Debates continue about the impact of health reform on small businesses. Mine is a small business so I’ve been paying close attention. I’ve even read every line of this legislation – three times. And every pundit analysis I can get my hands on.

My role as a strategist requires that I understand the law. My role as a business owner requires that as well. Most analyses make broad-brush statements and it’s not possible to know the full impact until each business does its own analysis. Here’s mine.

Unfortunately, there are no ‘upsides’ for my employees or business:

• My company is too small to be required to provide health insurance. That’s of no matter, I’ve been providing it all along.
• My company is unlikely to grow to the size required to provide health insurance. That’s of no matter, I’d do it anyway. As an employer I know the value of a healthy workforce.
• My company is too busy to even consider applying for grant funds for worksite health promotion and disease prevention. We’d lose productive work hours watching for RFPs, framing proposals and even more complying with paperwork. That’s of no matter, I’ve been providing that all along as well.
• My company is composed of workers too highly compensated to qualify for insurance tax credits, and I suspect no company like mine will qualify either. My employees are knowledge workers with advanced degrees and compensation above the $50,000 annual ceiling for the tax credit provisions.

Unfortunately  there are ‘downsides’ for my business, all related to new IRS rules.

Section 9006 mandates that about 18 months from now, my business – which really means my Executive Assistant, who is already plenty overloaded – will be required to issue 1099 tax forms to any individual or company from which we buy more than $600 in goods and services.   

We already issue an IRS Form 1099 to people like freelancers who are not ‘incorporated’ business entities. In any given year, that number ranges from 10-14.

That means we don’t send a 1099 to other incorporated businesses, that is, to Amazon, Amtrak, US Airways, Continental Airways, British Airways, Air France, Westin Hotels, Marriott Hotels, Holiday Inns, Kinko’s, Federal Express, Staples, Office Supply, Office Doctor, IT Edge, Samsung, Independence Blue Cross…I could go on.  

This new 1099 reporting is intended to capture currently unreported income to generate more government revenue and help offset the cost of reform. It’s been defended as an alternative to raising taxes on small business and is seen to be a fair trade for $35 billion in tax credits small businesses get under reform. It’s an attempt to collect the nearly $300 billion of income that the IRS says goes unreported.

I have three problems with that:

• First, my business won’t see any of that tax credit benefit, 
• Second, my business will incur additional costs, not only in staff time for obtaining tax IDs from every vendor, but also in accountant fees for processing and mailing the forms, and
• Third, my business is being required to help the IRS monitor tax reporting compliance of other businesses.

At this point, we estimate the number of 1099s we will file will increase to 1,000. I’m not sure how a small firm like mine is going to find its way through the mazes of large companies to get the information, but I’m angry that this law – touted as having so many ‘upsides’ – provides none for my firm but asks us to carry an additional burden that drives up the cost of doing business.

I can live without the ‘upsides.’ I’ve provided insurance and promoted wellness all along and will continue to do so.

But now, I’ve been mandated to become a de facto agent of IRS enforcement. Surely, the IRS has better tools for finding unreported income than asking small firms like mine to do it for them.

By Glenna Crooks. Full disclosure – I’ve practiced yoga fairly consistently for decades. It’s been good for me.

In grad school it helped me stay focused – and calmer – through killer statistics classes. Later, it was a way to unwind at the end of a workday. Still later, it saved me from surgery to correct fairly severe scoliosis. It’s not cured the deformity but I’m virtually pain free most of the time – no small feat for one who spends 18-24 hours on flights and 8 hours standing to facilitate meetings.

More disclosure – I am certified to teach, though I don’t. The same erratic travel schedule that prevents attending classes on a regular basis precludes committing to teaching them. I trained to be able to practice on the road. It was a good investment of my time and funds.

Yes, my time and funds. Anyone familiar with yoga knows that for the most part, students pay a small amount for a class – or series of classes – out of their own pockets. Sometimes, yoga is offered in schools, hospitals, churches, workplaces and prisons and the cost partially or fully paid by some third party. Sometimes teachers donate their services as part of the ‘selfless service’ that embodies the lifestyle.

Recent weeks presented an interesting confluence of events in my life as a yoga-practicing health policy analyst: health reform passed and Yoga Journal published a major article on methods, issues, controversies and implications of yoga research.

I started a yoga research literature review a few years ago. It was to be the opening chapter of an adaptation of my grantseeking guide (see www.strategichealthpolicy.com for a free download), revised and updated for yoga teachers intending to seek and secure third-party – including health insurance – financing support for classes.

I abandoned the project for many of the issues raised in the Yoga Journal article: research methods were relatively undeveloped, uncontestable positive results were scant and within the yoga community both were controversial. That’s right, even the need for research to demonstrate the value of yoga is controversial. Many thought there was proof enough.

Proof enough for an individual to pay? Yes, that’s been well-demonstrated. Thousands of times each day, people around the world pay out-of-pocket to attend classes. Proof enough for a third-party to pay? Far from it, at least as we have defined proof within the American health care sector.

Now, the health reform era is upon us, some people will press for yoga services as a covered benefit and if a serious discussion takes hold – and succeeds – in adding yoga to American health care armamentarium, yoga teachers will face issues common to other product and service providers. Clearly, not all yoga teachers will want to participate and none will be forced, but those who choose to do so will need to address – at a bare minimum – questions commonplace to physicians, hospitals and drug companies:

First, is yoga effective? Any prevention or treatment modality used in health care is expected to be safe and effective, demonstrating that it performs as advertised, promoted and hoped.

That means prospective research, such as trials comparing yoga against a non-intervention, a placebo or a standard therapy treatment, or a study of a sufficiently large population through ‘natural observation’ to gather similar evidence over many years.

Research such as this will raise questions about whether the ‘style’ of yoga matters, how many sessions might be required to achieve results and whether results last after classes are stopped. People in the study will be carefully selected and ‘assigned’ to each intervention group. They’ll be asked about other aspects of their lifestyle to assure that they’re not confounding the results with other possibly-effective therapies.

Side effects will be monitored. Injuries in class or suicidal thoughts outside of class (if any occur) will be noted so that cautionary warnings and contraindications can be addressed in coverage and reimbursement decisions. Other unintended consequences – weight loss comes to mind – will be documented but can’t be claimed a benefit unless the study was specifically designed to test for it.

Research might also need to tease out yoga’s “mechanism of action” as is the case for medications; for example, by what mechanism does yoga breathing techniques reduce hypertension?

Researchers will be required to seek approval from Institutional Review Boards protecting patients, may be required to vet research methods with regulators or payers, will likely be required to disclose financial interests in yoga and if any are found might be precluded from doing research and/or might be restricted from committees that address yoga policy and financing issues – all to assure research subjects are protected and conflicts-of-interest are prevented.

