Healthcare Contrarian

2011-01-05T09:53:00.000-08:00

Health Care: More Challenges, More Consolidation

In 2011, consolidations continued to climb, up nine percent over 2010. According to Irving Levin Associates, 980 healthcare-related mergers and acquisitions with a total value of $227.4 billion occurred in 2011. Consolidations reached their last peak of $268.4 billion in 2006.

Hospitals reflected the same trend. The value of the top ten hospital mergers and acquisitions for 2011 increased from $3.8 billion in 2010 to $5.6 billion. For all hospital consolidations, the value was approximately $7.3 billion.

As financial pressures continue to grow, more hospitals are likely to join forces to meet challenges such as decreased Medicare reimbursement, cuts in state Medicaid spending, investment in electronic medical records, movement toward forming accountable care organizations, increases in uncompensated care and uncertainty about health care reform.

According to Moody's Investor Services, hospital consolidations have a positive effect because they increase competition in local markets, improve efficiencies and provide added leverage with payers. Conventional wisdom about economies of scale supports their conclusion.

However, a 2006 study of the previous wave of more than 700 hospital mergers and acquisitions in the 1990s presents a different picture. It demonstrated that when hospitals merged, prices increased by 5 percent or more and quality remained unchanged or decreased slightly. The hospitals were able to save costs, but the amount saved was proportional to the degree of integration achieved. Many times operational, financial and cultural barriers impeded effective consolidation and its benefits. Based on my experience as a marketing consultant with hospitals that merged and "demerged," I've seen how disruptive and counterproductive consolidation can be. The process is enormously complex and emotionally charged.

As hospitals join forces to meet challenges, they face an entirely new set of challenges. Researchers at Boston University identified eight factors that are essential to successful integration: strategic vision, governance, leadership, organizational culture/values, financial systems, clinical services, information systems and support functions. Hopefully, hospital leaders can learn from the past and reap greater benefits from consolidation.

— Tom DeSanto

Sources: American Hospital Association data; , "How has hospital consolidation affected the price and quality of hospital care?", Research Synthesis Report No. 9, Willian B. Vogt, PhD and Robert Town, PhD, 2006; "A Conceptual Framework for Successful Hospital Mergers,"Alan Cohen, ScD, Boston University. Image: Google Images

2010-11-26T10:58:00.000-08:00

Improving Chronic Disease Outcomes with mHealth

More than 100 million people in the U.S. have at least one chronic condition, and the number is growing.

More than 270 million people in the U.S. subscribe to wireless services, and the number is growing.

What if wireless technology could be used to remotely monitor chronic conditions and to remind patients to manage them effectively?

People with chronic conditions could enjoy better health and avoid preventable medical and hospital visits. And, because chronic diseases account for 75 percent the $2.3 trillion America spends on health care, we could begin to control runaway costs.

That's just one of the many possibilities of mHealth — the use of mobile technology to support health outcomes.

A widely cited study by Myer, Kobb and Ryan reported that home telemontoring, video visits and coordinated care helped reduce emergency room visits by 40 percent and hospital admissions by 63 percent among elderly veterans with a variety of chronic diseases.

It is estimated that if patients with congestive heart failure, diabetes, chronic obstructive pulmonary disease and other chronic conditions agreed to have their doctors monitor them remotely and guide their self-care via mobile wireless applications, the result would be a $21.1 billion annual reduction in costs for emergency care, hospitalization and nursing home care.

As wireless technology continues to advance and its application to mHealth grows, the U.S. has an enormous opportunity to help its citizens better manage chronic disease and improve the effectiveness of our health-care system.

— Tom DeSanto

Sources: Information Week, MobiHealthNews, homehealthnews.org, healthcarereformmagazine.com. Image: research2guidance

2010-11-06T16:34:00.000-07:00

Immune system attacking a cancer cell

Overcoming Cancer's Stealth Capabilities

Cancer cells have a stealth capability that enables them to avoid detection and destruction by the immune system. That's why cancer can sneak up on us and multiply unchecked.

In a study released this week in Science, researchers were able to reveal and reverse cancer's stealth capability.

Researchers hypothesized that stroma, the nonmalignant connective tissue that surrounds tumors, plays a role in helping cancer hide. They discovered that certain stroma cells express fibroblast activation protein (FAP), which is found in areas where the body needs to suppress the immune system (such as the uterus, placenta and areas of inflammation).

To study the possible stealth mechanism, researchers bred transgenic mice with a genetic switch to turn off FAP-expressing (FAP+) cells. They injected the mice with cancer and allowed tumors to become well established. When they turned off the FAP+ cells, 80 to 90 percent of the tumors died within 48 hours. In further study with a group of mice with no immune systems, turning off FAP+ cells had no effect—verifying that the mice's immune systems killed the cancer.

The study is a first step toward new therapies that could one day target FAP+ cells to unleash the immune system's ability to detect and destroy cancer cells.

— Tom DeSanto

Source: Kraman, M. et al., "Suppression of Antitumor Immunity by Stromal Cells Expressing Fibroblast Activation Protein-alpha," Science, 330:827-30, 2010. Image: Susan Arnold

2010-10-30T15:31:00.000-07:00

A Major Reversal:
No Patents on Genes

Gene patents have been issued for decades. The Patent and Trademark Office has granted thousands of patents on genes from various organisms, including about 20 percent of human genes. This has enabled the biotechnology industry to drive remarkable advances in medicine.

In late October, the Department of Justice declared that human and other genes should not be eligible for patents because they are part of nature.

The road to reversal began when a lawsuit was filed challenging patents covering the BRCA1 and BRCA2 genes and patent-holder Myriad Genetics' screenings that determine predisposition to breast and ovarian cancers. A district court judge in Manhattan ruled the patents invalid because genes carry important information, whether in the body or isolated from it, that can't be patented. His ruling prompted the government to reconsider its policy.

A subsequent friend-of-the-court brief stated: "The chemical structure of native human genes is a product of nature, and it is no less a product of nature when that structure is 'isolated' from its natural environment than are cotton fibers that have been separated from cotton seeds or coal that has been extracted from the earth."

Such a reversal and adamant position could endanger the progress being made in diagnostic testing and in development of highly effective new drugs designed to work in conjunction with the patient's genetic makeup.

I often write about how this progress is already helping patients. BRCA2 screening provided early diagnosis to a cancer victim's children so they could avoid chemotherapy and invasive treatment. In clinical trials, patient-tailored cancer vaccines have brought remission in difficult cases. Extracted genes, and the potential they hold for improving people's lives, are not at all like the limited possibilities of extracted cotton fibers and coal.

The government's stand on patenting genes is not merely a matter of principle. It's a matter of life and death for current and future patients who depend upon the medical advances made possible through the development and delivery of gene therapies.

Appeals to the government's new stance are in progress. Let's hope they lead to a second reversal and further steps forward for biomedical science and the patients who benefit from it.

— Tom DeSanto

Source: New York Timeds. October 29, 2010. Image: Google Images

Trying a New Answer to Cancer Costs

2010-10-20T11:49:00.000-07:00

As cancer care costs continue to rise, UnitedHealth Group is looking for answers. It estimates that cancer drugs account for 35 to 40 percent of its spending on cancer treatment, and is testing a new way to compensate doctors for cancer care.

