In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Alex Blau, MD, and Brad Cohn, MD.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"This was just something we needed and we were surprised that it didn't exist."—Alex Blau, MD
While working the overnight shift at San Francisco General Hospital, Alex Blau, MD, and Brad Cohn, MD, found themselves at the corner of necessity and invention. The two young physicians in training were in their third year of medical school at the University of California San Francisco in 2008, and they were frustrated by their inability to communicate with patients from the Bay Area's diverse racial and ethnic communities.
"In healthcare your greatest diagnostic tool is your ability to communicate, to obtain a decent history and a physical exam from your patients. This is difficult to do with patients you can't easily communicate with," says Cohn, 29, now a resident in anesthesiology at UCSF and San Francisco General Hospital. "Patients who don't speak the same language as their providers sometimes do not have the opportunity to give that vital piece of information they need to in a timely fashion."
So, the pair came up with the idea for MediBabble—an iPhone/iPad app that allows clinicians to better communicate with nonEnglish-speaking patients during the initial exam and history-taking.
"Understanding a patient’s needs is really critical in developing an app that helps people."—Brad Cohn, MD
"This was just something we needed and we were surprised that it didn't exist," says Blau, 35, an emergency physician who has since left medicine to develop MediBabble. He is also medical director at Doximity Inc., in San Mateo, CA. "We both had iPhones and we thought ‘why isn't there an app that helps us? We can now walk around with computers in our pockets and impressive interface ability. Why don't we have a quick language app that allows us to play some questions for our patients?' Then we realized that we were perfectly situated to do it ourselves."
MediBabble—which is free and does not require Internet access once it is downloaded—focuses on the history-taking process during the initial patient interview.
"We specifically rewrote all of basic medical history taking," Blau says. "It turns out that most of the information we look to get as physicians is fairly predictable, depending upon a patient's complaint. We were able to organize history taking in a standard fashion, the way most physicians will approach it, based on patients' chief complaints and wrote out all of the questions that a physician would want to know the answer to."
Blau and Cohn and their small technical support staff at the company they formed—NiteFloat Inc. —had the questions translated by native speakers into six languages: Russian, Spanish, French, Cantonese, Mandarin, and Haitian Creole—the last of which was rushed into production to help clinicians in the earthquake relief effort on Haiti.
"Say a patient comes in complaining of chest pains," Blau says. "You simply pull up chest pain section and it will have the list of questions organized in the chronology you would normally want to ask as a clinician. You tap on your device and it will play those recordings that have been laid down by these professional interpreters out of the speakers of your device. It would be like they are hearing the interpreter in the room with them."
Blau stresses, however, that MediBabble is no substitute for a flesh-and-blood translator. "The tricky part obviously is how do you understand their response?" Blau says. "We wrote this history so it is all closed-ended questions that require only ‘yes' or ‘no' responses or gestural responses, such as pointing to a body part or holding up a number of fingers to indicate pain on a scale of 1 to 10."
Cohn says they intentionally limited MediBabble's ability to obtain information from patients. "You can't give information to a patient using MediBabble," he says. "This is for an emergency situation where collecting data quickly will allow you to improve the patients' health or allow you to get critical health information. It boils down patient responses into a format where you don't need to actually speak their language to understand their replies. But in order to give that information back to a patient you need to work with a medical interpreter."
The response to MediBabble has been strong. Since it was launched in February 2011, more than 15,000 clinicians have downloaded it. MediBabble was also voted the No. 3 new app of 2011 for internists and residents by the influential physician-review Web site iMedicalApps.com, which called it a "most superior" translation device.
Blau says NiteFloat wants to expand the breadth of the questions, the languages offered, and the content. "Right now it is focused on broad emergency and primary care complaints. But we have had a lot of specialists request additional content in areas such as OB/GYN and anesthesia," Blau says. Plans are also under way to launch an "internationalization feature" that will allow, for example, Russian speaking physicians to communicate with Spanish speaking patients.
While it's not charging a fee for MediBabble, NiteFloat asks users to donate money. "We have no plans to charge for the service. We continue to pay for MediBabble's development ourselves, but we're looking for foundation support," Cohn says. "We are technically not a non-profit, but we are also technically not profitable."