Second, is yoga cost-effective? Having passed the first hurdle regarding effectiveness, yoga would then be subject to a test of relative value against other therapies. This will likely be determined by a combination of cost and patient satisfaction factors. Yoga is less expensive than the spinal surgery I faced and I’m very satisfied not to have suffered the projected month of hospitalization, surgical risks and likely post-surgical pain. In fact, had I not learned yoga, even daily classes – were I to pay for them – would likely cost less than the pain medications that might otherwise be a staple of my day and would be immensely cost-beneficial over the disability others in my family have faced.

Could the same be said for hypertension? Generic medications cost only pennies per day and require only seconds to swallow, at far less cost and time investment than a yoga class or daily practice. In fact, even brand products are likewise less expensive and easier to comply with than a regular yoga practice. No therapy is effective – and is certainly not cost effective – if patients don’t use them. Medication adherence can be as low as 50%; are there data to show how yoga compares? If yoga is judged by payers to require more of patients who will not likely adhere to the regimen, payers may be skeptical and reluctant to cover it.

Third, how will yoga teachers and studios be regulated? It’s not a question of ‘whether,’ but ‘how’ requirements will be framed through regulations and provider contracts, and what group will monitor compliance with those.

Products and services reimbursed by Medicaid and Medicare, purchased with federal or state health funds, distributed through the VA, Community Health Centers, Indian Health Service, and Public Health Departments must comply with certain conditions and those will likely apply to yoga as well. Non-government third party payers set their own, similar standards.

Payers want to know they’re financing the activities of legitimate providers of care capable of assuring access and quality at a good cost, adhering to acceptable practices of promotion and protecting against fraud. This will happen through regulation and contractual agreements with providers that will address.

Quality

• Will yoga teachers, as ‘providers’ of health care, be subject to standards beyond those of their training schools?
• Will they be subject to state licensing (as are other providers and facilities), credentialing, periodic re-licensure and re-certifications, continuing education requirements and personal background checks?
• Will yoga teachers be required to collect and report injuries or adverse events sustained during classes, as do hospitals or pharmaceutical companies in reporting injuries and adverse events? If so, will those be published in increasingly-familiar formats like report cards on providers?

Access

• Will yoga studios, as a ‘setting’ of health care, be subject to requirements for access for special populations such as children, seniors and the disabled?
• Must yoga address non-financial barriers (e.g., language)? Government-funded providers must treat patients in their language – providing translators if needed. Must yoga teachers do likewise?

Cost

• To control for appropriate use, will a prescriber order be required, much like for physical therapy?
• Will the number of reimbursed yoga classes be limited, much as other visits for psychotherapy or physical therapy?
• Will payers require pre-authorization for yoga classes, such that the prescriber or yoga teacher will need to justify a prescribed number of classes, or additional classes for some patients?
• How will the fee for a yoga class be set? Will the rates be negotiated? Or set by the payer?  Will government get the ‘best price’ through rebates, competitive bidding, volume purchasing or price controls?
• If only a portion of the class fee is paid by a third party, may teachers collect the difference from the student/patient, or as in Medicare will they be prevented from doing that?

Marketing and Promotion

• How may yoga be marketed and promoted?
• Can claims be made for health outcomes without clinical evidence to demonstrate its validity? What endpoints are satisfactory to prove the claim? For example, is ‘toning muscle’ or ‘developing balance’ a satisfactory endpoint or must reductions in hip fractures from falls be demonstrated?
• Can one form of yoga claim superiority over another, and if so, under what criteria and circumstances?
• Must all promotional claims also include a list of possible injuries to assure ‘fair balance’ or ‘informed consent’ and clear warnings to patients?
• Will promotion to health care providers be allowed and if so, of what type? Sampling? Reminder items? Continuing medical education?

Fraud Protections

• Will yoga teachers be required to transmit class attendance information and provide progress reports to payers that provide coverage and reimbursement?
• Are payers entitled to know how often – and with what results – patients attend classes?
• Will yoga providers be required to link class attendance to electronic personal health/payment records?
• How will payers audit records to assure that billing matches the actual class attendance by covered patients?

Some payers – as businesses do now – may choose to offer yoga and never address the issues raised here. In my own company, for example, having seen the value for myself, I’d gladly underwrite the cost for my employees. The same might be true for even a very large company.

If yoga ‘goes mainstream’ in health care, however, it is likely that it – and other ‘alternative’ modalities – will be scrutinized. I know both sides and can envision a dozen questions more than the ones posed here.

It’s not my place to say what is best for yoga in America, its students and teachers, or what’s best for health care in America, its patients or payers.

A match made in heaven? It’s too early to tell. Time will. OK everyone, relax, take a deep breath….and another….

Disruptive Women welcomes Personal Trainer Morris White as our February 2010 Man of the Month.

A personal trainer for 22 years, Morris White has both men and women – and even children as young as 12 – as clients. He helps them with basic fitness, sport-specific fitness and self defense. He also trains people with special needs, including those with disabilities and eating disorders, and those recovering from a stroke and heart attack.

In his own life, he is a power lifter and a practitioner of Kung Fu, Yoga, desert hiking and survival quests and sustainable healthy living. He is currently working on a fitness community site.

I can vouch for his impact. I’m now in my third year with him, with regular work outs at 6 AM. The benefits have been worth every trek to the gym in those before-dawn hours.

Morris, I’m pleased to have the chance to talk about fitness with you. It’s an important topic, but rarely addressed in this blogspace. How did you get started training?

There were three very influential men in my young life. It was the 1970’s. My Father was a pharmacist and successful businessman who took me to monthly Toast Masters meetings and had me working in the pharmacy on weekends. He taught me the importance of physical poise and presence. One of his business partners was a Physical Therapist who mentored me in anatomy and exercise, from him I learned about anatomy and body mechanics At about that same time, I was introduced to Kung Fu by my best friend’s Father who was a Master of the art.  Kung Fu combined all the earlier lessons and helped me to develop my personal philosophy on holistic personal training.

Those were the years of my greatest lessons.

I attended Temple University but my advisors could not grasp what I wanted to become and what I wanted to do with my life. The usual response was, “So, you want to teach phys ed?” No.

From there to the gymnasiums I went, working under different titles until personal training evolved and became popular.

 What about fitness and training makes it your passion? 22 years seems a long time.

Seeing my mother die at young age and my father debilitated primarily by an unhealthy lifestyle, has made me even more intent to give meaning to my existence by living and enjoying life to its fullest and helping others to do the same through fitness.  The bonus is that by helping others achieve their personal goals, I get to meet great people that, in turn, enrich my life through their collective experiences and wisdom.

How do you approach training?

My philosophy of training is:

• Safety first. You should never be harmed or injured in the course of training.

• Strict, proper form. The best form produces the best, most efficient results.

