It is perhaps unrealistic to expect that they would be good at both warding off death and embracing it.

The antithesis of this worldview is found in the amazing work of the hospice community. They have been around for a while now. As someone who is willing to talk about death, I have had numerous conversations about hospice care, and have yet to hear a single person say this community’s work was anything but splendid. Quite a record, albeit anecdotal!

Maybe we need to make sure that their voice is heard more clearly in the health care “debate” about cost. Maybe we need to make sure experienced hospice workers are at every health care policy table. Maybe they have answers to our questions that would help us all grapple with death and dying a little more constructively.

They might even tell us what we want to hear.  More importantly, they might also tell us what we need to hear.

Do you ever wonder who the champion advocate for the patient is in the healthcare reform debate? More importantly, is the focus on consumer choice taking a front seat while the issue of how consumers will ultimately respond to those choices is being ignored?

Many people, myself included, believe that in aggregate, individuals are best equipped to advocate for themselves. In fact, this hypothesis forms the foundation for a key component of Health 2.0, in which the consumer takes more responsibility for managing his or her healthcare and by default, the delivery of that care becomes more fluid and cost-effective.

The rub, however, is that data suggest that most consumers of healthcare rarely if ever speak up.

A fascinating report published in the September issue of Milbank Quarterly shows that fewer than 40% of 5,000 patients surveyed complained to healthcare insurance plans when a problem arose, even when it cost them upwards of $1,000 in out of pocket expenses or if care (or lack thereof) led to a more serious health condition. What’s more, less than 15% of patients took steps to opt out of their current plans and search for a more palatable option.

What these results demonstrate is that current response to the coverage being delivered neither safeguards the patient or serves to highlight the most significant problems among current plans in the marketplace.

Clearly, two major components are missing in the current debate: unique, consumer-driven advocacy and optimized patient responsiveness. Without these, even the most attractive new options on the table may ultimately fail to lead to better overall quality of care.

I’ve been tasked with presenting the genetic and rare disease perspective on comparative effectiveness.

I’ll dispense with ‘rare’ right away.  If by rare, we mean single gene disorders, then perhaps it is a useful designation.

If by rare, we just mean the equivalent of the US definition of orphan disease, i.e., less than 200,000 people in the US, then we should ask a few questions. In the old model of test and drug development, the ‘block buster, body count’, model, rare was a useful designation.  In a system built for BIG, then rare needed a boost.  In the new age of personalized medicine, all conditions are rare. In fact, they are usually an N of 1 after factoring in the myriad of genes involved, epigenetics, environment and so on.  As we enter new ways of dealing with common conditions, they too will be fragmented into dozens, sometimes hundreds, of rare conditions.  Thus rare and common conditions have similar challenges in that realm.  For these reasons, I recommend we lose the word ‘rare’.  I know it has a rich and abundant history in the Orphan Drug Act, but in addition to the aforementioned issues, I think siloing our thinking around disease into these social constructs of abundance of disease misses opportunities that would blossom were we to consider gene families, pathways and targets instead of incidence and prevalence.

Let’s move then to single gene disorders.  Comparative effectiveness would have to go on unemployment if it depended on single gene disorders for its first tasks.  Most single gene disorders do not have a treatment, let alone several.  And once one is developed, it is hard for a second one to be developed given the lack of financial incentives in the old paradigm.  Perhaps a first step in comparative effectiveness for single gene disorders is creation of ANY treatment for these conditions.

On to genetic conditions.  I think genetic conditions have already been spoken for in all of the preceding posts – because all disease is a mix of genes and environment, and so all of the conditions spoke about, either explicitly or implicitly, are genetic to some extent.  That said, I believe genetic diseases, and genomic signatures of attributes of disease, like tumors, offer ways to quantitatively measure expression thereby offering a new level of scientific scrutiny for disease.  While most genetically and genomically authored tests and treatments are nascent and have not yet been scrutinized, we are seeing some assessments of genetic tests, at least.  These are not complete comparative effectiveness studies, but they use methodology that might offer something to the field of comparative effectiveness.  If the field does use methodologies like those of EGAPP, then it will be important to do a broader assessment of the methodology before wide spread implementation.  From the website, “The project’s goal is to establish and evaluate a systematic, evidence-based process for assessing genetic tests and other applications of genomic technology in transition from research to clinical and public health practice.”  There are those who ask why almost all tests that EGAPP has assessed have failed to meet the requirements to pass into clinical practice, when some of these tests have done so in a variety of ways.  EGAPP is a good example of how hard it will be to do comparative effectiveness, since its assessment (far from comparative effectiveness) is so difficult, resource and time consuming.