The growth of medical apps is exploding, with thousands of offerings for medical professionals and patients. For healthcare applications to be effective, Cohn says, there will always be a need for the physician's perspective. "You can build an app for what you know best," he says. "The more you work in the system as a physician, the more you can identify true need. The more time I spend with patients, the more I come to appreciate their struggles and what benefits them. Understanding a patient's needs is really critical in developing an app that helps people."
Sometimes people in the healthcare industry over think issues. It's all done with the best intentions, but a simple concept such as patient satisfaction can be made to appear as complex as ICD-10. Set up a study committee. Earmark funding. Conduct a survey. Mount a marketing plan. Hire a consultant.
A story last week in The Kansas City Star provides an excellent example of how common sense customer service can have a profound impact on patient satisfaction.
Since 1999, The Star report notes, The University of Kansas Hospital in Kansas City, KS, has relied on medical technician Paula Miller to lead a customer service training program. Miller's trained about 12,000 staff—from the C-suite to physicians to parking lot attendants—on the finer points of making patients happy. As a result, patient experience scores have gone from the single digits to the high 90s.
The curriculum at KU Hospital—as it's explained in The Star piece—is basic because the message is fundamental: Treat people with respect. Miller encourages her students to look people in the eye, speak gently and respectfully, and use titles like Mr., Mrs., and Ms., when appropriate.
While the story has a feel-good element to it, there is also a bottom-line component. We all know that starting next October dollars will be attached to higher Medicare patient satisfaction scores.
There are several takeaways from the story that can be applied by any healthcare organization willing to make an effort. The best part of the story is that KU Hospital didn't need a complex program, an arcane marketing scheme, a big consultant contract, a bright and shiny ad campaign, or a new customer service department with pricey specialists to get the job done.
Hospital leadership saw a need and identified the right person to lead the program.
Miller dedicates four days a week to her job as a medical technician. Every Wednesday, she leads customer service training for new employees.
While KU Hospital has not dedicated a large financial commitment to the customer service program, leadership has clearly invested a personal commitment to its success. Miller was picked by KU Hospital President Bob Page to lead the program in 1999, and her efforts still carry the vocal and visible support of the C Suite. That makes a huge difference. If staff doesn't believe that leadership is behind an initiative, it will fail. Hospital workers are remarkably adept at sniffing out a fraud.
The KU Hospital customer service program is well-structured with definite goals. And, it applies to all new hires. That is critical. The quickest way to kneecap such a program would be to exempt from participation a select caste of workers or executives. That sends the immediate and negative message to the rest of the staff that customer service is merely another mandate from on high to be obeyed by some and not a core value embraced by all.
Miller reminds her students that patients and their families are not always at their best when they are in the hospital. They could be in pain, or frightened, confused, or anxious. Miller encourages employees to empathize with these people who may be going through a traumatic experience. The new hires are left with the understanding that courtesy and respect are job requirements, not electives.
"There's plenty to do here. But patients should never get the feeling that we're too busy to take care of them," Miller told The Star. "People are not numbers. They're people, whether they're patients or co-workers. And when we treat each other the way we want to be treated, that's excellent service."
None of this is complex. This is not gene therapy or face transplant surgery. This is about common sense and courtesy at its most basic level. This is about treating people the way you want to be treated —the stuff our parents taught us. It doesn't take long to learn but once learned it goes a long way. This is something everyone can do.
The message from KU Hospital is as clear as its return on investment.
Primary care physicians say pervasive and stubborn social barriers such as a lack of access to adequate housing, transportation, and nutritious, affordable food may impact patient health as much as access to direct medical care, a survey shows.
The online survey of 1,000 primary care physicians, including 310 pediatricians, was conducted in September and October on behalf of the Robert Wood Johnson Foundation.
"What really becomes clear is that when you think about providing care, we have to think about more than just the medical service delivery system," Jane Lowe, team director for the Vulnerable Populations Portfolio at RWJF tells HealthLeaders Media.
"We have to think about how do we help physicians connect their patients to other providers or to services that are going to have as much impact on their health outcomes as the physician visit will have?"
They survey found that:
85% of physicians say unmet social needs are directly leading to worse health for all Americans.
85% of physicians say patients' social needs are as important to address as their medical conditions. This is especially true for physicians (or 95%) serving patients in low-income, urban communities.