• Keep moving. A body in motion tends to stay in motion.

Follow those rules and you’ll keep at it, making progress. You’ll avoid injuries and won’t suffer any set-backs in your workouts. You’ll also see results and be able to have an increasingly better quality of life. Even if you’re already fit, you’ll see improvements.  As I like to say to my clients, “one foot in front of the other and you’ll get where you’re going,”

Oh, and one more thing, never imitate what you see others doing in the gym.  So many people do their exercises incorrectly. Others may do an exercise properly but their routine may not fit your desired goals.  Always consult a professional about a new exercise or routine.

Do you have any dramatic examples of client improvements?

I could tell lots of stories of women who come to prepare for their weddings. They’re motivated for sure. Believe it or not, they’ve bought dresses three sizes too small and now need to fit into them. Plus, the regular workouts really help them with the wedding-planning stress.

But the one client and story that really inspired me was a 280 lb sedentary banker who lost the weight and became a marathon runner.

As he became physical healthier, his self-confidence and self-esteem also improved.  This newfound self-respect gave him the strength to not only run a marathon but to walk right out of a less-than-supportive, troubled relationship and climb the corporate ladder to a promotion.

(Laughing) Of course, I cost him lots of money – he kept having to replace his wardrobe as his body changed.

Have you ever seen anyone who did not see an improvement in working out with a trainer?

Yes. This is teamwork and a few people were not ready to engage – in part because they were not honest about their goals and readiness to begin.

As you’ve seen in my approach, I don’t just bark orders and count. Training – at least with me – is not bootcamp. When we work out, we work as a team. We’re in constant communication. I’m asking how you feel and you’re telling me. If something hurts, I know immediately from what you say and sometimes from the way you act. That allows me to make subtle changes in the next exercise I choose.

You must be ready to be honest with yourself and you must be ready to trust your trainer to help you.

Yes, I see how easily you detect when I’m compensating, using a muscle other than the one you intended and not doing it right.

Busted!

You see, personal training is not just science, it is an art and it’s very much like life. Life always tosses us curveballs and I have to be aware and be able to read the pitch. Part of that comes from the communication between me and my client. It begins the moment you walk into the gym and asking “how are you feeling this morning.” That’s not just a greeting, it’s a diagnostic question. The answer and your body mechanics tell me what you need today.

I also ask you what you have planned for the day. If you’re at your desk writing, I’ll prepare your body for that. If you’re traveling, you’ll be ready for the flight.

I’ve benefited lots from working out with weights, but notice that it’s rare to see a woman on that side of the gym. What about other benefits you’ve seen in your women clients?

There are a variety of benefits and they’re not just physical. My clients have dropped dress sizes, lost weight, sleep better and have better balance, posture and reaction times. On the emotional side, they are more grounded and have greater self confidence. Some tell me they can “stand up for themselves” better in the workplace and in relationships.

Whatever you feel physically, you’ll feel emotionally.

How do you get women to that side of the gym?

Easy. I take them there when the time is appropriate, focusing on their needs and goals and instilling them with the confidence that they can do the best for themselves. I also point out how “not to” workout, using the examples of others there. This is not intended to criticize those people since you’ve seen me intervene and correct someone who may be risking injury, but to give her the confidence that she can do it right.

Finding you was pretty much luck. I met the gym owner at a party, one thing led to another and I ended up doing something I said I’d never do – meet with a trainer and make a commitment to train. That was more than 3 years ago. If someone reading this was contemplating finding a trainer, what advice would you give them?

Look within yourself first. By that, I mean you must decide exactly what is important to you. What is your present discomfort – physical or emotional? What is your goal? What motivates you?

When you explain that to a trainer, they should do more listening than talking. They should be able to repeat back to you the concerns and goals you stated in your initial meeting as well as to communicate the plan of action to get you started and keep you motivated.

What I find is that someone might begin with one motivation – like dropping a dress size – but then as they work out, they feel better. In some cases, people start feeling better than they have in years. At that point, their motivation shifts and they work out because it keeps them feeling great. Fitness becomes its own reward.

Finally, realize that your success requires that you and your trainer are a team. The two of you must perform like a team. The chemistry must be there.

Do you train older people?

Yes, it’s one of my specialties. There are lots of benefits of exercise, but most people are concerned about cognitive decline in aging and recent research demonstrates that fitness can stem cognitive declines, so this is important.

Older people’s bodies don’t recover as quickly as they once did and this is an area where young trainers can improve on their training techniques. It’s hard for a young trainer to empathize with an older person who needs more recovery time between workouts, or who needs special emphasis placed on balance.

I work with an older person much like an Occupational Therapist, in that I try to help them re-tune with their bodies.

Regardless of what some people may believe, older people can make great strides in training and see remarkable progress.

Sometimes I see couples in the gym and I know you train couples. If a man reading this wanted to get his special woman into gym, what should he do?

The only way it works for a couple is if they have a shared goal for the quality time they spend together, for example, if they have a goal to enjoy a particular sport or an active vacation that requires a set of specific physical skills or fitness. Otherwise, it just doesn’t work.

I’d never advise a man to try to train the woman in his life. The best thing he can do for her is to be sure she has a trainer who is a professional who knows how to train women.  He might coax her a bit, but it has to be her motivation and goals that bring her to the gym.  Trust me, I know this from experience. This statement has been approved by my wife.

Would you recommend that people start a fitness program without a trainer?

No. To build a healthy and solid fitness foundation, I always recommend starting with the guidance of a qualified trainer.

But I do want to stress the importance of actually getting going and starting to move.  Our bodies were designed with motion in mind and our minds were made to think. Our body wants to be used and we feel better when it is. A body in motion tends to stay in motion; a body at rest tends to stay at rest.

Get out there start to move. No excuses. Even a little bit better every day, one foot in front of the other gets you where you’re going. Exercise “gives back” more in time and value than it takes. Remember that the days you don’t want to go to the gym.

Some people think that training is exhausting or should hurt – no pain no gain.

Absolutely false. You need not kill yourself in the gym to see improvement in your quality of life.

Exertion is OK, pain is not.

I remember telling you that your time was wasted on people like me and that you should be training trainers. What keeps you helping folks like me?

I like being a mentor to the younger trainers in the gym and the camaraderie that comes with working with other trainers but what is most fulfilling to me is my role as a personal trainer.

I train individuals and count my blessings. I get to help improve the quality of life for others and in exchange, I get to meet many wonderful and different people – all of whom have enriched my life.

Any other advice for today’s readers?

 

Don’t overdo it. Do something every day. Safety first.

Listen to your body and learn the difference between when it’s in pain or danger and when it’s just whining.

Try a trainer, and don’t hesitate to change trainers. A good trainer will recommend other training venues – much as I recommended RowZone for you.

