One-third of Americans say they have received tests, treatment or medications they didn’t need, according to a survey conducted for the Commonwealth Fund of New York.  Are you one of them?

Think about it.  We live in a market-driven economy where businesses thrive on getting us to consume more than we need, whether it’s a house that’s too big, a mortgage that’s unaffordable, or an investment that promises more than it can deliver.  Market-driven health care is motivated by the same imperative.  In our highly-caffeinated health care system, the mantra is volume, volume, volume.  That ‘volume’ is you and me, and the people we love.

Here’s a story about a colleague, a research scientist, who has a heart condition that she watches very carefully. She went for a nuclear stress test at a free-standing diagnostic testing center as part of her routine monitoring.  After the test was complete, the cardiologist told her she had a very serious problem that required open-heart surgery.  She was scared out of her wits and immediately thought of a family friend who had died recently during heart surgery.  The cardiologist wanted to do a cardiac catheterization and prescribe medication.  He also told her to stop jogging immediately.

My savvy friend knew she didn’t want to have more tests or treatment at that center.  Here’s why.  While on the treadmill, she overheard the doctor tell the nurse that the center had nine patients a day and needed to increase its census to fourteen a day to generate enough revenue to make it financially viable.  It’s true.  She walked out and never looked back. A second opinion from expert physicians recommended continued monitoring and she followed their advice.

About ten years ago, the Institute of Medicine of the National Academy of Sciences convened a group of experts who acknowledged a uniquely American phenomenon in health care: overuse.  It occurs when the possibility of harm exceeds the possible benefit.  Health care insiders say that overuse is an epidemic.  Epidemics are not good for anyone.

To learn what you can do to avoid unnecessary medical treatment, check out my new book coming out next month, The Treatment Trap, which has twenty smart steps for consumers.  Read the foreword by Jim Guest, president of Consumers Union.  In the meantime, share your story.  Together we can learn from – and empower – each other.

The following guest post is written by Candace Littell, Health Policy Advisor at Candace Littell, LLC. Candace Littell is a consultant with 30 years experience in healthcare policy and reimbursement. She serves as an advisor to corporate clients, healthcare providers, associations and related organizations.

President Obama’s 2011 HHS budget builds on the American Recovery and Reinvestment Act (AARA) investment in federally qualified health centers (FQHCs), providing an additional $290 million for further expansions.  With this increase, the administration estimates that health centers will be able to serve more than 20 million individuals in FY 2011.

Combined with other AARA provisions, this is good news for some of our nation’s “safety net” providers, including FQHCs, as well as public and nonprofit hospitals that treat many low income patients.  But there’s also a growing hole in the safety net as free medical clinics struggle to survive the current economic recession.

In a recently released research brief on safety net providers by the Robert Wood Johnson Foundation’s Center for Studying Health System Change^[1], the authors note, “while many FQHCs have benefitted from both the recent ARRA funding and federal expansion grants over the past 10 years, many free clinics without FQHC status were facing more serious financial strains than safety net hospitals and FQHCs.”  The report goes on to quote one FQHC executive as saying, “FQHCs got money, and free clinics are worried about keeping their doors open…There’s a big have and have-nots disparity.”

FQHCs include community health centers, public housing centers and some outpatient programs.  These providers receive federal payments for qualified services and are eligible for stimulus funds and federal expansion grants.  In contrast, free clinics do not receive federal payments and they are not eligible for funding available to FQHCs.  Instead, they depend primarily on private philanthropy and a team of volunteer physicians to provide care to the uninsured.

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Healthcare (insurance) reform has passed in the Senate and final negotiations are happening before it moves on to the President’s desk for signature. While the legislation is not perfect – in fact some would say far from perfect – it is a piece of legislation that is very much in keeping with our American philosophy, our constant pursuit of progress and change.

As the late Senator Kennedy’s career on Capitol Hill demonstrated, change is usually incremental, usually negotiated and usually compromised. But at the end of the day, change usually amounts to progress.

I see tremendous progress, too, as I look back on a decade’s worth of work to promote access to affordable quality health care using nurse practitioners in the role as primary care providers, thereby alleviating the burden on a strained primary care system.

We’ve come a long way regionally and nationally. The fact that we as a country are always striving to improve our path is what most invigorates me as a relatively new American. Our pursuit of progress is never ending, but it is what sets us apart from most countries in the world. We know our work is never done. As we enter a new year and decade, we always should remember that what makes us different from most people and countries in the world is that we have the freedom to purse progress and make change.