76% of physicians want the healthcare system to cover the costs associated with connecting patients to services that meet their social needs if a physician deems it important for overall health.
Only 20% of physicians feel confident or very confident in their ability to address their patients' unmet social needs.
Physicians said that if they had the power to write prescriptions to address social needs, these would represent 1 out of every 7 prescriptions they write— or an average of 26 additional prescriptions per week.
Lowe says the survey reflects a tremendous frustration on the part of primary care physicians who every day see barriers to good health that their patients face in the world beyond the office visit.
One common example of a stubborn environmental barrier that is cited by physicians is childhood asthma triggered by mold in substandard housing.
"If you are a physician, particularly a pediatrician, and you know the asthma could be easily managed if the environmental factors were changed, that has to be enormously frustrating," she said.
Lowe says the long-term costs of frequent asthma attacks have to be measured along with the short-term costs of frequent trips to a pediatrician or the emergency department.
"Asthma one of the biggest single causes of school absenteeism and it causes children to fall further and further behind in their studies," she said. "It has tremendous implications for their growth and development not just physically but socially, emotionally, and educationally."
Lowe says primary care physicians simply don't have the time to chase down and correct the socio-economic conditions that lead to adverse health effects for their patients. With that in mind, Lowe says she hopes the survey will bolster support for a RWJF-funded program called Health Leads that is now underway in about a half-dozen cities across the nation.
Health Leads relies on trained volunteer college students working with healthcare providers to identify social issues such as substandard housing or poor nutrition that may adversely impact patients' health. In addition, some hospitals team up with legal aid attorneys and other interdisciplinary teams that include social workers who take on substandard housing issues and other barriers.
"We are not naïve to think that physicians are going to do this," she says. "The most hopeful thing about this survey is that physicians are recognizing that there are these unmet social needs that are important to address, even though they don't know what to do about it."
Closing a safety net hospital kicks up a significant ripple effect for primary care physicians and underscores the need to involve those providers in the planning and aftermath of such a disruptive process, a study has found.
"The primary care doctors were trying to figure out what they were going to do," study lead author Kara Odom Walker, MD, told HealthLeaders Media. "They were really frazzled by the whole upheaval and trying to deal with it the best way they could. There was a lot of rich conversation that did not make it into the study."
The study found that many of the primary care physicians complained of profound professional and personal upheaval owing to the disruption of the care network. "A lot of medicine is informal networks of care where you call your friend, your local gastroenterologist who has been there forever to see your patient in who needs to be seen sooner than later," Odom Walker says.
The disruptions included reduced access to specialty care, overcrowding at nearby hospitals and emergency departments, delayed and poorer quality of care for patients, reduced communication and disrupted patient connections, and a loss of colleagues and opportunities to teach residents and medical students, the study reported.
"The usual way of doing business was completely disrupted and patients were confused," Odom Walker says. "It wasn't that their doctors' doors were closed, but patients felt like 'Oh my goodness what should I do next?' They were showing up with more acute issues at their physicians' offices or running out of medicines because a lot of these patients go to the emergency room and use it to refill prescriptions."
The study calls for greater input and participation from primary care physicians when a major disruption such as hospital closures loom in a healthcare delivery system.
"When a hospital closes or downsizes they really do need to think more about what happens to the primary care doctors because oftentimes they are not at the table," Odom Walker says. "Primary care doctors really know what is happening at the ground level but they are too busy seeing patients and keeping the doors open on their hamster wheel. They do experience the impact and they need to know what alternative strategies are available to get patients into care."
Odom Walker says she was not surprised to hear about the disruption within the MLK service area. However, she was surprised to learn that physicians from outside of the service area also were impacted by the hospital's closure.
"This was a safety-net hospital where mostly uninsured patients went. So you wouldn't expect private-pay patients and physicians who are mostly serving insured populations to be affected, but there is a ripple effect," she says.
"Even within the nearby Kaiser system, because those patients didn't have anywhere else to go, they just showed up in the ED and they couldn't be turned away. Then there were referrals through the ED with specialty care. You saw those delays building up."
The study did not specifically examine the emigration of physicians from the area after MLK closed, but Odom Walker says there is anecdotal evidence to support their departure.