Morris, thanks. This has been fun, though I can’t say that about 5:30 treks to the gym in the driving rain! I’m hoping it inspires someone to join a gym or find a trainer and have a motivation, goal and training style discussion.

 

If it helps, I’ll be pleased!

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.

Oh, and agreeing with Morris to meet twice a week at 6 AM for workouts – that was easy. Check. Now for the hard part of getting up and getting to the gym, especially during these cold winter months ahead.

So, what the problem? It’s the gap between what’s reported in the news, discerned in health report cards or explained to Congress and what I experienced in the care here in Philly, ‘on the ground.’

• Pap smear. My insurance company will record my having received a pap smear in some set of ‘positive’ promotions about how it supports prevention – but it took a second trip, required using additional vacation or work time because the plan was so inflexible as to preclude coverage of a test two weeks before the anniversary date of the prior test.
• H1N1. Experts quoted in a January 1 New York Times article on the nation’s H1N1 experience gave the government a B+ and ‘excellent’ ratings for it’s preparations – but that did not translate to my experience on the ground. And, by the way, good thing I got my flu shot elsewhere, because neither of my physicians was able to get seasonal flu vaccine at all.
• Bone Density Scan. My insurance company and physician will also be able to report that I was appropriately screened for bone density, but none of us know the most meaningful of results – my scores – because they are locked up somewhere that we can’t see for some reason I can’t discern. We don’t know if the trend is bad and if some more cost-effective intervention should be initiated now. More weight-bearing exercise, perhaps.
• Workouts. Oh and then there’s Morris, whose immediate, hassle-free response to scheduling made him my easiest disease prevention/health promotion action of all. Unfortunately, there’s no way to capture the value of what he’s done for me ‘on the ground’ to have him recognized ‘on the Hill’ or rewarded in any special report card of quality.  I can cite a smaller dress size, increasing strength and great flexibility but perhaps best of all, I recovered quickly with no lasting impact from being hit by a bicycle – a real testament to being fit.

From a distance, in the air or on the Hill, the health grades of items on my list might look good. They might, in fact, be B+ granted in the Times article from those vantage points ‘above it all.’

From ‘on the ground,’ however, it feels like grade inflation to me. All except for Morris: he gets an A+.

The following post by Glenna Crooks, PhD, founder and President of Strategic Health Policy International, Inc, is part of Disruptive Women’s “The Value of Health: Creating Economic Security in the Developing World” series.

Glenna Crooks solves some of the toughest health care problems of our times by distilling chaos and complexity into recognizable and easily digestible, action-oriented insights. Her clients, businesses and governments around the world, have used her Centricity Principle™ approach to create successful organizational, national and global transformational strategies.

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It has been long recognized that the growth of a nation’s economy improves the health of its people.

The converse is also true. Improving health is an economically wise and productive investment.

In fact, that’s the reason that health systems were established – by the King and the employer – documented as far back as 4,000 years ago.

There is good news to today’s world: a positive cycle of gains in both health and economic security occurs as either one is improved.^[1]

Have we taken the value of health for granted? I think so and find that especially the case among those of us in the health community. We talk endlessly about improving health outcomes as if those outcomes were an end in themselves. We have fallen victim to the notion that health expenditures are a cost, rather than an investment. We have forgotten our origins in economic growth and security. We have set our sights too low.

It’s high time we set higher goals. Disease creates barriers and slows progress towards economic status and security. As health improves, people experience both immediate and long-term economic benefits. Individuals become more productive; they enhance not only the quality of their lives but their capacity to enrich economic well-being.^[2] “Health is an economic engine.”^[3] This is true not only for individuals but also for families and societies.

World Health Organization (WHO) and World Bank benchmark reports outline the relationship between good health and economic development; good health is not only a means to reduce poverty, but also a means to accelerate national and personal economies.^[4],^[5]

• Individual health increases personal productivity and earnings. Extending healthy years of life increases the number of working, income-earning years. Healthier workers are more productive economically during their working years as well.
• Good health reduces the funding required to treat disease, allowing people and nations to invest in other needs.
• A healthy population encourages foreign investment, technology transfer, and facilitates access to global markets.^[6]
• Healthy children are more prepared for school, miss fewer days of school, attend school for more years, and learn more while in school.  In addition, longer life span is associated with more years in school and each year of schooling results in a 15% higher starting wage and a doubling of the rate of subsequent salary increases.^[7]
• Natural resources previously inaccessible due to disease (e.g., agricultural acreage unusable because of malaria) are made available for production and farming.^[8]

Health benefits everyone. Illness harms everyone – not only those who are sick, but also other, healthy household members. The healthy must work harder or longer to make up for lost of income when the major breadwinner is ill and in some societies, girls miss school to care for sick relatives.^[9] As households cope with illness, they may also reduce spending – including on food – to account for declining in income.^[10] These adjustments have ripple effects through the entire family, though are not generally counted in cost of disease because they are losses borne by the household overall.^[11]

In recent decades, education and on-the-job training were viewed as the principle determinants of human productivity.  In recent years, however, economists have recognized health as equally important and it is time that those of us in health care do likewise.

Half of overall economic growth in the US in the past 100 years is estimated to be related to improvements in health and cross-national studies have shown that the 27-year difference in the life expectancy between low- and high-income countries – 51 vs. 78 years – is associated with a difference of 1.6% in annual compounded economic growth rates.^[12] The return on improvement in health is very large, overshadowing gains from most other investments.^[13]

These issues are not trivial. Though wealthy and poor countries benefit, the poor in any country benefit most and the imperatives for health today, stated well by the Institute of Medicine, have never been greater.

It is in both our domestic and our international interests.^[14] Here’s hoping that as the new year approaches that we will provide the quality of care we have pledged in healing oaths and that we will set our sights even higher, returning people to productive lives in the workforce – or if they are not enriching our economy but enriching our hearts – to fruitful lives in families and communities across this nation and the world.

In other blog posts I have noted the critical role of women as “Dr” Mom, Sister, Friend, Spouse — and policy maker. In this series, the role of women in the development of the developing world has also become clear. That role is critical. It can’t be ignored. Here’s hoping that as the new year approaches we will pledge to help them. Their heroic efforts will be made ever more successful if we do.

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^[1] Mirvis DM, Bloom DE. Population Health and Economic Development in the US. JAMA 2008;300(1):94-95.

^[2] Sachs JD. Macroeconomics & Health: Investing in Health for Economic Development. WHO Publications 2001:21.

^[3] Bloom DE, Canning D. The health and wealth of nations. Science. 2000; 287(5456):1207-1209, as cited in Mirvis DM, Bloom DE. Population Health and Economic Development in the US. JAMA 2008;300(1):94.