However, I look forward to our foray into comparative effectiveness.  I believe it is time for the practice of medicine to move from being a cottage industry.  Comparative effectiveness, coming of age in the genomic/informatics era, while we move toward individualized medicine (commonly known as personalized medicine), will be an effective tool if, in the words of the post by Randel before me:

“A fair, open, cooperative public/private process, if designed properly will enhance the information needs of patients, physicians, and scientists and eliminate wasteful and ineffective medical technologies and procedures. Implemented without a fix of the payment system, however, the fear that this may stifle access and innovation will be realized.”  If we wish to move medicine out of the cottage industry realm, reimbursement has to come too.  There are exciting months ahead of us – let’s not call each other names like rare or common, genetic or infectious, popular or unpopular.  No disease, condition, or disorder should be left standing around the edges of the dance floor while the rest are dancing.

Stay tuned to the collaborative discussion about health reform resulting from the flash mob on June 17, 2009.

Inform Health Reform

http://fastercures.blogspot.com/2009/06/fastercures-joins-healthcare-advocates.html

I am not usually one to take on the Vatican. In fact, I toured its lovely treasure-filled buildings only three months ago and marveled at the wealth and power it denoted. However, the Pope’s recent pronouncements during his travels in Africa that condoms and abortions are morally wrong have filled me with righteous indignation. I too have spent time in Africa. But I wasn’t there to make pronouncements from on high. I was there to make a documentary about the increasing number of married women with AIDS in Kenya. I walked through Kibera slum and watched large families crammed into corrugated metal sheds without plumbing or heat.

Even so, I probably wouldn’t take on the Pope…except for an article in today’s Washington Post. Apparently, the Vatican’s top bioethics official said the two Brazilian doctors who performed an abortion on a nine-year-old rape victim “did not merit excommunication, because they acted to save her life.” HELLO! In my book, that’s called a pro-choice stand. Bravo for Archbishop Rino Fisichella, president of the Pontifical Academy for Life. Perhaps he should have a chat with his boss.

Abortion is not a black and white issue for me, despite having worked for the better part of a decade for Planned Parenthood Federation of America and NARAL on reproductive health issues. That’s why the pro-choice position has also seemed to me to be the reasoned one. It allows individuals to make decisions and encourages each of us to define for ourselves what is reasonable and acceptable. There is a trust factor in being pro-choice. For example, if there is the possibility that a nine-year-old may be raped by her stepfather, you want to believe that the pregnancy will be ended as swiftly and humanely as possible.

Good for Archbishop Fisichella for being able to see that issues related to reproductive health have gray areas! And that it is often possible to be both pro-life and pro-choice while having to accept difficult decisions. Is it too much to hope that Pope Benedict XVI might also see the light? If he truly listens to the people of Africa and other continents, and opens his eyes to their hopes for their own lives – I have faith that he may begin to understand the healing power of condoms and the life-affirming necessity for legal, safe abortions.

For several years, my family has held a grab bag holiday get-together. People are to bring inexpensive gifts, often intended more for laughs than for use. My extended family includes nieces and nephews ranging in age from 15 to 30, some with children and others who are sexually naïve, even if not virgins. Mine is not a family that discusses sex. My living siblings are reborn Christians, who deem appropriate only discussions of abstinence for those youth not yet married. However, as a nurse, I’ve made it clear that their auntie will not shy away from sexual discussions. I have been known to initiate such conversations with a niece or nephew and even their friends when I have some time with them.

“ONE PREMIUM LUBRICATED Lifestyles® LATEX CONDOM”

So this year, one of my grab bag gifts was condoms. My courage to make this a visible ‘gift’ at the holiday party arose from New York City’s model of making condoms available anywhere and everywhere. The city has rightfully been aggressive in distributing condoms since Thomas Frieden assumed the position of Commissioner of the Department of Health and Mental Health and saw that a large proportion of people in the city who are HIV-positive don’t know it and can be spreading it unintentionally by having unprotected sex. In 2007, the city launched a NYC-branded condom and has since given out over 70 million of them for free. (more…)

The New York Times recently reported on Health Reform Private House Parties. At this particular party, the participants easily sided with the angels: health care is a right, insurance should cover everything and coverage should be available from government and businesses. There, that was easy. Bet they had a nice time.

Partygoers were not asked for solutions and the devil is always in the details, so let’s use my favorite – flu shots.

First, the New York Times reported that party participants quickly agreed that “…health care was a right…” It makes me wonder; if health care is a “right,” what of “responsibility”?

- If I have a “right” to flu shots to help prevent flu disease, do I have a “responsibility” to get them to protect myself, reduce my medical care costs, improve economic productivity and protect others around me?
- If I don’t get the shot, infect others and cause them to be ill, am I responsible for the cost of their care?
- If others I infect miss work, am I responsible for the cost of temporary workers or losses incurred by their employer? Am I responsible to the government for the loss in taxable productivity?
- What if they die as a result of the flu I transmit to them? Am I culpable?

Second, participants also agreed “…that insurance should cover ‘everything,’ not just some services….”
- If a flu shot is covered and I choose not to get one, should I be required to pay for any doctor visits and medicines I need?
- Should my employer have the right to charge me for the temporary help that might need to be hired to replace me on the job?
- Should Uncle Sam have the right to tax me for earnings I would have made if I had been on the job?
- Should the cost of something so reasonably priced be covered for everyone? Really, I mean everyone? Even the wealthy who can well afford the cost?