"People did talk about how their colleagues were leaving and not going down the street—they were going to different parts of the state or out of state," she says. "It was not so much in primary care, but many of the specialists who were committed to serving an underserved population said, 'If I can't practice here anymore I will go somewhere else.'"
Odom Walker says she's not sure what could have been done differently when MLK closed.
The hospital lost its accreditation and shuttered with little warning. "But if more primary care physicians were at the table they would have thought about how to get the word out a little better so patients wouldn't have experienced so many delays in care, or put off getting medications refilled, that there were doctors still in the area to take care of them, and an action plan to get them to the care that is needed," she says.
With Medicare and Medicaid facing possible budget cuts, Odom Walker says it's time to develop some uniformed procedures for hospital closings so that other communities aren't thrown into disarray if their safety-net hospital shutters.
"That would be an important next step—thinking through who, what, when, where, and how to do this in a way that doesn't affect people's lives," she says. "Right now there is no true oversight of a hospital closing. It is a contract with the community and no one is there to oversee that bond."
Healthcare created 17,200 jobs in November—a healthy increase from the 11,600 jobs created by the sector in October.
Healthcare remains a leading source of job creation in the overall economy, and was responsible for 14.3% of the 120,000 new jobs across all sectors in November, data from the Bureau of Labor Statistics shows.
Through the first 11 months of 2011, healthcare created 295,100 jobs—more than the 263,400 healthcare jobs created in all of 2010. Healthcare is on a pace to create 321,000 new jobs by year's end. So far this year, the 295,100 new healthcare jobs represent more than 24% of the more than 1.2 million non-farm jobs created in 2011.
Hospitals created 8,700 new jobs in November. The 83,200 new hospital jobs so far in 2011 are more than double the 37,300 new hospital jobs reported in all of of 2010, BLS data show.
Ambulatory services, which includes physicians' offices, created only 4,700 new jobs in November, after reporting 17,000 new jobs in October, 23,400 new jobs in September, and 20,200 new jobs in August. Ambulatory services have been responsible for 58% (171,800) of new jobs in healthcare so far in 2011, and created 166,100 new jobs in 2010.
Physicians' offices created 63,700 new jobs in the first 11 months of 2011, compared with 25,300 jobs created in that subsector for all of 2010. Physicians' offices created 2,700 jobs in November and 8,000 jobs in October after posting 9,700 new jobs in September.
BLS data from October and November are preliminary and may be revised considerably in the coming months.
More than 14.1 million people worked in the healthcare sector in October, with more than 4.7 million of those jobs at hospitals, and more than 6.2 million jobs in ambulatory services, which includes more than 2.3 million jobs in physicians' offices.
In the larger economy, the nation's unemployment rate dropped from 9% to 8.6%—its lowest level since March 2009—fueled by 120,000 nonfarm payroll additions. Nonetheless, 14 million people were unemployed. The number of long-term unemployed, defined as people jobless for 27 weeks or longer, was 5.7 million in November, essentially unchanged from October, and represented 43% of the unemployed.
A study this month in the journal Academic Pediatrics provides a pithy example of a persistent disconnect for the wellness movement in the healthcare workplace.
The study by researchers at the UCLA School of Medicine and the RAND Corp. examined the menus at 14 children's hospitals in California and found that only 7% of the nearly 400 entrees were considered healthy.
"As health professionals, we understand the connection between healthy eating and good health, and our hospitals should be role models in this regard," Lenard Lesser, MD, the primary investigator on the study, said in a media release. "Unfortunately, the food in many hospitals is no better—and in some cases worse—than what you would find in a fast food restaurant."
While the study concentrates on children's hospitals in California, it is not unreasonable to suggest that these poor nutritional standards could be found in many other hospitals across the nation. If so, the study illustrates that while many hospitals talk the talk on improving nutrition, staff, patients, and visitors at hospital cafeterias still chew the fat.
Most—if not all—hospitals ban tobacco use, so they probably don't sell cigarettes in the gift shop. Why then should the standards be different for unhealthy food? Health issues related to overweight and obesity are key healthcare cost drivers. We all know that. So why promote it?
Simply stated, if your workplace wellness initiative features a weight loss program—or especially if you're contemplating heftier health insurance premiums for heftier employees—you shouldn't be selling cheese fries and sugary drinks in the lunchroom.