This health insurance reform bill is not the end all or be all, but it will help make affordable health insurance available to more than 30 million Americans who have been without it. Furthermore, the legislation contains many provisions for others who fall through the cracks and will need additional care and support.

That’s progress for individuals, families and America, as Walt Disney would have said. And not until you take a ride on the Magic Kingdom’s The Wheel of Progress will you truly appreciate how important it can be to take even a small step in the right direction.

Happy New Year! And a toast to a New Decade and our new Pursuits of Progress for individuals, families, and our country.

Healthy New Year everyone!

Like many people I’m starting the year with healthy – and preventive care – intentions. How about you?

That put a few items on my holiday ‘to do’ list:

• Get a pap smear,
• Find H1N1 vaccine,
• Wrestle the results of a recent bone density scan (Dexa) out of the hands of the medical center and into the hands of my physician, and
• Confirm with Morris White, my trainer, that I’d continue workouts.

The pap smear was easy – this time. I’d not been able to get one during my late-summer vacation visit to the doctor because the appointment was two weeks prior to the annual date of the prior test. That required another trip. Holiday downtime was a good time to do that. Check that off the list.

In doing so, I finally found an H1N1 vaccine dose! Getting a seasonal flu shot was easy at www.phillyflushots.com, but even after calling several immunization providers and both of my physicians at least twice monthly since H1N1 became available, checking websites and following news reports of shots at pharmacies – well, no success. Luckily, my doctor had just received a few doses of H1N1 that day of the pap smear. Check that off the list.

Results of a bone density scan months ago had still not shown up at my doctor’s office. Holiday time was a good time to badger for the ‘results,’ though it was hardly worth the trouble. Turns out  my physician is not part of that medical center’s ‘network’ and can’t get detailed results. Only a note: ‘normal.’ Sorry, that’s not good enough. Neither my physician nor I know whether there has been any change in bone mass since prior tests. Sure, the test results might be ‘normal,’ but the measures might also be trending in a direction that means I’m losing bone mass, something we both should know about. No check there, still on my list.

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Think you have maternity coverage? Think again.

Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because I think Disruptive Women readers will find it useful, each month I’ll post an example of a health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.

My goal, however, is to find a way to improve health insurance for beneficiaries and I have some suggestions at the end of this post.

This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation: When our client, Ms. R, found out a few years ago that she was having a baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits. Making the call was merely a formality. When she originally purchased the policy, she was single and didn’t opt for the maternity rider. After she got married, she added maternity coverage because she wanted a family.

Indeed, when she called the insurance company, they confirmed she had the insurance she needed. However, after her first OB check-up she received a letter saying she was, in fact, not covered.

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As I mentioned in my post last week, Disruptive Women in Health Care is tackling the issue of drug adherence, often referred to as America’s other drug problem.  From a health policy standpoint, the issues cross financial, clinical, behavioral, and cultural boundaries.

Over the next two weeks, Disruptive Women and guest bloggers, all experts in their respective field–each representing a different perspective — patient, physician, nurse, pharmacist, researcher, behaviorist, policy analyst, distributor, to name a few–will share their analyses, opinions, and solutions.

At the completion of this series, we will compile an e-book as we did when we tackled the issue of Comparative Effectiveness Research.

THE SCOPE OF THE PROBLEM

A new report, Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease, issued by the New England Healthcare Institute (NEHI) found that patients who do not take their medications as prescribed pay a price in poorer health, more frequent hospitalizations and a higher risk of death.

Collectively, noncompliant patients incur up to $290 billion annually in increased medical costs–that’s $290 billion in avoidable medical spending every year, according to the NEHI report.

This is not a new problem, nor is it unique to the US.  In 2003, the World Health Organization (WHO) issued a landmark report entitled Adherence to Long-Term Therapies in which it noted:

Adherence to therapies is a primary determinant of treatment success. Poor adherence attenuates optimum clinical benefits and therefore reduces the overall effectiveness of health systems.

“Medicines will not work if you do not take them.”  Medicines will not be effective if patients do not follow prescribed treatment, yet in developed countries only 50% of patients who suffer from chronic diseases adhere to treatment recommendations. In developing countries, when taken together with poor access to health care, lack of appropriate diagnosis and limited access to medicines, poor adherence is threatening to render futile any effort to tackle chronic conditions, such as diabetes, depression and HIV/AIDS.
This report is based on an exhaustive review of the published literature on the definitions, measurements, epidemiology, economics and interventions applied to nine chronic conditions and their risk factors. These are asthma, cancer (palliative care), depression, diabetes, epilepsy, HIV/AIDS, hypertension, tobacco smoking and tuberculosis.