Third, participants agreed that “…coverage should be readily available from the government, as well as from employers….” They agreed that individuals and businesses should have to pay a “small health care tax” to fund care.
- Who are they kidding, “small health care tax?” Have they looked at cost projections lately?
- And what about non-coverage barriers? Coverage is only one barrier to care. Ask those in rural areas, anyone not fluent in English or medically literate.

And yes, I’m still harping on flu shots. The season is not nearly over and there are plenty of doses left to protect the nation from the $87.1 billion – or more – that flu could cost us this winter.¹

1. Molinari NA, Ortega-Sanchez IR, Messonnier ML. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine 2007;25:5086-5087.

The following post appeared last week on the Get Better Health Blog:

President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the change.gov website.

The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system: (more…)

Remember Harry and Louise? Sitting at their kitchen table, the nondescript couple burst onto the national stage in a 1993 television commercial that deftly attacked Bill Clinton’s proposed health care plan and made even those of us committed to universal health insurance afraid of its consequences.

I can’t recall the lines Harry and Louise used, but 15 years later I remember the message: America is built on choice, health reform will take away that choice, and if we pursue the proposed reforms we’ll deeply regret it. Then a medical student, I was convinced (albeit naively) that we should have a healthcare system like those of our European counterparts. I was seeing many, many patients who had waited too long to visit the emergency room because they didn’t have insurance – and the accompanying detritus of medical neglect. But I was moved by Harry and Louise. I am not a person who is easily swayed, and yet their message made sense to me. It put a chink in the ideological armor of the left that persists even now.

Today, as we think about how to pursue smart and sustainable healthcare reform, we would do well to remember that Americans – myself included – like to get something in return for their money. And we like to have meaningful choices. As we try to make the system better, let’s not sacrifice choice. In fact, expanding choice is actually the best rationale for reform. We like to think they have choice in our current system, but there are a myriad of choices that are made for us before we even walk into the doctor’s office or taken away from us after a decision is made.

Take advance directives. Americans cling to the false hope that we have the power to decide how we will die. That we can refuse unnecessary care, die with dignity, have the needs and the questions of our family members answered, and opt for extraordinary measures if we choose. This image of death on our own terms is a fallacy.

Last year, when my grandmother lay dying in a California hospital, I saw firsthand how little say a family has in the care a loved one receives at the end of life. Private insurance, a willingness to pay out of pocket, and two doctors in our family did nothing to give us choice. One morning, I came into her ICU room to discover that even though her care providers had observed an unexplained drop in the urine flow from her catheter, no one had checked it. No one had laid hands – or eyes – on the patient. The simple solution was the right one. Her catheter had slipped out of place. And this simple oversight meant she had been sitting in her own urine long enough to break down the skin and cause what would turn out to be a life threatening bed sore – if you can imagine that. As a family we chose to have her be turned regularly to heal the resulting bed sores. Yet despite dividing up the duties so there was a family member with her in the hospital 24 hours a day for months, we couldn’t always get hospital staff to change diapers or assist with turning her even though the evidence shows that these steps are essential.

Despite differences in opinion on her need for dialysis, we found we were at the mercy of the renal physician on duty that week. Just as we chose the follow the advice of one insistent physician to take the more aggressive step to undergo dialysis, that physician would go off service and we would be faced with a new doctor who adamantly refused that same course of action.

And even though she had proactively chosen her physician and her physician had attending privileges in the hospital in which she lay, we found this same doctor who had known her for decades had very little say in the care she received. Instead she was left at the mercy of a new hospitalist every week, each with no knowledge of her case and wildly varying approaches and expertise. I had no choice but to explain the nuances of her case to a new doctor each week. Years of working in medicine and policy were meaningless (in that way alone it was the ultimate democratizing experience). I was totally unable to protect the choices she had made for the end of her life. They willfully ignored her advance directives and the wishes of her family. And they blithely dismissed our choice to have accepted standards of care. What she did want she couldn’t have and what she didn’t want was forced upon her.

When the Aspen Institute polled Americans last summer, they overwhelmingly agreed that health span was more important than life span (91% to 9%). We want a system that helps us stay healthy, and living healthy years is more important to us than living more years. But this is not a choice we are given in our current system. We cannot choose our own definition of a healthy life in the current system.

So the next time you think you have a choice about the health care you receive – think twice. Do you have more reproductive choices than you did 15 years ago? Do you have more preventive health care choices within your insurance than you had 15 years ago? Do you have more choice to vote with your feet when you are treated with disrespect and callousness in a health care encounter than you did 15 years ago?

Harry and Louise were right. We do need choice. But Harry and Louise were also wrong. We will only protect and expand choice through change. And if you watch the latest (2008) installment of the Harry and Louise ads you will see that they too would take their words back.