The Problem

• Spending on cancer treatment is rising 15 to 18 percent annually, nearly double the rate of general health care costs.

• Drugs account for an estimated 65 percent of an oncologist's income.

• Customarily, doctors purchase cancer drugs, infuse them in their offices and then bill insurers for their cost plus a 15 percent profit margin.

How can cancer costs be reduced while ensuring that patients receive proper treatment and doctors are compensated fairly?

Their Answer is being tested in five cancer clinics for breast, colon and lung cancer. It works like this:

• Doctors decide in advance which drugs they would like to use in the patient's treatment plan, from generic chemotherapeutic agents to more costly branded drugs.

• UnitedHealth pays the doctors for whatever choice they make, but without the customary markup. Instead, the doctors receive a set fee that includes the profit they would have made, plus costs for managing patient care.

• If the doctors use a drug not in the treatment plan, United Health Group covers the cost of the drug, but will not increase the separate payment covering markup and patient management.

• In addition, treatment data would be shared among participating clinics to identify the most effective methods.

Reaction

Some groups argue that the plan could provide an incentive for doctors to withhold treatment from patients, especially if the separate payment doesn't cover enough costs.

I believe separating the ability to earn additional profit from prescribing more expensive drugs is a step in the right direction. We need to trust physicians to decide which drugs they prefer to use, cover the cost of those drugs and to provide them with collective data to support future decisions — without rewarding more expensive treatment options.

The outcome from the test program remains to be seen. In the meantime, UnitedHealth Group is to be applauded for seeking answers that respect physicians' judgment and support their financial success.

— Tom DeSanto

Source: Wall Street Journal, October 20, 2010. Graphic: Google Images

Maybe They Really Don't Hear Us

2010-09-15T13:50:00.000-07:00

Teens never seem to listen. Maybe it's because they really don't hear us.

Hearing loss among adolescents increased by 31 percent between 1988-1994 and 2005-2006, according to a study recently published in JAMA. (JAMA2010;304[7]:772-778)

The prevalence of any hearing loss among adolescents was 14.9 percent in the earlier group and 19.5 percent more recently. Although the reasons for the increase are unclear, risk from loud sound exposure from listening to music may be partly to blame.

Hearing loss affects more than 6.5 million adolescents. Males are more likely to have it, as well as individuals from families below the federal poverty level.

It's time for adults to pay attention to a trend that not only increases frustration within families, but could have significant educational and social implications for the next generation.

— Tom DeSanto

Image: Titan Teens iPod desktop

Recession Today Keeps Patients Away?

2010-08-25T11:39:00.000-07:00

Doctor visits, hospital admissions, outpatient surgery, laboratory testing and prescriptions have all declined according to recent reports:

Doctor visits fell 7.9 percent in May 2010 compared to the same month in 2009. (Thomson Reuters)

Hospital admissions fell 2.3 percent in April 2010 compared to the same month in 2009. (Thomson Reuters)

Outpatient surgical volume fell 2.6 percent at AmSurg Corp. compared to 2009. (same-facility procedures)

Laboratory test volumes fell 2.3 percent in the first quarter of 2010 at Quest Diagnostics.

New prescriptions for maintenance drugs fell in the first quarter of 2010 at CVS Caremark Corp.

According to the Wall Street Journal, "such cutbacks have happened before in recessions, but the drop seems to be more pronounced this time, industry analysts say."

Insured Americans are moving toward higher-deductible health plans and shouldering a greater amount of the cost of their care. As a result, they may be forgoing health care, especially when money is tight. The recession also may be causing people to delay or opt not to have elective procedures.

Whatever the cause of the unexpected drop in utilization, it will have the effect of lowering America's health care expenditures. Some believe this goes beyond the recession and may be the advent of consumerism in health care and the beginning of more practical utilization of health care services.

I say that this is a time when we must determine whether the decline in utilization is coming at a greater cost. Are people with chronic conditions receiving proper care to manage their health and prevent greater complications? Are people receiving immunizations and preventive care, especially children and older adults? Is it possible that the decline in utilization also is the result of the uninsured and underinsured choosing shelter, food and basic necessities over health care?

Before we celebrate a victory for health care consumerism, let's examine the cost of free-market forces.

— Tom DeSanto

Source: Wall Street Journal, July 29, 2010.

Physicians Needed for Health Care Transformation

2010-08-11T13:03:00.000-07:00

Yesterday, MDNews.com, an emerging online news network for physicians, posted an edited version of my "Peer Perspective" submission on its website. Here is the full text:

"As new health care reform laws drive us away from focusing on volume and more toward achieving greater value, physicians will have renewed opportunity to practice medicine as a science and art. Your expertise will be vital to setting and achieving higher standards of care and in squeezing out redundant or unnecessary costs. Focusing on volume has robbed physicians and their patients of the time it takes to provide comprehensive, consistent care. Focusing on quality has the promise of restoring more effective and fulfilling practice — if physicians embrace change and champion the role as leaders of transformation. It's easy to dismiss standardization, checklists and other quality and patient safety initiatives as an affront to freedom. In reality, they may actually serve to support physicians by removing risk and enabling you to excel as you apply your considerable talents and experience with an enhanced emphasis on achieving optimal outcomes."

My hope is that physicians will rise up, cast off the chains of bureaucracy that have bound them, and lead us to new age of medicine.

— Tom DeSanto

Image: MDNews.com Website

Summit Illuminates Health Care Transformation

2010-07-26T17:09:00.000-07:00

At this year's American Hospital Association Leadership Summit, I saw an impressive parade of luminaries shed light on many pressing challenges faced by the health care industry.

Chesley B. Sullenberger, the pilot who landed ill-fated USAirways flight 1549 safely in the Hudson River, advised us that the routinized, safety checklists that made his heroics possible have an important place in health care. Contrary to current complaints, such lists would not rob doctors of their autonomy. Instead, checklists would ensure best practices and allow doctors to excel, while guarding patient safety.

Al Gore, former vice president of the U.S., spoke of sustainability—a challenge faced not only in the economics surrounding our consumption of Earth's resources, but also in the delivery of health care.

Steven D. Levitt, co-author of Freakonomics and Superfreakonomics, reminded us of the role of free market forces in health care. He warned that we may need to "make people decide between taking grandma off life support and paying for their kid's college education."

Dee Dee Myers, former White House press secretary, reminded us of the direct, positive correlation between the percentage of women in top leadership roles and achievement of success. Although health care provides many opportunities for women, leadership roles continue to be scarce.

Newt Gingrich, former Speaker of the House, warned of the enormous competitive pressure coming from China and India. He said health care providers will need to deliver very high quality at a much lower cost or face the prospect of bankruptcy.

Ian Morrison, health care futurist, reiterated that health care reform is moving our industry from focusing on volume to creating value. Glenn Steele, Jr., President & CEO, Geisinger Health System, and his leadership team discussed how they develop programs that simultaneously improve care and provide increased value. They prove that transformation is already in progress.

Many speakers explored approaches to the complexity of implementing changes mandated by new health care reform legislation, as well as the challenges of improving outcomes while squeezing out costs. The convergence of so many experts and accomplished professionals offered enlightenment and some rays of hope in the storm.