Yes, it's a matter of choice and will power. But why, as champions of healthier living, would hospitals provide a temptation to people who are trying to improve their health? Would you wave a Marlboro in front of an ex-smoker?
The UCLA/RAND study found that many hospitals provided healthy alternatives such as fruit, but that less than one-third of the hospitals provided point-of-sale signage that offered nutritional information or promoted healthy eating.
Even worse, 81% of the hospitals offered high-sugar items such as cookies and ice cream near the cash register—which any tabloid news junkie or candy bar fiend at your local supermarket will confirm is Ground Zero for impulse buying.
In addition, half of the hospitals in the study did not indicate to consumers that they carried healthy entrees, and 44% did not have low-calorie salad dressings. Cracker Barrel and Shoney's do that!
There is some good news. While the findings were released this month, the study was conducted in July 2010 and the researchers said that since then some hospitals have taken steps to eliminated unhealthy offerings. For example, some have eliminated fried foods, lowered the prices for salads, and hiked prices for sugary drinks, or eliminated them altogether.
Lesser said it best: "If we can't improve the food environment in our hospitals, how do we expect to improve the health of food in our community? By serving as role models for healthy eating, we can make a small step toward helping children prevent the onset of dietary-related chronic diseases."
Phrases such as "practical-minded" and "consensus-builder" are used a lot when friends and colleagues of Marilyn Tavenner talk about the No. 2 administrator at the Centers for Medicare and Medicaid Services.
Tavenner, who has served as a nurse, HCA executive, and Virginia health secretary, was nominated by the Obama administration last week to replace Donald Berwick, MD, as administrator at CMS.
By most accounts, the low-key and soft-spoken Tavenner will not bring to the top job at CMS the "visionary" status that Berwick enjoyed among the healthcare intelligentsia. The comments of Tavenner's friends and colleagues, however, suggest that she is a highly competent expert in healthcare administration who is also not laden with the issues that made Berwick's tenure contentious. Berwick assumed office as a recess appointment by the Obama administration nearly 18 months ago. He leaves CMS on Dec. 2, weeks before his term was to expire. Republicans vowed to block his confirmation.
"She is not going to be a bomb thrower. She is not going to be tossing political hand grenades," says Virginia State Sen. Edd Houck, D-Fredericksburg. Houck worked with Tavenner when she was secretary of Virginia Health and Human Resources from 2006 to 2010 under Democratic Gov. Tim Kaine.
"I keep coming back to the same word, she is so pragmatic in working toward a mutual result that if folks would let that attribute come through they would find that she is a true professional," Houck says. "She has been in healthcare her whole life. She is not a politician. She is a healthcare practitioner."
Although she served under a Democratic governor, Houck says Tavenner worked well with Republicans in the Virginia Senate. "Marilyn was agile and sensitive to the partisan differences. She was politically astute," he says.
Erik Swensson, MD, the CMO at Capella Healthcare, has known Tavenner for 26 years and saw her rise in the ranks from nurse to CEO at what is now HCA's CJW Medical Center in Richmond, VA. Since then, Tavenner has served as a regional executive for HCA.
"She is very comfortable in her own shoes. She knows who she is. She knows what she wants to do but she also understands how to get things done and what things can and cannot be," Swensson says. "CMS is in an extremely difficult setting given the politics of the country. But for somebody who has taken care of patients, dealt with physicians one on one, dealt with hospitals on multiple levels, and on the private side and the state side and now on the federal side, she is one of the very few people who would have that experience."
Swensson sat on the board at Johnston-Willis Hospital when Tavenner applied for the CEO job.
"We had more-senior applicants, but I remember when Marilyn had her time before the board she said 'You all know me. I know you. I know what this hospital needs. I know what it takes to run it. I know I haven't been a CEO before but I can do this job and I won't let you down,'" Swensson says. "She said it with sincerity that we knew Marilyn had, so we gave her the job, and she didn't let anybody down."
Later, when Johnston-Willis merged with nearby Chippenham Hospital, "Marilyn brought them together and without much rancor," Swensson says.
"She saw who the players were and she saw what their issues were and she talked to them and got things resolved. It wasn't like Marilyn was coming in with Marilyn's vision of 'this is what you have to do.' Her attitude was 'let's find out how we are going to get it done.'"