In the intervening years since the WHO issued its report, adherence has become more problematic.  Numerous reports highlight the ongoing challenges, which are especially critical in the mental health arena.

A study in the American Journal of Psychiatry found that close to 60% of schizophrenics who were prescribed anti-psychotic drugs did not take the medication as prescribed by their physicians.  “We looked at adherence to anti-psychotic medication because they form the backbone of treatment for schizophrenics,” said Dr. Dilip Jesete, co-author of the study.  “These medications are good, but only work when taken properly.”

The study found that psychiatric hospitalizations were higher for people who did not take their medication as prescribed.

When schizophrenics, a disease which affects over 2 million Americans, do not take their medication, they are at risk for dying by suicide.  Four out of ten people who suffer from schizophrenia attempt suicide and one in ten die by suicide.

SOLUTIONS

Despite the complexity of adherence related challenges, a number of promising solutions, innovative responses and well-researched efforts are underway.  Many of these will be described in greater detail in our Drug Adherence series.

Some of these include:

• Text message alerts to remind patients
• Greater use of health care teams
• Integration of health information technology
• Creation of online and offline medication management systems, reminders
• Health e-games
• Insurance reforms
• Public awareness campaigns
• Patient education
• Mobile phone applications
• Research in gender-based barriers

We look forward to your comments and input as we shed light on this critical policy issue.

It has been estimated that 3 out of 4 people report that they do not take their medications as directed, resulting in hundreds of billions of dollars annually in related medical costs and an enormous number of hospital admissions and readmissions.

The reasons for this are complex and varied.  This is a particularly vexing challenge for young, chronically ill patients, for people with mental health diagnoses and for the elderly who may suffer from memory impairment.  Anyone on a complicated drug regimen knows how committed one must be to remain adherent.

For some, cost is an issue while for others side effects can be unpleasant, travelling can compromise the best of intentions as can the need for refrigeration when none is available.  Some patients must take some drugs on an empty stomach and others on a full stomach.  Some patients are simply not ready to accept they have a serious, or lifelong illness. It is complicated.

Because the implications, both clinical as well as financial, are significant, we have invited a number of our Disruptive Women bloggers, as well as some other experts in the field, to join us in a series of policy posts on this critically important issue.

Beginning next week, on October 19th, we will launch our Drug Adherence series which will analyze this challenge from a number of perspectives:  patients, providers, researchers.  In addition, we will also offer innovative solutions.

At the completion of this series, we will compile all the posts into an e-book, just as we did when we tackled the issue of Comparative Effectiveness Research and created our Comparative Effectiveness Research e-book.

If  you or someone you help care for has experiences you would like to share, or you have research, solutions and other thoughts on this topic, I hope you will share them with us.

Ever wonder why your physician only spends 5-10 rushed minutes with you during your office visit? You may think it’s because there are simply too many patients vying for her time, but that’s not the real reason. The root cause is that health insurance companies are stealing time from your visit by requiring excessive documentation from your doctor. She can’t give you the time you need, because doing so would put her out of business.

In a special report on the administrative burden of healthcare, MedPage Today revealed that PCPs spend about one third of their income on documentation required by health insurers. Because they run a business with thin margins, they must increase the volume of patients they treat in order to cover the salaries of the staff required to manage this “paper weight.”

About 49% of all physicians have said that they are considering retiring or quitting medicine in the next two years (the rate is lower for specialists), largely because of increasing documentation requirements and decreasing reimbursement.

Primary care is hardest hit by costs of coding and billing requirements, since they charge relatively little for their individual services. Imagine the difference in complexity between freezing a wart versus removing an appendix. Yet the number of people required to document, code, and process the paperwork for those two procedures are similar. The reimbursement, however, can differ by thousands of dollars.

The average PCP requires 4.5 staff to manage the administrative challenges associated with practicing medicine. If you consider that the average annual income for a PCP is $149,200, then it’s easy to see why a PCP’s income barely covers staff salaries, let alone the overhead associated with office space, supplies, and computer technology.

How can family physicians survive in this hostile reimbursement environment? There are really only two choices: to work in large group practices or to cease accepting insurance. (Of course, I’m leaving out the third option: to choose a different career).

I have decided to join an insurance-free practice. Now, before you assume that this means “concierge medicine” with exorbitant membership fees – let me tell you that it’s not what you think. DocTalker Family Medicine simply charges an hourly rate for my time – and I do whatever is appropriate for the patient, whether it’s a house call, an office visit, an email, or a phone call. There is no membership fee, people can pay with their credit card, cash, check or PayPal, and once we’ve met in-person and a full history and physical is performed, much of their care can be accomplished remotely.