^[4] Sachs JD. Macroeconomics & Health: Investing in Health for Economic Development. WHO Publications 2001:1-210.

^[5] World Bank: World Development Report: Investing in Health. Oxford University Press 1993;iii:17-37.

^[6] Mirvis DM, Bloom DE. Population Health and Economic Development in the US. JAMA 2008;300(1):94.

^[7] Mirvis DM, Bloom DE. Population Health and Economic Development in the US. JAMA 2008;300(1):93-94.

^[8] World Bank: World Development Report: Investing in Health. Oxford University Press 1993;iii:17.

^[9] World Bank: World Development Report: Investing in Health. Oxford University Press 1993;19.

^[10] World Bank: World Development Report: Investing in Health. Oxford University Press 1993;21.

^[11] World Bank: World Development Report: Investing in Health. Oxford University Press 1993;18.

^[12] Mirvis DM, Bloom DE. Population Health and Economic Development in the US. JAMA 2008;300(1):94.

^[13] Yusuf S, Nabeshima K, Ha W. Income and Health in Cities: the Messages from Stylized Facts. J Urban Health: Bulletin of the NY Acad Med 2007;18(1):i35.

^[14] Howson CP, Fineberg HV, Bloom BR. The pursuit of global health: the relevance of engagement for developed countries. Lancet 1998;351:586.

We start this short Labor Day week on a hopeful note. The President will speak to the nation on health reform in just two days. Perhaps this is the tipping point we’ve been hoping for and it will break the logjams, bring all the players back to the table, keep them there and forge the next steps forward.

Recently, however, is unsettling debate about the value of prevention – saying it costs more and won’t help our health care crisis. Yes, prevention will cost more health dollars. Let’s get over it and move on – and beyond – that. I did on August 1, 2001, just six weeks before that fateful September 11 day.

I was the wrap-up speaker at a conference focusing on resistant pathogens and the problems that could ensue for the American hemisphere from emerging diseases. The audience as comprised of public health, medical and national security experts. The session was broadcast globally to 80 nations in three different languages. I opened with these remarks;

“We began this session stating that our goal was better health outcomes. I would like to propose a bigger goal: world peace and prosperity—for everyone, not just in this hemisphere, but throughout the entire globe.

Peace and prosperity will not be possible if we fear our neighbors for the pathogens they may harbor in a handshake. These will not be possible if we spend our money treating diseases that we could have prevented. These will not be possible if we are burying our loved ones precisely at the time when they are the most economically productive, or, when they are very young or very old and not enriching our economies, but enriching our hearts.”

The reaction was stunning. People cried. Afterwards, when the telecast was done and I came off stage I saw what it might be like to be a rock star. I was surrounded. They came to touch me and to tell me how I had touched them. It was then that I realized how weary we all are of working our best to shave another cent from the health care dollar and how much we all wanted a higher purpose for our work.

Regardless of what transpires in health reform debates, I hope that policy makers will realize that health – though valuable in-and-of itself – is an instrument of bigger goals.

I hope they will not set their sights too low and act as if it’s all-and-only about cutting costs. I hope they will see that a healthy population is a productive one and in this economy that’s exactly what we need: people who are capable of managing the stresses of these modern times, who can work more productively and work longer to bring this nation – and the world – forward to its full potential of peace and prosperity for all.

I just finished a great book: Why She Buys. I was stunned to learn just how much of the US economy is controlled by women: 65% of apparel, 52% of all auto and truck, 45% of consumer electronics and 70% of travel purchases. If influence over purchases is considered, women influence 80% of auto and truck, 91% of home, and 61% of consumer electronics purchases.  

Wondering about health care? It turns out that Dr. Mom makes more decisions than Dr. Welby; directing 80% of expenditures. It’s not just Dr. Mom, I’m guessing, but Dr. Wife, Dr. Sister, Dr. Friend and Dr. Daughter (or Daughter-in-Law) who help others with the health care maze.

A great book. I recommend it, though it raised my ire and blood pressure more than once as I realized how even with that level of seeming economic power that product design, marketing and purchasing is not woman/customer/consumer-friendly.

More women are in the workforce, complicating the activities of daily living.  Have children, a special-needs child and/or get divorced and life gets more complicated still. Time compression and multi-tasking is a way of life. How I wish that health care was like Ryland Homes, who designs and builds for the life a woman leads: a window over the kitchen sink to watch younger children in the back yard as she prepares dinner in open-plan kitchen-family room while supervising the older children’s homework, and of course, a computer workstation to check her own emails. Her day likely starts at 5 and ends at 11, errands are saved for weekends. Getting to the gym? Well, someday…..

Of course, that assumes she’s able to afford a Ryland Home. Many women are not. They face those chores in neighborhoods where the kids are not safe playing outside.

Heaven help any woman if she or someone she loves gets sick. Yeah, heaven help her, because it’s likely that health reform won’t. For women, the “unintended effects” of health policy decisions are not hypothetical. There’s a fight on, a battle, a war on the Hill and we’ll be left to deal with the collateral damage.

Drawing on some insights offered by author Bridget Brennan, sifting them through what I experience and what other women tell me, here are some reasons I’m not buying…

 

First, women’s busy lives make primary care essential. We understand prevention, practice it for ourselves and children and try (often unsuccessfully) to get the men in our lives to do likewise. So where are the health reform proposals for radical increases in primary care physician fee schedules and more widespread access and better compensation for physician assistants and nurse practitioners? Forget loan forgiveness programs that might provide us with care in a decade. Increase the payment rates now.

Radically improve primary care access and health care will finally be woman- and health-friendly. Offices will staff-up, use EHRs and shorten our wait-times. I doubt any woman believes that her physician needs “incentives” to do these things and provide good care, by the way. Health care is not an economic transaction for us, it’s a relationship and we’d sniff out a mercenary in the first visit. We understand the real problem — that there are plenty of “disincentives” to being a primary care provider. We notice other people and we care. As I watch my own physician gain weight, get weary, get cynical and burn out, it’s not because she lacks incentives. I see her office staff and how surley they can be. It’s because they’re all working in an increasingly hostile climate created by policies put in motion far from her exam room. 

Second, women want to know about the practical benefits of a product or service. Brennan cites evidence that women have higher language fluency, one reason why we find it easier to give and listen to speeches. I’m listening….but don’t hear the practical benefits of reform proposals. Deficits a decade out? In this recession? Sorry, that’s not compelling.

How do I make it through this year? What, really, is this going to do to my taxes? I might be willing to pay more, but I need to know I’m getting some value for it. What impact will it have on my small business (remember many small business owners are women, we generate jobs and have much better business success rates than our male counterparts)?  What will it do to my wait times for doctor visits? Appointment waits for a mammogram in my town are already six months. Will that get better or worse?