Laurens Sartoris, president Virginia Hospital and Healthcare Association, has known Tavenner for years, and says that while she brings a formidable level of expertise to the job, she is not a mere policy wonk or a technocrat.
"When you use the term technocrat there is almost a pejorative sense to it," he says. "To be a technocrat and try to run something means you probably get lost in the weeds. Marilyn doesn't get lost in the weeds. Not that there isn't an important place in the world for policy wonks but I would never characterize Marilyn as someone with her head in the clouds."
In many respects, Sartoris says, Tavenner reflects the character of the people in rural Henry County in western Virginia, where she was raised. "Her feet are very firmly planted," he says. "She is also a person of few words. She doesn't talk to hear herself think and for a long time she has been used to getting to the nut of the problem and trying to address it without a lot of the other distractions that may surround it."
"It is the way she has always been. See a problem. Analyze it. Come up with an approach you are going to take and make the decisions," he says. "Considering the job she is going into, decision making is an important part of process with all those different pots boiling on the CMS stove right now."
Sartoris declined to speculate on the suggestion that Tavenner was picked because she provides a sharp contrast to Berwick.
"I can't say why the White House picked her, but I can tell you why I would pick her," he says. "Marilyn has the necessary management skills to deal with a large and extremely complex organization and be a quick decision maker, using appropriate analysis of the appropriate facts presented. That is the Marilyn I have known for a long time."
Houck says he believes Tavenner could flourish at CMS if Congress will give her the chance. "If they could lay aside the partisanship and work with Marilyn, I think they will find she is very easy to work with in terms of trying to get a mutual agreeable result," Houck says. "But I am not sure that is part of the equation in Washington these days."
We need a new holiday to commiserate our annual health insurance renewals. We could call it National Premium Supplication Day. Hallmark could issue a special greeting card:
"On Premium Supplication Day, We Brace Ourselves for More to Pay. We See the Co-pay Costs Uptick, and Pray To God We Don't Get Sick."
Every year about this time, people across the nation who are lucky enough to have jobs -- and lucky enough to have healthcare coverage through their jobs – head to HR to find out how much more of their paycheck will go toward premiums, deductibles and co-pays, and what benefits they'll lose.
For many workers, those insurance hikes will eat most -- if not all -- of the relatively small annual raise they may have received. The high deductibles will make access to preventative care unaffordable for many.
Companies aren't to blame. They try their best to make healthcare affordable to their employees – often subsidizing the cost to a great extent. When it comes to controlling healthcare costs, most companies are as powerless as their employees. Healthcare is expensive, and there is nothing to suggest that it will get any cheaper.
Mercer this month released a study which shows that the national average cost of healthcare benefits was about $10,146 per employee, up 6.1% from the previous year. The Mercer estimate is conservative. The Kaiser Family Foundation/Health Research & Educational Trust 2011 Employer Health Benefits Survey reported in September that the average annual premium for family coverage increased by 9% to $15,073 in 2011. Since 2001, KFF/HRET noted, family premiums have increased 113%, compared with 34% for workers' wages and 27% for inflation.
Whatever cost growth estimates you pick, they are unsustainable. At some point, perhaps sooner than later, businesses will determine they can't afford to provide healthcare coverage. Some surveys have suggested that many businesses have already made the decision to drop their coverage in 2014 when provisions in the Affordable Care Act take effect, particularly the individual mandate.
It would be no small irony if our for-profit healthcare system prices itself out of existence and ushers in a government-sponsored single-payer system. We are trending that way as "cost containment" in our healthcare system has come to mean passing more of the financial burden onto the healthcare consumer.
It is under these circumstances that we are seeing a surge in the wellness movement – the idea that employees should take greater responsibility for their health or pay the consequences.
At face value it seems reasonable. Why should the rest of us pay for your lousy lifestyle choices? However, the wellness movement also has huge potential for abuse and discrimination. It also raises troubling questions about who gets thrown overboard, and where we draw the line on employer intrusions into our personal lives.
For example, The New York Times reported this month that – rather than rewarding good behavior – a growing number of employers are telling workers who smoke, are overweight, or have high cholesterol to pay a larger share of their healthcare costs. According to The Times, policies that impose financial penalties on employees' poor health choices have doubled to include 19% of 248 major U.S. employers. Benefit consultants Towers Watson projects a doubling of that number again next year.