So what does that cost? The average patient in our practice spends $25/month on their primary care needs. Isn’t that amazing? We can charge reasonable rates because we’ve reduced office staff from 4.5 to 0.5 people/provider and we pass on the savings to patients. We answer our own phones, we see almost all patients within 24 hours, and we’re available 24/7 by phone and email. And you know what? We’re happy to do it because we find meaning in every interaction. We aren’t being crushed by a paper weight.

As healthcare reform moves forward, and new ways are sought to wring money out of a crazy and convoluted system, it might just make sense for some of us to opt out and get back to basics: a doctor or nurse available 24/7 for your primary care needs at a price you can afford. No red tape, no unnecessary office visits, no insurance company hassles.

Anderson Cooper sent a reporter to our practice to see for herself what hassle-free medicine actually looks like. I hope you enjoy the segment… and if you’re in the DC or Virginia area, please check us out for yourself!

This post was originally published at Better Health.

Perhaps you’ve seen it: the grocery-shopping mom, complaining about a sugar tax, saying it’s hard enough to raise a family in these times.

I saw it, and could not believe it. Was this ad actually claiming that families need sugared sodas to make it through tough times?

It took watching it on line at http://www.nofoodtaxes.com/ads/ several times to see that yes, indeed, that’s what it claimed.

I’ll agree that a soda and other sugared items are a nice occasional treat, but I see no evidence that they’re necessary to keep a family happy – or that there are no alternatives.

I’ve begun talking to kids about what they drink. Here is what I got:

• I used to drink apple juice, now I drink water.
•  I drink water; that’s good for you.
•  I drink milk when I eat and water other times.
•  I used to drink (naming a brand soda) but now I drink water. The (soda) made my feel icky and I did not know how much until I stopped drinking it all the time.

Personally, I’m not a huge fan of plain water. I like a slice of lemon in it.

What about you?

Do you have a favorite alternative to sugared drinks?

Do you have any recipes for the beleaguered Mom trying to keep her family happy in these tough times? Do you have any tricks for weaning a family off sugared drinks?

Big news: The FDA is holding a public hearing to discuss online promotion of FDA-regulated medical products – including prescription drugs, prescription biologics, and medical devices. The hearing will be November 12 and 13, 2009 in Washington, DC (registration closes October 9 – see also registration instructions from Eye on FDA), but public comments can be submitted in writing or electronically now through February 28, 2010. View the docket details and full Federal Register notice.

A common reaction around the Web has been “Finally!” – with remarks like “This is NOT a Hoax!” and “Just in time for Web 3.0,” the FDA has set a date to start figuring out “how to deal with Web 2.0.” (NPR Health Blog).

But after the initial shock and sarcasm subsides, the potential significance of the FDA’s (albeit long overdue) move forward this week starts to sink in – this could result in the most significant set of regulations since the FDA’s guidelines for broadcast direct-to-consumer (DTC) advertising in the late 1990s. We’re talking industry-changing stuff here – or rather, industries-changing, because you can be sure that pharmaceutical companies, physicians, consumers, Internet and social media companies, the advertising and public relations industries, and everyone whose revenue includes online advertising are all major stakeholders in this public policy debate.

So what has the FDA highlighted as the key elements for discussion of this issue? (List below drawn from the 9/21/2009 FR notice)

1. For what online communications are manufacturers, packers, or distributors accountable?
   • (paraphrased) What communications and discussions should be considered “by, or on behalf of” versus independent of influence from these companies – and when and how should companies “disclose their involvementor influence,” particularly “on third-party sites”? Should different types of online media platforms and different intended audiences of these platforms be considered differently when addressing these questions – if so, how?
2. How can manufacturers, packers, or distributors fulfill regulatory requirements… in their Internet and social media promotion, particularly when using tools that are associated with space limitations and tools that allow for real-time communications (e.g., microblogs, mobile technology)?
   • (paraphrased) How should product information be presented on these platforms so that users have appropriate access to both risks and benefits?
3. What parameters should apply to the posting of corrective information on Web sites controlled by third parties?
4. When is the use of links appropriate?
   • (paraphrased) Should there be rules about the use of “links to and from Web sites,” including links to or from unbranded websites to or from clearly branded company websites? And what research and data exists about the click-rates in different contexts of users seeking information about medical products?
5. Questions specific to Internet adverse event reporting
   • (paraphrased) How are companies that are obliged to report adverse effects of products using online media tools, if at all, to monitor information about adverse effects of their products? Should these companies be obliged to monitor and/or report information from online communications concerning adverse effects of their products?