How rigid will regulations be? I called for an annual pap smear recently. The timeframe that worked for me was a brief vacation window, but as the office informed me, is two weeks before the date of last year’s test. Oops! Two weeks shy of the “annual” date and I can’t qualify for reimbursement. By the time the “regulated” date comes arrives two weeks later, I’ll be into a busy work and travel season and unable to take the time off work. I’ll postpone, probably until next spring. I’m taking two risks, first, that this pap smear won’t be normal, but then my pap smears have always been normal and this one probably will be as well, and second, that my physician is  not on some PFP or HEDIS-watch that will impact her pocket for non-adherence to clinical guidelines. Being self employed means that the visit to the doctor will take me out of the office for a least a half-day, during which time I won’t be earning an income. Will reform create more flexibility so that I can get care on a vacation day?  Will it adapt to my needs as a working woman?

Third, women value social harmony. Perhaps that’s neurobiology, perhaps it’s an evolutionary gift that promoted the survival of the species when we jointly cared for children and each other when the men failed to return from a hunt or a battle.  Perhaps it’s just having broken up too many preschooler fights.

We know there is very real risk in conflict, likely no single ‘bad guy’ and that if there’s a fight on the playground, chances are no one is truly “innocent.” In fact, the one finger-pointing is probably the one who started it. So a word to the wise health policy wonk and politician…stop blaming someone else. I’m guessing women know that it’s not so simple as blaming doctors or drug or insurance companies. Actually, we now suspect that you might actually be part of the problem…creating confusion. Could it be because you are running for re-election? Or helping some buddy who is? I want to buy a system that heals and have become firmly convinced that a healing system cannot be built by those who fight and finger-point.

Last, when women buy they want to know they can “plug and play,” that the product will make our lives easier. Men, Bridget Brennan says (citing the literature), like to buy now and figure it out later. Tinkering is apparently fun. Not for women. We don’t relish hours of cell phone, computer or DVD programming. We already have a “to do” list longer than most arms. Maybe this is the biggest disconnect for us and my own greatest sense of frustration.

I’ll agree that the system is broken and needs to be fixed. I join other women who know just how important health is — after all, we’re the ones who take of sick kids, friends, spouses and parents. But health reformers are pushing ahead, promising better access and quality at lower costs even though Peter Orszag (who I personally admire and respect as one of the scary-smartest people on the planet) recently told the Council on Foreign Relations. “The truth is that we don’t know today all of the steps that are necessary to move towards providing higher-quality, lower-cost care.” 

The policy players might be willing to ‘buy it’ now and figure it out later, but as a woman, I’m not. I’ll make  my buying decision when the seller can tell me exactly what I’m buying, how it will work, how it will make my life easier, how it will care for the people I care about – including my primary care physician, and how much it will cost. With that, I’ll assess the value to me, my family and my business and make my decision.

Where this Disruptive Woman is concerned….even if today’s health reform –  in its current form — passes, it fails. 

 

Should managed care sue patients?

We arrive at the dawn of yet-another health reform effort with laws and regulations already in place to protect patients. These arose in past decades when the healer-patient relationship was eroding, presumably at the hands of uncaring clinicians and for-profit medical enterprises.   

The list of those rights was extensive and today’s debates are adding to the mix – guaranteed coverage despite pre-existing conditions comes to mind. The discussion of patient rights has always been politically attractive and I won’t denigrate any one of them. I’m not just writing from a policy perspective, but a personal one as well. I’m a patient, too.

The discussions of patients’ rights, however, has neglected the flip side of rights—responsibilities on the part of patients, and the support that we all need from our communities to be healthy people. Today’s healers are beset with immense responsibilities, yet with few reciprocal rights of their own in their relationships with patients or communities.

As patients, communities and a nation, we all too frequently fail to follow medical advice or practice healthy behaviors, and yet expect that helath care will ‘make it right’ when we become ill or incapacitated.  We smoke, abuse alcohol and drugs, carry guns, drive fast, forget seatbelts, neglect immunizations, shun prenatal care and spread sexually transmitted diseases. We ignore social problems until they create health care consequences—low birth-weight babies, elderly who lack social acceptability, and teens suffering gun-shot wounds. When these risky behaviors result in chronic or high-cost illnesses and disabilities, health-care providers are expected to assure that we get the care we need, insulating us from the cost of our choices by providing whatever we need within a fixed budget. The time has come to broaden all of our health policy and political discussions to encompass the realities that, with rights come responsibilities.

So some questions:

• If managed care has a responsibility to meet all the patients’ needs, do patients have the responsibility to practice healthy lifestyles?
• If patients have the right to sue health-care providers for the failures to meet the patient’s expectations, do health-care providers have a similar right—to sue patients for the costs incurred from their failures to follow medical advice?
• At what point do patients who have rights also become citizens who have responsibilities, particularly as we all—collectively—pay for each other’s health care?
• If the community has a right to call on health-care providers to keep us all productively at work and at school, do communities have a responsibility to do their share as well?
• As the population ages and more health-care costs are attributable to lifestyle, can we afford not to hold patients and communities more responsible for their own health-damaging, cost-increasing behaviors?

What will it take?  Will clinicians, payers and managed care groups be forced to sue patients and communities to get the debates going?

Consider hypertension.

 Health-care providers collectively are asked to:   

• identify patients at-risk from population-based studies,
• call them in for examinations and diagnosis,
• counsel them about diet, exercise, smoking cessation and lifestyle modification,
• prescribe the right medications
• stay current on latest treatment interventions,
• subsidize the cost of those medications,
• place patients in compliance programs to be sure they are taking the medications,
• follow-up to assure the medications are working,
• adjust those medications if they are not as effective as hoped.

 The patient, on the other hand, need do nothing. The patient need not

• stop smoking,
• eat right,
• exercise or
• adhere to the prescription’s directions.

Further, the community need not be supportive, either. Communities need not 

• assure that streets are safe so that people can exercise near their homes,
• that children have healthy food in schools,
• that public policies support healthy lifestyles or
• that those who need help paying for treatments receive that help.

 Yet, years later, if the patient has a heart attack or stroke, the healer must arrive at the emergency room, provide intensive care and help with rehabilitation, all within a negotiated capitated-care rate.

 

No, not politically right. Right, as in “correct.” And not politically correct, just “right, correct.”

In fact, in the past few years I’ve been politically incorrect according to a number of my critics. I have said that patients have a responsibility to play in the course of their own health and care.

It’s something I believe as a patient myself and as a policy maker as well.

My critics believe that in saying so I am “blaming patients” for their illness. Quite the contrary. I believe I am empowering – and I hope activating – them. I’d prefer that I – and they – not be a victim of whatever has befallen us. The best way I know to do that is to get activated and involved – even if that means something as simple and helpful as breathing well through the worst of times.