The case against smoking is obvious. It's a vile, dangerous, and expensive habit that claims thousands of lives and costs billions of dollars each year for otherwise preventable healthcare. If you light up, you should pay more.
It gets a little stickier, however, with issues like high cholesterol, and overweight. How will companies determine how much more an overweight employee will pay? Will they literally exact a pound of flesh? Will we have a ritualized public weigh-in on Premium Supplication Day?
There are also economic issues at play here. Studies have shown that people who earn less money tend to be more inclined toward overweight, use tobacco, and engage in other unhealthy lifestyle choices. Are we prepared to impose another tax on the people who can least afford it?
Cigarettes cost more than $50 a carton, so smokers can afford to pay more. Again, it gets a little trickier with obesity and high cholesterol. Maybe that well-intentioned smoke-free-but-overweight worker lives in a rougher neighborhood that doesn't provide safe and convenient venues for exercise.
Maybe the closest Whole Foods Market is across town, and the only store nearby is a Kwikki Mart that is known more for its microwave burritos than for fresh produce. Maybe that worker has two jobs and doesn't have the energy at the end of a 16-hour day for a jog around the block on dimly lit streets. Are we are going to punish this person?
There is also the slippery slope argument about wellness that affects everybody because we all have bad habits. Smoking and obesity are low-hanging fruit. The wellness crusaders will return. Will social drinkers be told to stick a cork in it or pay more? What about rock climbers, sky divers, bicyclists, skiers, or others who take part in nominally hazardous hobbies? Will they be told to limit their exercise to a treadmill? And, how and who will we test for compliance?
It probably won't play out like this, but this is not a far-fetched scenario. The wellness movement might slow healthcare cost growth, but it won't stop it.
Along with the annual hikes for premiums, co-pays and deductibles, National Premium Supplication Day may soon provide workers with a list of personal fitness mandates. Much of this seems like rearranging deck chairs on a sinking ship.
As healthcare costs continue to rise, like frightened passengers, we'll become more desperate about containing those costs, and more willing to toss to the sharks those lesser among us who don't pass muster.
Uninsured patients spend less time in the hospital than insured patients, according to a study that suggests that ability to pay plays a greater role than medical need when determining length of stay.
"The only two explanations we could come up with are either people without insurance are being discharged prematurely or hospitals are keeping people who can pay longer to increase revenue," Arch G. Mainous, III, the author of the study, told HealthLeaders Media.
The study, published in the December issue of Annals of Family Medicine, examined nearly 850,000 adult discharges between 2003 and 2007, at for-profit, non-profit, and government hospitals nationwide. The findings show that in hospitalizations for ambulatory care-sensitive conditions – which should have been avoidable through disease management and preventive care -- uninsured patients stayed an average of 2.8 days.
Privately insured patients stayed an average of 2.9 days, and Medicaid patients averaged 3.2 days. For patients hospitalized with non-ACSCs, the average length of stay averaged 2.7 days for the uninsured, compared with 2.8 days for the privately insured, and 3.1 days for Medicaid patients.
"We have relatively robust findings that appear over and over that people without insurance, regardless of what they come in for, stay a shorter period of time, even on things where they might be sicker," says Mainous, a researcher with the Department of Family Medicine at the Medical University of South Carolina, in Charleston.
"We controlled for how sick they were. We controlled for people who left the hospital early against medical advice. It still shows up," he says.
The study found that in-hospital mortality for uninsured patients with non-ACSCs was higher than at both nonprofit and for-profit hospitals, while there was little difference in mortality among patients hospitalized for ACSCs.
Mainous says the findings "are not completely surprising but very distressing."
"Healthcare businesses providing uncompensated care would be like providing uncompensated hamburgers at McDonald's. There is only so much you can do in terms of supplying free stuff," he says. "As we see the proportion of people without insurance continuing to rise, it is a wake-up call. Are we going to have a two-tiered system where there is going to be a small proportion of people who get a level of care and others who don't?"