— Tom DeSanto

Image: Tom DeSanto

Childhood Obesity: Signature Project Sounds the Alarm

2010-07-15T16:19:00.000-07:00

First Lady Michelle Obama has made childhood obesity her signature project. Speaking out on the issue is a noble start to overcoming an alarming problem.

Obesity has tripled among America's adolescents. It rose from 5 percent in 1980 to more than 18 percent in 2008. Among children 8 to 11, obesity increased from 6.5 percent to 19.6 percent. (CDC)

Associated risks for obese children include increased incidence of heart disease, high blood pressure, diabetes, breathing problems, sleeping difficulties, low self-esteem, depression and anxiety. (American Academy of Child & Adolescent Psychiatry)

Continuing risks during adulthood are dire. Computer generated forecasts, reported in the New England Journal of Medicine in 2007, estimated that by 2035 the prevalence of coronary heart disease will be 5 to 16 percent higher than today due to childhood obesity.

Major culprits for the epidemic include poor dietary habits and a more sedentary lifestyle, most likely learned from parents. A recent study reported the overall obesity rate among adult Americans was 33.8 percent in 2008. (Journal of the American Medical Association, January 20, 2010)

Obesity is an enormously complex issue. Changing the underlying social and cultural causes will require a sea change. Making incremental progress will require the cooperation to implement—and sustain—practical measures that can make a difference.

In 2004, the Centers for Disease Control and Prevention (CDC) released a report outlining ten key strategies schools could take to combat childhood obesity. It continues to issue reports, guidelines and tools. Are they working?

A study reported in Health Affairs in March 2010 offers some hope. San Francisco State University researchers compared body mass index data from students in fifth and seventh grades before and after California adopted regulations banning sodas, highly sweetened beverages and junk foods in pubic schools. Based on eight years of data, researchers found that before the measures were enacted, obesity rates were increasing in all groups. In the three years after the ban, obesity rates slowed in all study groups except fifth-grade girls. (UPI)

To stay healthy, children need guidance in schools and at home. Actions speak louder than words. America has been taking some action against childhood obesity with limited success. Maybe what we've needed is the First Lady's words.

— Tom DeSanto

Image: Kevin Lamarque/Reuters

Medicare Cuts: A Zero-Sum Game or Worse

2010-06-24T14:03:00.000-07:00

While Congress debates the "doc fix," Medicare has reduced payment to physicians by 21.2 percent.

The Senate passed a bill that would provide a 6-month, 2.2-percent hike in payments instead. The House has not.

If the bill eventually passes, the cost of reprocessing claims is likely to wipe out the physicians' 2.2-percent increase. Medicare would also spend about 30 cents per claim on reprocessing.

The result? A loss of resources and goodwill. And a negative impact on patient care.

Physicians may be inclined to see fewer Medicare patients. Already more than 17 percent restrict the number of Medicare patients in their practice. The rate among primary care physicians is 31 percent. (Based on 9,000 physicians surveyed by the American Medical Association)

Physicians may also change how they treat patients. When Medicare payment rates were reduced for outpatient administration of chemotherapy drugs starting in 2005, physicians responded by switching chemotherapy agents. They were less likely to dispense the drugs with greater cuts in profitability and moved to higher-margin drugs instead, offsetting some of the savings intended by the legislation.

Congress can try to cut costs by reducing payments to physicians. But, in the end, it's likely to be a losing proposition. Real health care reform will come when government chooses to put its trust in physicians, instead of putting its hands in their pockets.

UPDATE: Temporary sanity prevails. From modernhealthcare.com, Friday, June 25:

"... the House passed on a 415-to-1 vote legislation that replaces a 21.2% Medicare physician pay cut with a 2.2% raise through November. The White House announced Friday that President Barack Obama has signed the bill into law."

Another temporary fix. The sad saga continues...

— Tom DeSanto

Sources: Health Affairs, June 17; USA Today; Image: Google Images

Battle on the Front Line of Patient Safety

2010-06-16T12:07:00.000-07:00

Nearly 12,000 nurses in the Minneapolis/St. Paul area went on strike on June 10. Their chief complaint was that business decisions are adversely affecting the standards of nursing care and patient safety.

Registered nurses are on the front line for patient safety. Research proves it.

In a study released in the May/June 2010 issue of the Journal of Hospital Medicine, lead author Jeremy Sussman, MD, MS, concludes that "cuts to hospital staffing can hurt interactions between health care providers and patients, threatening robust nurse-to-patient ratios, which have been shown to affect patient safety."

A 2006 study found that hospital with high RN staffing had lower rates of five adverse patient outcomes (urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding and longer hospital stays) than hospitals with low RN staffing.

Another study demonstrated that a 10 percent increase in the proportion of nurses holding a bachelor's degree was associated with a 5 percent decrease in two adverse outcomes: the likelihood of surgical patients dying within 30 days of admission and the odds of failure to rescue.

Mass layoffs of 50 or more hospital employees (with an increasing number of nurses and clinicians) reached a record high in April 2010 according to American Medical News. Nursing strikes, judicial action and lawsuits are running rampant from Pennsylvania to California. Add to this the projected nursing shortage and it's easy to imagine a serious decline in patient safety.

Dr. Sussman and his colleagues suggest that the federal government could connect hospitals' financial stability to patient safety. For example, government stimulus funds could be used to enable hospitals to employ nurse discharge advocates who could help reduce rehospitalization by providing instructions for compliance with medication doses and follow-up visits.

Government funding could also be earmarked to support nurses and clinicians by providing new technologies and methods that have been proven to reduce medical errors. According to the website Dead by Mistake, "every year approximately 200,000 American patients die preventable deaths as tools to make them safer go unused."

The number of innocent casualties is already too high for America not to take bold steps in the battle for patient safety.

— Tom DeSanto

Sources: Sussman, Halasvamani, Davis (2010),"Is the current recession compromising hospital quality?," University of Michigan, Journal of Hospital Medicine, Volume 5, Issue 5; Lovell (2006), "Solving the nursing shortage through higher wages," Washington, DC: Institute for Women's Policy Research; Aiken, Clarke, Sloane, Sochalski, Silber (2002), "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction," JAMA, 288, 1987-1993; Image: Minneapolis Star Tribune

Beyond the Headlines: U.S. Cancer Costs Double

2010-06-04T12:53:00.000-07:00

"US Cancer Costs Double in Nearly 20 Years" was the headline of a recent Associated Press article. At first thought, it's easy to conclude that the major driver is expensive cancer treatment. Maybe not.

The article covered a new study conducted by the U.S. Centers for Disease Control and Prevention. Among the surprising findings:

     - Rising costs were driven by increasing numbers of cancer patients.

     - Costs from inpatient care dropped from 64 percent to 27 percent.

   - The percentage of total U.S. medical costs from cancer treatment remains at 5 percent, unchanged for decades.

Among caveats for drawing conclusions:

     - Data doesn't include diagnostic tests and scans.

     - The study covers data between 1987 and 2005.

