Prevention

The New York Times Economix blog, following up on last fall's "Ideal Stimulus Package" grab bag of ideas, invited a whole bunch of consumers, patients, workers, doctors, businesses, insurance companies, tax and public finance experts to opine about what health care reform should look like (not sure if they asked the trickier question of how to pay for it). First batch of responses is up now. Check back later for more.

It took more than a decade but the Senate has passed sweeping legislation to give the FDA authority to regulate nicotine and tobacco advertising. Stopping tobacco use is the mother of all preventive health measures. And prevention is a big missing link in our current health care system—you know, the system we want to change.

The vote was a strong bipartisan 79-17. That's a good omen for those of us who would like to see some bipartisanship on health care reform (in an era when we are not seeing a lot of bipartisanship.). 

Matt Myers, president of the Campaign for Tobacco-Free Kids, (whom I have known for many years and who has toiled longer and harder for this moment than anyone I can think of), said:

Sen. Robert Byrd, 91, entered the hospital last month with what his office described as a minor infection.

And then he got a major infection. Acquired in the hospital. His office has said the staph infection is responding to treatment, but it has kept the frail West Virginia senator in the hospital for nearly a month. 

Reducing such infections has been a major goal of the health care quality movement. But now, the recession is forcing some hospitals to cut back on their infection control budgets, Maryn McKenna writes on her Superbug blog. Some of these infections can be mild; others are fatal. The CDC estimates that about 1.7 million people acquire some form of infection in the hospital each year; nearly 100,000 die. They also add billions of dollars to our health spending.

In a survey of 2,000 infection preventionists—conducted by the Association for Professionals in Infection Control and Epidemiology—41 percent reported cuts in funding for infection-prevention efforts in the past 18 months due partly to the struggling economy.

You've heard of the medical home? Well, we're here to tell you about what you might consider the medical mobile home.

And it's a mobile home with data!

The Family Van, Harvard Medical School's Winnebago-sized mobile clinic, offers free tests and counseling to medically underserved patients in Boston. Most of them do not have their own doctor, and instead head straight to the emergency room when they get sick.

A study published this week in BMC Medicine found that the van program saved the health care system more than $20 million in 2008 alone. The data, using what one expert called an unusually straightforward approach, is welcome because it's useful to get good solid numbers on  preventive care and cost savings.

The Boston Globe writes:

As US healthcare costs spiral upward and lawmakers debate ways to overhaul the system, a team of Harvard-led researchers suggests that such alternative approaches are an overlooked but valuable return on investment. Using a formula they developed, the researchers figure that The Family Van returns $36 for every $1 invested.

Earlier today we looked at the penny-wise, pound-foolish impact the economic recession was having on our health—skipping a test now that could have prevented a much more costly (and dangerous) disease in the future. To understand why our society fails to invest in wellness and prevention, we need to understand the incentives for health and health care that exist in our current system.

An apple a day keeps the doctor away, but, unless you're counting farm subsidies, all the incentives in health care point the other way. Our fragmented system is filled with cross subsidies and opaque prices that obscure the true value and costs of care. It rewards volume not value, focusing on output, not outcomes. Changing the status quo is not easy. As Dr. Gary Kaplan, Chairman and CEO of the Virginia Mason Medical Center and founding member of Health CEOs for Health Reform wrote on this blog:

When doctors substitute low-margin, high-value care for high-margin, low-value care, they incur an immediate financial penalty. Ironically, doctors often receive much less reimbursement or no payment at all when they provide simple, value-added care.

Former Senate Majority Leader Bill Frist was in town the other day, and we had a chance to talk for a bit after he took part in a distinctly nonpartisan discussion about social determinants of  health (and how much of it comes down to education). While he isn't closely involved in the health reform efforts in Washington, he is watching from afar - and he sounded a lot more encouraged as an outside-the-Beltway Republican than some of his colleagues sound here inside.

Frist divides his between teaching at Vanderbilt, work in global and public health, and his affiliation with a private investment firm focused on the healthcare industry.

You know the clichés about death and taxes. How about wellness and taxes?

Robert Pear of the New York Times reports that Senate Finance Committee chair Max Baucus (D-MT) and Senate HELP committee member Tom Harkin (D-IA) (a long-time champion of wellness and prevention) want to use tax credits or other incentives to encourage workers to live healthier lives.  

There's a growing bipartisan sentiment that our health care system must do a better job at prevention and wellness. Many of our health care problems arise from such factors as tobacco use, obesity, nutrition and lack of exercise. A health care system that addresses these problems—before they make us sick—keeps us healthier and saves money both in health care bills and lost productivity. The challenge for lawmakers is coming up with a way of promoting these goals without having employers or insurers discriminate against people on the basis of their health or medical history (including their psychological history—depression screening can be a component of workplace wellness).

So how's your health? And have you earned any good degrees lately?

American adults just aren't as healthy as they could be, a recent study by the Robert Wood Johnson Foundation Commission for a Healthier America found. Between 2005 and 2007, a little more than 45 percent of adults ages 25 to 74 reported being in less than very good health. And education levels seems to be a factor.

The study, Reaching America's Health Potential Among Adults: A State-by-State Look at Adult Health, found that the greatest indicator of health was education level. Nationally and on a state-by-state basis, people with higher levels of education were more likely to be healthy. Adults with a high school education were more likely to be unhealthy than college graduates. Adults who had not graduated from high school were more than three times more likely to be unhealthy than college graduates. The disparity between education level and health varied from state to state. Delaware was the best (only nine percent difference between overall adult health and overall health of adult college graduates) and California (with a nearly 20 percent difference) was the worst.

A colleague sent us this fabulous opinion piece written by a cardiologist named Lee Biblo that appeared recently in the Milwaukee Journal-Sentinel. It was called "Many paths to a healthier society" and it begins:

I am a physician—a cardiologist, raised in a fee-for-service environment. The more procedures I do, the more I get paid. The more time I spend talking to and counseling patients, the less I get paid. Don't blame me. I didn't set up this screwy system. 

Bilbo devotes a lot of the article to the need for more preventive medicine—practiced not just by health care professionals but by all of us. School boards need to make sure there's healthy food in the cafeteria. Businesses should provide workout areas instead of smoking sections. Governments should structure tax and spending decisions to promote wellness and health. All of us should eat well, stop smoking, exercise regularly, wear seat belts, and understand the importance of screening as well as things like flu shots.

He concludes:

Sorry—fortunately, I am not an employer, a school board member or the government—I have to go now, grab a candy bar and a cola for lunch and then do a few procedures.

Teenagers. They grow up fast—pretty soon they're starting to drive, applying for college, and, according to a recent study, not getting the preventative care they need. And if we're serious about a health care system that promotes wellness, prevention and a long-term effort to bring down rising rates of chronic disease, the teen years are a good place to start.(Not to mention that it might help their parents' blood pressure.)

Using data from the Medical Expenditure Survey, researchers at the University of California, San Francisco determined that only 38 percent of adolescents age 10 to 17 had a preventative health care visit in the past year. UCSF researchers also found that most teens weren't getting counseled on important health issues such as dental care, healthy diet, regular exercise, wearing a seat belt or bicycle helmet, and the dangers of secondhand smoke. Only 10 percent of teens discussed all of these issues with their doctor, and less than half discussed any of these issues with their doctor.