Mainous says the study isn't about a chasm between rich and poor so much as it is about the insured and the uninsured. "If you look at the Medicaid group, they did actually well," he says. "Those folks seem to stay in as long as the privately insured, or ever longer. The cut point for access to care is insurance."
Mainous says he hopes the study will help policymakers as they try to determine how this nation will pay for healthcare. "We are probably going to move more and more away from employer-based health insurance. As we do that and more people become uninsured it is going to be a big issue. If you go from 46 million without insurance to 100 million people without insurance I don't think it is sustainable," he says.
"This boils down to the final ethical issue: Do we consider healthcare a business? That is the take home question. If you consider it a business then you let in people who can pay your fees and you try to make money," he says. "If you don't consider it a business, then we need to look at it in a different way."
The average per capita cost of healthcare services covered by commercial insurance grew by 8.03% over the 12 months ending in September, while costs for Medicare healthcare services grew by only 1.97% for the same period, Standard & Poor's Healthcare Economic Indices show.
The two cost growth indices have both grown in the last several months but at significantly different speeds, with commercial plans far outstripping Medicare, even with the federal healthcare program's older, sicker population, which uses healthcare services more.
David M. Blitzer, chairman of the Index Committee at S&P Indices, attributes the variance in cost growth trends to "the fact that the rate-setting process is administrative and subject to administrative and political issues instead of economic issues."
"It's real obvious," Blitzer told HealthLeaders Media. "It's some guy who may not care that much saying, 'Here is how much you are going to charge. Period! Don't bother me!' That is going to have a different result than if it is negotiated in the market. That's not politics. It's kindergarten economics."
Robert Zirkelbach, spokesman for America's Health Insurance Plans, agrees with Blitzer that the different rates of growth for commercial plans and Medicare can be attributed to cost-shifting.
"Medicare simply dictates the prices they will pay for services, and often those prices are well below the cost of providing those services," Zirkelbach told HealthLeaders Media. "So, what happens is doctors and hospitals charge more to people with private insurance to cover the costs of those services."
September's annual growth rate for Medicare was the lowest in the six-year history of the index. The Medicare index reported its highest annual growth rate of 8.3% in August 2009, but has consistently and sharply decelerated since then, S&P says.
Zirkelbach says provider consolidations also play a role in rising costs for commercial plans. "Our members are getting rate increase requests from providers by as much as 60% and 70% in some markets across the country," he says. "There is a growing body of evidence and research showing that as hospitals consolidate, that leads to higher prices for services. In some markets there is only one 'must-have' hospital in a region that is able to charge significantly more for services, often 200%, 300%, 400% of what Medicare pays for the same services, and that is having a direct impact on the cost of care."
Overall, the average per capita cost of all healthcare services covered by commercial plans and Medicare grew 5.75% over the 12 months ending in September, representing the fifth straight month of modest cost growth acceleration, the indices show.
In April, the index for all healthcare services posted the lowest annual growth rate in its six-year history, 5.37%. Since then, the rate of growth has accelerated slightly each month. Another set of S&P trackers, the Hospital and Professional Services Indices, posted increases of 5.51% and 5.78%, respectively, from their September 2010 levels.
Healthcare costs easily outpaced the 3.9% growth in overall inflation as measured by the Consumer Price Index for the same 12-month period, Bureau of Labor Statistics data show.
The S&P Healthcare Economic Indices estimate the per capita change in revenues accrued each month by hospital and professional services facilities for services provided to patients covered under traditional Medicare and commercial health insurance programs.
The annual growth rates are determined by calculating a percent change of the 12-month moving averages of the monthly index levels versus the same month of the prior year.
Blitzer says it would not be wise to use the cost growth trends identified in the S&P report as an argument for a wider single-payer system. "Mandating lower rates in the short term may look wonderful, but you may wake up some day and discover you don't have enough doctors, or doctors will only do the procedures that only have high-profit margins," he says. "They're not stupid, otherwise they wouldn't be doctors."
Cost-shifting in healthcare will happen as long as providers are required to offer the same services to two groups of patients at substantially different prices, Blitzer says. "Some people suggest it is evil or they are cooking the books. I don't think that is fair. You have fixed costs from running a medical practice or a hospital, and at the end of the year you total the revenues, you subtract the fixed costs, you subtract the variable costs which can be attributed patient by patient, and you hope the number that is left is a positive number."