It's likely that the advent of very expensive cancer therapies and greater frequency of cancer screenings over the past five years are contributing to an ongoing rise in costs. Hopefully, this may continue to be offset somewhat by the shift to less expensive outpatient care.

The study also reminds us that demographics will play a significant role. The number of older Americans is increasing rapidly and they're living longer. With age comes the greater possibility of developing cancer.

When we study current costs, will we discover an even greater increase as we multiply a growing number of patients and increasingly more expensive treatment costs? Most likely.

Will cancer patients be able to afford treatment?

Between 1987 and 2005, the proportion of cancer costs paid by private health insurance rose from 42 to 50 percent while out-of-pocket costs fell from 17 percent to 8 percent. That finding was unexpected, but welcome news.

Did that trend continue between 2005 and 2010? Headlines about the increase in personal bankruptcies due to catastrophic medical costs would tell us otherwise.

We can't know for sure until we look beyond the headlines.

— Tom DeSanto

Source: Associated Press article by Mike Stobbe published by google news; Graphic: Tom DeSanto

Solemn Remembrance: Mother's Day U.S.A.

2010-05-14T15:31:00.000-07:00

In honor of Mother's Day, Save the Children® released its annual Mother's Index. It ranks how well mothers and children fare in 160 countries based on health, education and economic status.

The best place for mothers was Norway. The worse was Afghanistan. The United States, as wealthy and advanced as we are, came in at 28th place among more developed countries.

Maternal and infant mortality rates, as well as less generous maternity-leave policies, were cited as major contributors to the United States' low ranking.

Both Portugal (#19) and Greece scored higher (#24.) These countries have far fewer resources to support mothers. If we take the magnitude of per-capita health-care expenditure as one measure, we find that Portugal spent $1,897 and Greece spent $2,197, while the U.S. spent $6,096. (United Nations Human Development Report 2007)

We all know high health-care expenditures do not automatically equate to better health. With health-care reform in motion, we can do something about it. But major stakeholders such as federal and state government, providers, physicians, insurers and consumers are battling over what they may have to "give up" in the name of progress.

The United States is already giving up the health and welfare of future generations. Where's the voice for the mothers and infants who die needlessly? Whatever happened to "as American as motherhood and apple pie?"

— Tom DeSanto

Image: Google Images

Headlines Reflect Irony of Prevention vs. Treatment

2010-04-20T09:08:00.000-07:00

Health risks and medical advancements both make sensational headlines. This ironic juxtaposition recently appeared on iGoogle.

America's approach to health care is that we often wait until people get sick and then use our considerable medical arsenal to make them well.

Saving lives through advanced treatment is more rewarding to the American psyche than saving and improving lives by taking smaller, less visible steps such as preventive care and health education.

As America's health care expenditures become unsustainable, I see more balance and less bravado in our future. It's about time.

— Tom DeSanto

A Tale of Two Indias

2010-03-20T17:43:00.000-07:00

Recently I had the joy of exploring India for 20 days. Tradition, triumph, squalor and splendor all flow together in a sea teeming with all the variety and richness of humanity. Improbabilities and possibilities abound.

What about health care in the world's largest democracy? In the marvelous paradox of that great nation, it all depends on which India you're in. Traditional India plods on as a new India rises.

Traditional India

The opportunity to receive adequate health care is slim to none for most people. India's government devotes less than 5 percent of its GDP on health care for a population of more than 1 billion people. In rural areas, families spend nearly 27 percent of their income on health care and 35 percent of those who are hospitalized fall below the poverty line. (India Knowledge @Wharton, 2/11/10)

Public health services suffer the same fate as many Indian institutions: overcrowding, crumbling infrastructure and corruption. Private health services are unaffordable, often unregulated and sometimes substandard. Excellent health care is available in urban areas to those who are wealthy. Reform on a massive scale is beyond possibility anytime soon.

The New India

The opportunity to become a global hub for medical tourism, clinical studies and R&D is growing due to highly qualified doctors and scientists, state-of-the-art technology and low costs. India's health care industry is expanding rapidly and generates US$40 billion each year. It is now only second to education as the major service-sector employer in India, providing jobs for about 4.5 million people, directly or indirectly. (India Knowledge @Wharton, 2/11/10)

America's health care reform presents new opportunities for India. New laws will add 32 million Americans to the rolls of the insured and will require the type of back-office outsourced services at which India excels. Studies show that up to 41 percent of health plan costs are administrative. Pressure will intensify to deliver low-cost services for enrollment, database organization, claims processing and other support. India has the answer.

Services that can't be outsourced to India by law will still provide opportunity. Major Indian outsourcing firms Wipro and Tata Consultancy Services have set up operations in Atlanta and Cincinnati. Infosys will soon follow suit in Dallas. (Christian Science Monitor)

People tend to accentuate the shortcomings of India. After my journey, I can attest that there is no shortage of ingenuity and tenacity in India. The wheels of progress can move slowly, but my hope is that the rise of the new India will bring better health and well-being to all.

— Tom DeSanto

Image: Taken by me in Jodhpur, India in March 2010

Health Care Reform Lobbyist Windfall

2010-02-08T13:02:00.000-08:00

In 2009, more than $1.2 billion was spent on lobbying related to health care reform.

More than 1,750 businesses and organizations hired 4,525 lobbyists—8 for each member of Congress. (The Center for Public Integrity)

It accounted for more than 1/3 of the total of $3.47 billion spent on lobbying for all issues (Center for Responsive Politics) and set a new record for the amount spent on a single issue.

Lobbying organizations included 745 trade, advocacy and professional groups, 207 hospitals, 105 insurance companies and 85 manufacturing companies. (For a detailed database of lobbying expenses, visit www.publicintegrity.org/articles/entry/1953)

The expenditure is understandable given the amount of money at stake. But imagine how many people we could have helped in 2009 if we spent the $1.2 billion directly on health care.

— Tom DeSanto

Image: jsoares from worth1000.com

Learning from Giant Viruses

2010-01-05T11:48:00.000-08:00

Recent events in the world, economy and health care challenge us to rethink old assumptions and to develop a repertoire of new business approaches. We can find inspiration by looking at viruses.

Conventional wisdom has long considered viruses to be nothing more than little bags of genes that randomly turn into self-replicating molecules by tapping into host cells' machinery to make more particles. As a result, viruses have not been widely recognized as living organisms.

Assumptions were first challenged by the discovery of giant viruses in the 1990s. The mimivirus, at more than 400 nm and 1,000 genes, redefined size and complexity. Most recently, as reported in the Proceedings of the National Academy of Sciences, the discovery of Marseillevirus redefines possibilities.

These giant viruses live within amoeba and adopt genes from a variety of origins, including bacteria, eukaryotes and other viruses, to improve their function. Because amoeba consume and contain a variety of particles and organisms, these giant viruses have access to more possibilities for genetic material and opportunities for "self-improvement."

In 2010, we would do well to challenge assumptions. Nothing we encounter is small or insignificant. Much like the inside of amoeba, our organizations are filled with a variety of possibilities. Let's adopt and assimilate small particles of inspiration, knowledge and experience to devise new approaches that improve our collective effectiveness. Interdependence can be contagious and bring new life to our organizations during these difficult times.