My views were confirmed when I saw the award-winning “Smile Pinki” on HBO last evening. This compelling documentary of the work of The Smile Train¹ broke my heart. It also healed my soul. What an organization! What a venture into providing free surgery to care for children with clefts in India (and other countries)!

The circumstances of these young lives are devastating, but the eyes of the children, the obvious potential of life within them and loving tenderness of their parents keeps you watching. It was late, I was tired and faced early calls today, yet could not walk away from the TV.

Then comes the soul part for me, the part that makes me forget the angry attacks I’ve received. A hospital worker provides discharge instructions to a group of parents on how to care for their children at home and delivers the empowering message.

To paraphrase, she says, “Since this hospital has helped your children, you have the responsibility to help others, to tell others about us and to help them get the 200 rupees to come² here. This hospital is useless without patients. You are heroes, this is a big country and we can cure others. Tell them about us.”

The film ends with a sense that the parents will do just that. Despite illiteracy, the economic poverty and hardships of their circumstances, the discrimination encountered by their children and the blame from and rejection by their in-laws, you get the impression the message got through.

The parents took bold steps for their children and the children showed amazing spirit and courage themselves. That’s taking responsibility at its best and it will be good enough if they stop there. I suspect, however, that they’ll do even better and reach out to help others. And it does not get any better than that.

If they can do it, so can we.

Why am I smiling? Not because I was right, but because I followed up on my soul’s leading and checked out The Smile Train. Then, I donated. Our firm supports projects to improve the health of women and children in the developing world. Today, in some small way, we helped to heal the smile of one child and the heart of that child’s Mother.

References
1. www.smiletrain.org
2. Care provided to the children is free, but parents must provide for transportation and food costs.

Medical ethicists have made amazing contributions to health care.

They’re heroic in their fearless pursuit of better care for beings – especially the human ones. They seem never to forget that is what they do. They work on the edges of what we know and are usually ahead of what we believe. They poke and prod us to do better. God bless ‘em.

Bob Veatch – one of my very favorites – has written a brilliant new book¹ on the subject and I recommend it highly. It is a product of decades of deep thinking; he’s produced yet another gem.

Unfortunately, the title does not reflect the depth of his thinking; it’s far shallower than that.

The text pushes the edges of what we know and is ahead of what we can produce in health care today, but the title pushes it over the edge. I suspect some editor or publisher picked it. The Bob I read, have heard speak and have once met is better than that.

I recommend it as required reading for anyone – legislator, regulator, staff, advocate, clinician, institution, payer or reporter – involved in health reform. It is brilliant, thoughtfully constructed and engagingly-read.

So, why do I dislike the title? For two reasons:

First, I don’t see Bob arguing that the patient heals themselves – or even can. Rather, I hear him addressing the myriad of uncertainties that accompany any clinician-patient interaction, the complexity of the health care system we have produced and the lack of any one, clear culprit in the mess we face today. It is full of cautionary tales for those who think another set of regulations, EMRs and financial incentives will “fix” it all.

Second, my review of the history of healing says that no culture has ever believed that patients are healed ‘on their own.’ My read of today’s health care crisis agrees.

Healing, one of the two gifts from the divine in every culture we know about (the law² being the other), proceeded as a gift from ‘a more powerful one’ to the individual in need. That powerful one was initially – and in views of many remains today – the divinity of the patient’s choice. Clinicians, as healers, were aligned with that force, for the good of the patient and the community. That alignment created medical oaths and held them to high standards.

Sure, we’re more scientific today and some us even believe that illness is divine retribution³ , but just knowing how a virus replicates in our bodies or where a cancer s metastasizing is insufficient comfort. If we’re sick, we want help. As Bob points out, patients have different, highly important views about what will help will work and be best for them. They may see it in prayer, in medicines, in exercise or even in reframing their definition of health (and beauty!).

Compelling evidence of what the patient needs can be seen elsewhere in this blogspace. Phyllis Kritek⁴, like so many other clinicians before her, needed healers:

• A healer to be welcoming upon arrival. This was her first visit to an unfamiliar facility and yes, the receptionist is a healer. This facility can take note of the reception desk of one client I visit. The name plate reads “Director of First Impressions.” That facility should read that and weep at the impression it created in that first encounter.
• A healer to usher her to change,
• A healer to explain the consent form, research project,
• A healer to see explain the contrast media,
• A healer to see her as a person that ethicists so vigorously ask them to address – as a human person as she received care.

As a clinician, Phyllis had the presence of mind to cope better than most. Like a clinician, trained in and ascribing to ethical standards, she should have been treated and she articulates anger that is unfortunately the norm in health care today. In her dependent (she needed the tests) and vulnerable (near naked) state, she nonetheless was able to capture, record, process and report her experience. God bless ‘er.

It leaves me wondering about solutions to the plight she describes.

• Perhaps the Ritz Carlton should take over the all-but-clinical operations of facilities.
• Perhaps, as Jennifer McCabe⁵ describes in this blogspace, we all need to show up with an advocate to assure we really get care.
• Perhaps the National Health Council should get more airtime to address their health reform proposals, which are directed to addressing the patient-centric issues Bob Veatch pokes us to think about.

You tell me….but to do so, you’ll have to read Bob’s book first – the best, most thoughtful, sobering set of cautionary tales about health reform, told by a very wise man.

Required reading. For everyone. Especially those engaged in reforming the care we’ll get.
References
1. Veatch, Robert, Patient, Heal Thyself, Oxford University Press, Oxford, 2009.
2. For an examination of the law as gift, see Alan M. Dershowitz, The Genesis of Justice, Warner Books, New York, 2000.
3. Raman, L., and Winer, G, “ Evidence of Immanent Justice Reasoning in Adults,” paper presented at the 107th Annual American Psychological Association Meeting, Boston, 1999.
4. http://www.disruptivewomen.net/2009/05/26/health-care-or-product-management/
5. http://www.disruptivewomen.net/2009/05/11/thoughts-on-being-a-patient-advocate-how-to-compose-a-patient-advocate-agreement/

On April 2, Julie Connelly reported that “Doctors Are Opting Out of Medicare.¹” The article focuses initially on specialists but quickly turns to primary care clinicians as well, noting that 29% of Medicare patients surveyed last year were looking for primary care physicians.

Note to my health reform buddies working towards universal coverage… apparently having insurance coverage is not enough.

It’s a surprise to me that it took so long for this problem to hit the presses. About five years ago I had the opportunity to travel across the country with a small group of medical and employer leaders, facilitating discussions between physician groups and local employers collaborating to improve access, quality and cost dynamics in their local areas. To prepare, I called local physicians to “take their pulse and find out where it hurt.” They hurt plenty.