We – and the FDA – want to know what you think. What are your gut reactions to all of this – do you find anything particularly worrying, are there any potential outcomes you’re especially hoping for?

If you submit any comments to the FDA – and we hope you will – come by and tell us about it in our comment section here (and we promise to do the same). More information about the public hearing and submitting comments is available here.

Several months ago I was attending a funeral.  After being introduced to a relative’s relative, my family member asked me if I knew what had happened to Mr. Smith, pointing to the elderly man walking with a cane.  It was a miracle my family member said.  A miracle I wondered, looking skeptically at him.  Yes, Mr. Smith was having a CAT scan and the results showed that he had pancreatic cancer.  A miracle I asked, why so.   As it turned out the patient, who in his early 80’s went to his doctor complaining of not feeling well.  Abdominal pain. Distention.  General malaise and discomfort.  One thing led to another and CAT scans were ordered.   And as the family story goes, “by mistake” a CAT scan of his pancreas was performed.    And as I understand the story, the tumor was removed.  No metastasis was found.  The gentleman was advised to be sure to come in for his scheduled checkups and to tell his doctor about any subsequent health problems, and to be prepared for follow-up tests.   He was told that some tests will be repeated in order to see how well the treatment is working.  The recent death of actor Patrick Swayze reminds us that pancreatic cancer is so difficult to detect and diagnose early. There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer.  The signs of pancreatic cancer, are often like the signs of many other illnesses.[1]   Hmmm, I agreed, a miracle by accident.

As I check Facebook before going to Program Planning for Health Behavior Change class, I can’t help but look at this pre-class behavior of mine in terms of some of the concepts I am learning in the classroom. We can keep in touch with all of our friends quickly and efficiently with the click of a button and thanks to the Internet, but on the whole we aren’t quite as compulsive about getting the recommended nutrition, exercise or health services upon which our livelihoods depend.

Much blame has been put on individuals for not exercising, eating properly, or managing their chronic conditions, thus burdening the healthcare delivery system. Some ask, if we have tons of healthcare literature out there and people know what is the ‘right’ thing to do—eat 3-5 fruits and vegetables a day, exercise for 30 minutes most days of the week, etc.—why aren’t people more adamant about taking care of themselves?

Sure, people are accountable for their actions. But I ask, what is it about the environment we live in that makes it so easy to instill the habit of checking Facebook constantly, yet so difficult to inspire people to take care of themselves? Why aren’t venues that sell fresh fruit and vegetables as abundant as fast food restaurants? Why has the food industry been able to sell us larger portion sizes that provide a bargain for our pocketbooks but make us chronically sick? Why are we so reliant on automobiles and don’t live closer to where we work, shop, go to school, etc.? And since we don’t walk or bike everywhere, why are our lives so demanding that we don’t have time to make moderate exercise part of our daily routines?

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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.

In the midst of furious showdowns on health care reform at town hall meetings, a moment of peace surfaced in Montana when President Obama drew bipartisan applause after calling a mother heroic.  This mother of two had voiced her concern about the Medicaid program she relied on for her child who has multiple chronic conditions.  The president reassured her and went on to discuss how our disease-care system does not proactively manage chronic conditions.

Children and young adults with chronic medical conditions and disabilities (CMCD) need proactive management now and for their entire lives.  Our health care system fails to serve the young people who need it the most.

Children with CMCD are completely dependent on adults for their health care.  Poor health management negatively affects their growth and development, education, and socialization – and drags the entire family down.  As the mother of a young adult with CMCD and the founder of a non-profit created because of our experiences with poor quality health care, I cannot understand why this population is not a major focus of health care reform.

One path to start on is to build on successful programs to create a comprehensive system of care.  Take a look at the 35% of children with CMCD covered by SCHIP/Medicaid. Medicaid provides a specialized set of comprehensive services known as EPSDT, Early Periodic Screening, Diagnosis, and Treatment Program. The current model of care in favor for chronic conditions is the medical home. First conceptualized by the American Academy of Pediatrics for children with CMCD in the 1960s, the medical home has yet to become the standard of care for children with CMCD in Medicaid.  Pairing EPSDT with the medical home would be a step forward in developing a system of care for children covered by Medicaid.    Another step is to expand EPSDT and medical homes to cover the remaining publicly covered children with CMCD enrolled in SCHIP.

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