— Tom DeSanto

Sources: Science Daily, The Scientist.com, GiantVirus.org. Image: Science Daily

Blogs Gone Bust

2009-12-30T12:33:00.000-08:00

Blogs are like mining towns. Folks establish them in hopes of striking a mother lode of connections or pursuing dreams of communicating richly. Then, when expectations are unmet or other demands prevail, they abandon their blogs and move on. The blogosphere is littered with the dusty remnants of blogs gone bust. They are the ghost towns of the Web.

After 18 months of blogging weekly, I'm cutting back on my commitment. My zeal for health care in its miracles and madness remains unabated. But I no longer have the time for weekly sharing.

Unlike old mining towns that are reduced to ruins by time and the elements, blogs are preserved fully in all their glory. Come on in to explore, discover and enjoy the past. Most likely, you'll find new posts in the future.

—Tom DeSanto

Image: www.urbanhonking.com/bodieweb

Destructive Division on Healthcare

2009-12-04T11:18:00.000-08:00

Healthy debate innovates.
Hateful division destroys.

I'm tired of seeing words like "battle," shootout,"and "kill" in headlines about healthcare reform.

"A house divided against itself cannot stand."
— Abraham Lincoln

Enough said, for now.

— Tom DeSanto

Thanksgiving Talk: Triumph and Tragedy

2009-11-27T11:31:00.000-08:00

When conversation at Thanksgiving dinner turned to health, personal stories poignantly told the tale of American healthcare.

A relative in his seventies talked about how open-heart surgery and a knee replacement enabled him to continue an active lifestyle. His care was covered by his health insurance. A future bicycle tour in Europe was being planned.

Another relative told how her friend had recently died from a stroke at age 44. It was caused by blood clots that could have been prevented with coumadin. But the woman couldn't afford it because she had no health insurance. Her friend's funeral was being planned.

The disparity in America's healthcare system is outrageous. In a land of plenty, people are dying because they can't afford basic care that could save their lives. Shouldn't we all have the opportunity to live abundantly?

If we simply addressed the disparities, America could improve the health of its population and the effectiveness of its healthcare system. The healthcare debate so often is about money. It's also about morals. We need to do what's right.

— Tom DeSanto

Image: Tom DeSanto

Gesundheit! Here's to America's health?

2009-11-20T17:31:00.000-08:00

Would the German model of healthcare work for America?

Under German law, every citizen must be insured and has a choice of public and private options, including more than 250 gestzliche Krankenkassen (state sickness funds) that are heavily regulated. The government determines healthcare standards and sets premiums based on risk, such as age and health status. Although the government collects premiums through taxes and pays each citizen's chosen health care provider, it stays out of the business of managing the day-to-day delivery of health care services.

Monthly costs in the German system amount to about 15 percent of the citizen's income, split by employee and employer. Spouses and children earn automatic coverage as soon as a wage-earner pays into the system. German children are never without health care because its covered by general tax revenue. The public option is for Germans earning up to $66,000 a year. Those who earn more can buy private insurance, but only 20 percent of the choose to do so.

How does it work? It depends whom you ask. No one is turned down for care. And the quality is considered world-class in major cities.

German citizens grumble about rising copayments and the quality of non-medical services and a reduction of preventive care.

Physicians grumble about being underpaid and overworked. In 2006, they took to the streets in protest. Until recent reforms that repealed the required prescribing of generics, they also felt over-regulated.

Citizens and physicians alike sometimes feel like they pawns in an epic battle about cost between the government and insurance companies.

No health system is perfect. But a competitive system with some centralized regulation and a public option that covers everyone could be a step forward, if Americans can agree on it.

The best thing, I believe, about the German system is full coverage for all children. This is a source of shame for America. Upcoming generations need a good start. Their future and the future of our country depend on it.

— Tom DeSanto

Image:clker.com

The Freakonomics of Chemotherapy

2009-11-12T14:40:00.000-08:00

In Super Freakonomics, Levitt and Dubner paint a bleak view of the value of chemotherapy. Is their view cynical and fatalistic? Or is it clear and realistic?

The authors acknowledge the effectiveness of chemotherapy in treating leukemia, lymphoma, Hodgkin's disease and testicular cancers, but they label it "remarkably ineffective" overall, citing the following statistics:

- Although the 5-year survival rate for all cancer patients has been shown to be 63 percent, barely 2 percent of survival is attributable to chemotherapy. For multiple myeloma, soft-tissue sarcoma, melanoma of the skin and cancers of the pancreas, uterus, prostate, bladder and kidney, chemotherapy had zero discernible effect.

- A typical chemotherapy regime for non-small-cell lung cancer, which kills more than 150,000 Americans each year, costs $40,000, but only extends life by an average of 2 months.

- Cancer patients make up 20 percent of Medicare patients, but consume 40 percent of the Medicare drug budget.

- More than $40 billion is spent each year worldwide on cancer drugs.

If chemotherapy is so ineffective, why is it so widely prescribed? According to the authors, major reasons include:

- a natural response to financial incentives (Oncologists typically derive more than half their income from selling and administering chemotherapy drugs.)

- an attempt to inflate survival rates (A few extra months of life, expressed as a percentage, can look quite impressive.)

- an over-belief in the efficacy of chemotherapy

- a promise of hope for recovery or extending life

The observations made in Super Freakonomics cast light on some of the struggles inherent in reforming America's health system. Even if chemotherapy can be proven to be ineffective, its use is unlikely to be curtailed greatly.

The government will find it difficult to impose limits on constituents that put a "death squad" label on panels that evaluate efficacy and allocate resources.

Manufacturers of chemotherapeutic agents will not simply abandon incentives that promote chemotherapy. Their lobbyists will lean hard on legislators.

Oncologists want to save lives. Patients are willing to endure chemotherapy's toxic rage to overcome cancer. Families cling to it in desperation. And we all know cancer survivors who attribute their priceless second lease on life to their treatment regimen. Chemotherapy is hope.

With the advent of companion diagnostics, chemotherapy may one day be as effective as we hope and believe it should be. Oncologists would be able to match individual patients with the chemotherapy drug(s), dose and timing that works best for their specific biological makeup. They would also avoid chemotherapy when it would have little or no effect.

In the meantime, as I look at chemotherapy—and healthcare in general—in economic terms, it reminds me of a saying that is attributed to John Wanamaker. (Revisions are mine.)

"Half the money I spend on [healthcare] is wasted; the trouble is I don't know which half."

— Tom DeSanto

Source: Super Freakonomics, Steven D. Levitt and Stephen J. Dubner, HarperCollins 2009, pp. 84-86. Image: www.canceractive.com

Are Job Losses Truly Sickening?

2009-11-05T22:01:00.000-08:00

As of the end of October, America's unemployment rate reached 10.2 percent. More than 15.7 million people are out of work. It's the highest rate in 26 years.

Without a doubt, America's economic ills affect the health of its citizens. Loss of employment often limits access to health insurance, leading people to postpone or avoid treatment, stop taking medications and forgo preventive care. But studies have shown that the experience of job loss itself can have harmful health effects.