When we started on the East Coast, physicians said they were worried that “one day they would not be able to take Medicare patients.” Moving westward, by the time we reached Dallas later that year they “no longer accepted Medicare patients.” By the end of the year, in the Pacific Northwest, they did not take new patients aged 60 because “in five years they would be on Medicare.”

It was about that time my Mother moved from Indiana to Florida. I breathed a sigh of relief when she found a physician.

It was also about the time I met some physicians near my home, introduced by mutual friends who suspected we had similar health care improvement interests. We did. This practice was the most ideal primary care setting I’d ever seen. It consistently received the highest quality ratings of any practice in Southeastern PA and it projected that in a few years it would close its doors.

They seemed to me the “canary in the mine,” signaling a problem. I wondered if their patients knew. I wondered how they’d keep going. I wondered about my own physician group, just a few blocks away.

I started caring about physicians – including my own – in a new way. That perhaps will be the subject of another blog post.

I visited that practice just last year, two years after their self-predicted demise. They were still thriving. How? Like Dr. Steven Knope, cited in the New York Times story, they had formed a concierge practice – established across the hall from the existing practice. Because some patients paid more, in up-front fees, this practice was able to keep the doors open for those who could not afford more “dedicated” service time provided within the concierge group but who depend on inadequate coverage and reimbursement.

It gave them, as well, the ability to gain back some of the satisfaction I read into Dr. Knope’s noting that he treats an elderly woman for $5 visits – real money for her, he says, but “…she listens to what I say.” By that, I take it to mean she follows his advice and he finds that – not the money – satisfying.

It’s not just “about” the money, but without enough to keep the doors open, primary care is at risk.

Final note to my health reform buddies working towards universal coverage… apparently having insurance coverage is not enough.

References
1. http://www.nytimes.com/2009/04/02/business/retirementspecial/02health.html?_r=1&scp=1&sq=Opting%20out%20of%20medicare&st=cse

Medpedia launched recently. It’s a great idea, a ‘wiki-style’ source of authoritative health information. You can find it at www.medpedia.com.

It will distinguish itself by limiting contributors to those MDs, and PhDs credentialed to address the clinical topics.

So far, so good. What could be better? Three things.

- First, include contributions from “credentialed” patients and caregivers themselves – that is, those who have encountered the disease “up close and personal,” who have demonstrated that they understand it, have managed it and survived it – or not.

That important patient information could be in a separate segment, perhaps, or noted as such, but it should not be ignored. Patients and caregivers have important contributions to the overall understanding of the condition itself, as well as to the experience that other people will have. Credentialed clinicians might well know how to describe metastatic cancer or viral replication dynamics, but only a credentialed patient can offer insights into the interior state of the person who has that experience. Likewise for the caregiver who helps them.

Yes, it’s true that those patient insights can be found on other sites, but those sites may not be as accurate as Medpedia seeks. Lacking these patient insights Medpedia is replicating on the web what happens far too often in clinical settings – clinicians and patients talking different languages and “past” each other, rather than “with” each other.

- Second, address controversies upfront. Clinical knowledge is growing at a rapid pace. As one edge leads, disagreements will ensue. As the other edge trails, likewise. These controversies are some that have spawned patient groups to go their own way and have allowed charlatans to prey on people desperate for help. Acknowledging those controversies will tell more of the truth about health care – that it is not exact, that there are unknowns and that important individual differences are at play in the course of any illness.

- Third, provide some “so what?” information. Medpedia is developing into a great encyclopedia and that is fine as far as it goes, but today’s – not to mention tomorrow’s – health care will not be as accessible as anyone – clinicians or patients – would like. Information is only the beginning and clinicians don’t need the information on Medpedia. They know it. Patients need the information, but they also need to know what to do with it. This is the thorny part, and it must be addressed.

Don’t take my word for it. Check out the conditions on Medpedia. Today’s version of Alzheimer’s, for example. I’m no expert, but in keeping with what I hear from those who are and related to my three hopes for the future of Medpedia:

- First, contributions from “credentialed care givers” would say that Medpedia estimates of the $45,000 annual cost of care is a gross underestimate of the true costs – which include lost income to caregivers and the known impact on their own lives in higher mortality and morbidity.

- Second, contributions from treating clinicians would indicate that with some patients they get better results than this article would indicate. Perhaps those insights would improve the progress towards clinical solutions for the condition.

- Third, both expert clinicians and caregivers would urge some actions for anyone who suspected the onset of Alzheimer’s – such as early diagnosis so the patient and family can make adequate financial and legal plans and identification of support systems for the caregivers.

All the best to Medpedia. May it begin to fill some important gaps in health care.

Health reform. Heard enough about it? I sure have.

Not sure about you, but what worries me is the dizzying array of policies, politics and propaganda and as much as I hope we will see our way through this, I find it impossible sometimes to imagine that the possibilities for improved health care – and improved health – will emerge from the current climate.

We’ve been reforming healthy systems for 4,000 years; you’d think we could ‘get it right’ by now, eh? Perhaps bringing some simplicity to the complexity will help: in the form of health reform’s history.-

- First, records left by early civilizations indicate that health systems were created by the king and the employer. Each knew that a healthy workforce was a productive workforce, providing gold for the king’s coffers via taxes and products for the marketplace.

- Second, the earliest written records demonstrate that health care systems were regulated by the king. The first written law – the Code of Hammurabi dating to 1800 BCE¹ – contained access provisions requiring care for all, even ordering slave owners to provide health care for their slaves. It also contained price controls for physicians to follow, setting differential prices in sliding fee-schedules for different classes of people – the wealthy, tradesmen and slaves.

- Third, as health systems evolved, quality issues arose. The emperor’s ancient Rome, for example, took over warehousing medicinals when product tainting was suspected and the Oath of Hippocrates² created early peer review and process improvement mechanisms.

- Fourth, access, quality and cost, have always been the ‘big three’ of health reform. As access improved, costs increased. As price controls were created, quality suffered. As quality improved…well, you get it. Over time, we’re learned to meet one or two of our ‘big three’ goals, only to see the others careen out of control.

- Fifth, what is new is that for the first time, we’re trying to solve for all three simultaneously.

Can we do it? So far, no government has succeeded. No criticism of the current Administration intended, but this is a ‘very heavy lift’ and house parties aren’t going to help advance a cause this complex if all they do is focus on problems and not also address solutions – like personal responsibilities that each person can take now.

Sorry to beat the drum but have you protected yourself, your family, your workplace and your community with influenza immunization yet?

Especially if you’re inside the Beltway, your local public health experts are warning that flu is on the way³ and there is plenty of injectable and nasal spray left!

References
1. http://www.wsu.edu/~dee/MESO/CODE.HTM
2. http://www.cirp.org/library/ethics/hippocrates/
3. http://www.washingtonpost.com/wp-dyn/content/article/2009/02/01/AR2009020101975.html

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.