Workers who lost their job through no fault of their own, were twice as likely to report the onset of a new illness such as high blood pressure, diabetes or heart disease within 18 months, compared to those who remained employed. (Strully study, Harvard School of Public Health review of U.S. Panel of Income Dynamics data in 1999, 2001 and 2003)

When men became unemployed, symptoms of somatization, depression and anxiety increased. The men made significantly more visits to their physicians, took more medications and spent more days sick in bed than employed individuals, even though the number of diagnosis in the unemployed and employed groups were similar. (Linn, Sandifer and Stein study, American Journal of Public Health, May 1985)

Researchers in the 1970s estimated that every 1 percent increase in the unemployment rate in the U.S. leads to an additional 6,000 additional deaths each year. (Jin RL, The impact of unemployment on health: a review of the evidence. Canadian Medical Association Journal, Sept. 1, 1995)

All of us are sick of seeing the reports of rising unemployment. And rising unemployment is making our nation sicker.

Now, more than ever, we need to provide all our citizens with access to healthcare. It's a daunting task in times of economic duress. But we must not settle for anything less.

— Tom DeSanto

Image: Market Watch

The Reluctant Symbiosis of Companion Diagnostics

2009-10-29T11:59:00.000-07:00

In nature, the rhinoceros and oxpecker have a perfectly symbiotic relationship. The rhino provides ticks for the bird to eat and the bird chatters loudly at the approach of danger. In Swahili, the oxpecker is known as "askari wa kifaru," the rhinoceros guard.

In healthcare, a symbiotic relationship between diagnostic and pharmaceutical companies makes perfect sense. Pharmacogenetic tests can guide the development and application of new drug therapies. But the relationship doesn't come naturally.

The pursuit of personalized medicine should be driving new relationships, but a recent report by PricewaterhouseCoopers (PWC) found that partnerships around companion diagnostics are slow to develop. Between 2004 and 2008, only 45 such partnerships were formed, with 21 of them relating to cancer.

Big Pharma is the greatest collaborator to date, mostly focusing on cancer. Funding remains strong for cancer research and resulting drug therapies are high-ticket items. Companion diagnostics can help prove effectiveness and guide treatment, especially given the role of genetics in cancer progression.

Why aren't more relationships progressing?

Diagnostics companies are hesitant to devote the resources required to develop companion diagnostics. Often their focus remains on clinical laboratories, their customary target and proven source of revenue. If they do pursue companion diagnostics, the preference is to go it alone and retain the value of the diagnostic within their own company.

According to Ted Snelgrove, who guided the development of the highly successful Oncotype Dx® breast cancer assay, development is difficult and expensive. Success for a test that costs more than $3,000 requires a strong value proposition and persistence. It is especially challenging when pharma partners prefer to keep more than 90 percent of revenue generated from companion diagnostics, leaving a small remainder for innovative diagnostic companies.

Will diagnostics and pharma become more like the rhino and oxpecker? I believe so. But the dynamics governing the relationship promise to be complex. Considering the trend toward FDA oversight, healthcare reform and continuing advances in technology, it will be difficult to determine who provides the ticks and who protects from danger.

— Tom DeSanto

PWC study available online at www.pwc.com/us/en/healthcare/publications/diagnostics-2009-moving-towards-personalized-medicine.jhtml. Recent webcast by Ted Snelgrove available at www.dxma.org.

Additional source: Clinical Laboratory News, October 2009. Image: www.flikr.com

A Complex Case Worthy of Dr. House

2009-10-22T13:16:00.000-07:00

Each week in a mythical New Jersey hospital, Dr. Gregory House collaborates with his team to solve an incredibly complex medical case.

Now a dozen real-life New Jersey hospitals are collaborating to solve an incredibly complex financial case.

For 10 years, New Jersey hospitals have suffered from an average profit margin of less than 1 percent. To improve financial health, New Jersey hospitals must reduce waste and cut cost while improving patient care.

A recently approved demonstration project will help determine if hospitals and physicians can collaborate more closely to improve safety and quality of care while reducing costs.

CMS approved a gainsharing plan proposed by the New Jersey Hospital Association in which hospitals are allowed to use current Medicare funds to provide incentives to participating physicians who excel at achieving exemplary outcomes while helping hospitals save money. (Physician participation is voluntary.)

The plan takes collaboration to new levels in many respects. Each hospital and its physicians will become more closely aligned in efforts to improve quality and efficiency. Governing the incentive program will require active steering committees with at least 50 percent physician participation. The dozen hospitals will work together through representatives on a global steering committee to share ideas, expertise and best practices.

In each episode of House, specialists and the hospital have less than 60 minutes to solve the case. This demonstration project brings together motivated physicians and administrators in twelve hospitals over three years to help find a way to restore the financial health of New Jersey's hospitals.

CMS is overseeing the project and will monitor success based on hospital readmissions and other data. Will collaboration bring success? The case is enormously complex and only time will tell. Stay tuned.

— Tom DeSanto

Based on "Gainsharing Pilot Tests if Hospitals, Physicians Can Reduce Costs," Mark Taylor, H&HN, October 2009. Image: fanpop.com

A Brief on Biologics, Biosimilars and Bioethics

2009-10-14T12:30:00.000-07:00

The November/December issue of AARP, The Magazine features excellent articles on "The New Miracle Drugs."
It inspired me to write this brief overview.

Biologics are produced by living organisms and are engineered to specifically target proteins involved in causing disease. Many studies support their effectiveness in prolonging life and relieving symptoms for cancers, autoimmune diseases and other serious illnesses.
- More than 300 biologics currently on the market
- Comprise 25 percent of new drugs approved by FDA
- Comprise 13 percent of FDA black-box-warning labels
- $1.2 million to develop
- 10 years in research and development
- Possible annual cost of use: $100,000 Avastin, $60,000 Rituxan, $32,000 Enbrel

Biosimilars essentially are generic biologics.
- No approval process in place at FDA
- 10 to 30 percent savings predicted by FTC
- $9 billion in possible Medicare/Medicaid savings over 10 years

Bioethics experts caution against the inequity of the benefits of biologic therapy being available only to those who can afford it.

"It is indisputable that any patient should have access to these drugs [biologics], regardless of income or insurance status."
— Ruth Faden, PhD, director of the Johns Hopkins Berman Institute of Bioethics

Issues and Answers

Citing the extraordinary cost of developing biologics, the pharmaceutical industry has requested 12 to 14 years of exclusivity before biosimilars could be released. The FTC released a report recommending a shorter period to encourage development of new drugs and bring down prices. AARP lobbyists claim that 3 years should be sufficient to recoup costs. The battle is on.

Current prescription-drug pricing protocols and increases in the number of uninsured and underinsured patients can make biologics unaffordable. The current reform environment also promises to put pressure on development and approval of expensive therapies. Greater emphasis on patient safety may also have an affect.

Biologics are saving and improving lives where there was no hope. As technology improves for targeting biologics, new applications will arise and safety will improve. If an FDA approval process and agreement on clearing the way for biosimilars can be achieved, we can begin to address affordability issues and bioethical issues of equity and access.

— Tom DeSanto

Source: AARP, The Magazine, November/December 2009: "New Miracle Drugs," Mary A. Fischer,
"What Price A Miracle," Sheree Crute. Image: www.pharmaceutical-technology.com

Healthcare Innovation: Key to Reform

2009-10-02T11:27:00.000-07:00

Bill Moffitt is renowned for his vision in developing the point-of-care blood analysis market. He identified a constellation of trends – far in advance – that led him on the path to innovation. His work helped move testing from centralized hospital labs to revolutionary hand-held devices that deliver immediate and accurate results.

In a recent webcast for the DxMA, Bill stressed that healthcare reform should focus on delivery models. He sees people as the primary cost-driver in healthcare and that improving their productivity is the key to success. The goal should be to develop technologies that enable clinicians and staff to provide equal or better care at an overall lower cost.

Bill's view, based on 35 years of experience in the diagnostics and device industry, comes to us with wisdom and experience. It is a long-term view that may not be popular with reformers looking for a quick fix by tweaking the system.

From early research through the acquisition by Abbott Laboratories, development of point-of-care blood analysis at i-STAT required a more than a decade. For the first five years, i-STAT supported "negative profit" for a product they knew would succeed. Today, that product is a major contributor to enhancing care and reducing costs.

Innovation requires vision, time, money and confidence, but it can generate improvements on a massive scale. Hopefully, the accomplishments of visionaries such as Bill Moffitt will serve as proof that any successful plan for reform must identify practical innovations and provide long-term support for their development and implementation.

— Tom DeSanto

Image: Abbott

Clarify Language to Cut Costs

2009-09-28T17:36:00.000-07:00

The Plain Language in Health Insurance Act, now in committee, would require the Federal government and private insurers to write all new documents in plain, easy-to-understand language.

Imagine being able to quickly comprehend benefit plan descriptions, drug formularies, explanations of benefits, enrollment forms and other documents. (Any clear description of the Medicare benefit donut hole defies imagination.)

Similar plain-language legislation was proposed in 2007 to cover documents issued by all government agencies. The House passed it. But the Senate never took action.

The Federal Plain Language Guidelines encourages use of simple words, short sentences and paragraphs, and pronouns (such as "you") that speak directly to readers. It discourages legal, foreign and technical jargon, as well as double negatives. (Examples at www.plainlanguage.gov.)

Count me in for "language reform." Eliminating bombast and double-talk from health insurance would improve health care immensely. If only we could do the same with the health-care debate.

— Tom DeSanto

Image: telegraph.co.uk

Taking Stock of Vaccine

2009-09-24T16:28:00.000-07:00

The U.S. government has approved four H1N1 vaccines and says its 195-million dose order will be sufficient to cover 300 million Americans.

Good news for America's stock of vaccines. Bad news for biotech stocks.

After the announcement, many H1N1 vaccine manufacturers saw their stocks quickly lose 7 to 8 percent of their value. When dire pandemic predictions made shortages seem likely, investors flocked to those stocks. Values skyrocketed. Since supplies now are deemed sufficient, a sell off ensued. Such is the free market.

It seems unfair that the reward for accelerating development to ensure an adequate stock of vaccines is a loss in stock value. The silver lining of the pandemic vaccine race, however, may be greater realization that most production still uses chicken eggs, a 60-year-old technology, that takes 6 months. Most likely the government will sustain funding for the next generation of vaccines and antivirals.

That is an investment with enduring value.

— Tom DeSanto

Image: www.lenzwatch.co.za

Recovery is real. Reform is abstract.

2009-09-14T14:56:00.000-07:00

Illness swept through my family. My daughter had influenza symptoms that recurred at least twice. (To our surprise, it was not H1N1.) Then my wife caught it and her condition worsened until she had pneumonia. Between the two of them, treatment included:

8 office visits
2 blood tests (mostly for white count)
2 Z-Pak (azithromycin) prescriptions
1 nasopharyngeal swab H1N1 test
3 chest x-rays
1 Levaquin prescription

At the time, did we really care about cost? No. We have health insurance that enabled us to receive treatment. And all that mattered was that eventually they would both be fine.

A series of EOBs and invoices are arriving. Soon we'll discover our out-of-pocket costs. We'll pay them and move on. A perfect system? No. But we got what we wanted.

And that's one of the greatest challenges of healthcare reform. We're willing to settle for what we have as long as our experience is reasonable and outcomes are acceptable. We're reluctant to risk making changes to achieve abstract concepts such as affordability, sustainability, efficiency, value, efficacy, universality and equity.

Americans will demand and debate healthcare reform, but in the end, their response is likely to be "keep your hands off my healthcare."

— Tom DeSanto

Image: mdconsult.com

From Paradise to Pandemic

2009-09-07T09:38:00.000-07:00

Paradise. On our annual trip to the Caribbean, I was delighted to discover that faded coral reefs throughout the National Park at St. John, USVI, are coming back with a level of growth and intense color I haven't seen in years.

Pandemic. Immediately upon our return, the flu struck our household with hurricane force. It started with our daughter and proceeded to demolish the health of each family member.

All the symptoms, respiratory to GI to fever to headache to body aches, are intense and long lived. Sometimes symptoms abate, only to return with ferocity. It has disrupted our family for nearly three weeks.

The lesson in all this is that although nature takes it course, we need to be diligent in whatever steps we can take to secure our well being .

Thankfully, the coral reefs appear to be healing in spite of dire warnings about global warming.

Thankfully, my family will get over the flu. But, having been struck by the awesome power of this new flu strain, I can tell you not to take dire warnings about a pandemic for granted. We all need to take precautions.

I'll be back to blogging about health care when good health returns.

— Tom DeSanto

H1N1: Battle at the Front Lines

2009-08-12T06:45:00.000-07:00

A battle between public safety and personal freedom is brewing in hospital emergency departments.

With staffing already compromised by the economic downturn, workers who contract H1N1 could further reduce emergency room staff by infecting others.

Hospitals are developing programs to help reduce the spread of H1N1 among staff, but education alone may be inadequate to ensure the ability to address the epidemic. Many emergency department workers now face mandatory vaccination.

Public safety

CDC experts project that H1N1 may affect as many as 40 percent of Americans. H1N1 has already caused 7,511 hospitalizations and 477 deaths in the U.S. (CDC) That number is expected to soar. 160 million doses of injectable swine flu vaccine are slated to be available by October. Our emergency departments must be ready.

Personal freedom

People have a variety of good reasons for opposing mandatory H1N1 vaccination. Two major objections are possible allergic reaction to the egg products used in vaccine production and compromise of religious beliefs. Fear is also a factor. Previous swine-flu vaccination efforts in 1976 were halted when unexpectedly high numbers of patients developed a paralyzing condition called Guillain-Barre Syndrome. Although no report conclusively blamed the vaccine, apprehension lingers.

The Realities

Caught between serving the public interest and honoring their employees' personal preferences, some hospitals will require employees to prove the validity of their objections if they want to avoid vaccination.

At the time of employee vaccination, skin testing will be performed to prove claims of egg allergies. For religious objections, workers will be required to submit correspondence from religious officials on letterhead with a phone number for verification. Behind the scenes, hospital officials most likely are asking their legal departments if they can fire employees who refuse vaccination without sufficient grounds.

Emergency workers are like soldiers. They are called to serve and may be required to sacrifice in the public interest. Could mandatory vaccination be overkill? Maybe, if the pandemic peters out. Otherwise, minimal risk now could save many lives later.

— Tom DeSanto

Image: H1N1 virus, CDC

Reform: Physicians Beat Politicians

2009-08-05T05:38:00.000-07:00

I'd rather see healthcare reform come from physicians, not politicians.

By implementing innovations in medical practice developed by physicians, we can improve the efficiency and efficacy of America's healthcare system. Here's one example.

To promote faster, more effective diagnosis at lower administrative costs, Bruce Friedman, MD, active emeritus professor of pathology, advocates the merger of pathology and radiology into a new medical specialty called integrated diagnostics.

The model for this multidisciplinary approach already exists in breast care centers where patients receive imaging and pathology services for rapid, on-the-spot diagnosis of any masses that may be detected.

Dr. Friedman suggests creating integrated diagnostics centers (IDCs) where pathologists and radiologists would work side-by-side to develop higher quality assumptions. Patients would benefit from collaboration of specialists, more convenient scheduling and immediacy of diagnosis.

Currently, few of the nation's more than 8,000 hospital laboratories are involved in integration with radiology services. One pioneer in diagnostic integration is Jonathan Braun, MD, PhD, Chairman of the Department of Pathology and Laboratory Medicine at UCLA. He is advancing the convergence of diagnostics at the UCLA Radiology Pathology Center.

Beyond hospitals, existing clinics already providing imaging and pathology services could be adapted into IDCs , as well as small hospitals that are no longer economically viable.

Doctors Freidman, Braun and their colleagues are fine examples of creating a better healthcare system from within. That's true reform.

—Tom DeSanto

Social Media: Meet the Flockers

2009-07-29T21:04:00.000-07:00

In less than two years, the number of American adults who visit social media websites at least once a month has more than doubled. That’s nearly one-third of the population, or more than 55.6 million people. (Forrester Research)

Choices for social media involvement continue to multiply as well. Traffikd.com lists more than 600 social media and social networking sites in 39 categories.

Why are we flocking to social media in record numbers?

Individuals engage in social media to fulfill their own self-interest, according to Yochai Benkler, Harvard professor and faculty co-director of the Berkman Center for Internet & Society. He believes social media is a free collaborative network in which we define our individual needs and desires and act in collaboration that translates into personal fulfillment. Our motives vary. We may seek a solution to a problem, pursue interpersonal relatedness, reinforce our identity, or develop a reputation in anticipation of future work. (www.knightpulse.org/blog/09/07/21/why-do-people-join-social-networks)

I've identified five stereotypes of social media users that confirm Benkler’s assertions. How many seem familiar to you?

1. Wolves sell covertly with messages that appear to be helpful or educational, but often lack substance.

2. Climbers build reputations by posting incessantly to keep their name in the news.

3. Mavens fill our spaces with recommendations for everything from restaurants to rappers to revolution.

4. Boors lack respect for others, either from innate rudeness or lack of netiquette.

5. Blabbers share life’s every detail.

There's a bit of each of these stereotypes in all of us. We don’t merely use social networks; we are the networks. Seeking fulfillment, we flock together and create social media in our own image.

—Tom DeSanto

Image: social-media-expert.jpg from Google images

An Rx for Reform: VBID

2009-07-15T06:38:00.000-07:00

Value-based insurance design (VBID) can help reduce healthcare costs and improve outcomes.

VBID reduces copayments for procedures and medications that meet evidence-based criteria for benefit and raises copayments for those that don't. The implications are enormous, especially for patients with diabetes.

The cost of treating diabetes in the U.S. amounts to more than $200 billion each year. (Associated Press/Novo Nordisk)

The least compliant diabetes patients are twice as likely to be hospitalized than the most compliant and their healthcare costs are nearly double. Each dollar spent on medication saves $7 in medical costs. (Medco study)

Patients with diabetes are significantly more likely to take medications for secondary prevention when their copayments are lowered, according to new study presented at the Society of General Medicine annual meeting. It provides solid evidence for the effectiveness of VBID. (Learn more at www.youtube.com/watch?v=JwI3effEnPE)

Advocates of VBID believe that the concept could make a significant impact in the Medicare population. Nearly 70 percent of Medicare spending comes from the 23 percent of the nearly 26 million beneficiaries who have 5 or more chronic conditions. Almost 20 percent of Medicare Part D recipients either delay or decline fulfilling prescriptions because of cost.

Imagine if we made the medications with the best evidence-based performance available at an affordable cost, so patients could be more compliant. The University of Michigan Center for Value-Based Insurance Design has been an advocate for this type of reform since 2005. Now policymakers are taking action.

Congressman John Dingell introduced legislation that includes provisions for modifying cost-sharing and payment rates that would encourage the use of services that are most effective in demonstrating value and promoting health.

Our healthcare system has many chronic conditions. Improving its health will require a bold and consistent treatment plan. VBID is one prescription that shows great promise.

—Tom DeSanto

Image: University of Michigan Center for Value-Based Insurance Design logo

Obesity: Let's Lose Misconceptions

2009-07-07T20:34:00.000-07:00

Grim statistics on America's obesity epidemic and Wal-Mart's bold statement supporting healthcare reform were released on the same day. To me, it seemed very ironic.

I applauded Wal-Mart's stance in my blog, but cynically wondered if America's largest retailer might be faulted for the fattening of America.

I imagined huge numbers of large people buying vast quantities of discounted, unhealthy snacks. Could there be a correlation between the states with the highest percentage of obese residents and the number of Wal-Mart stores there? After all, aren't Wal-Mart stores concentrated in the South?

My search for truth eventually led me to an article entitled "Wal-Mart's Weight Effect" in the June 8, 2009 issue of Forbes. I found out that I was dead wrong.

Forbes reported that researchers at the University of North Carolina-Greensboro discovered that "greater consumer access to a Wal-Mart store was associated with lower body mass indexes and lower probability of being obese." How could that be? Their data suggests that when people gain purchasing power, they buy healthier food.

Shame on me. I now realize that many of us who don't struggle with weight are part of the obesity problem. Our misconceptions and stereotypes contribute to a lack of understanding of the complex economic, social, cultural and emotional issues that contribute to obesity.

We need to lose our unhealthy misconceptions about obesity before we can hope for a healthier, less-obese America.

—Tom DeSanto

Map: Trust for America's Health, AP

Wal-Mart Roars on Healthcare Reform

2009-07-02T11:41:00.000-07:00

In a letter to the White House, Wal-Mart declared its support for healthcare reform that requires employers to provide health insurance to their workers. The company is enormous and so is its show of support, an opinion contrary to that of most large companies.

Wal-Mart posted FY2009 revenues of $401 billion and has 2.1 million associates worldwide. The nation's largest private employer has spoken. But is it fervor or fluff?

A recent Wal-Mart TV commercial proclaims that 94 percent of its full-time and part-time associates have health insurance and the company won't be satisfied until 100 percent are covered. http://walmartstores.com/Video/Default.aspx?id=1340

More specifically, 53 percent are covered directly by Wal-Mart. The other 41 percent are covered under family members' plans or Medicaid (for 36,000 employees), according to the New York Times.

What about Wal-Mart's coverage? Its plan features wellness care, including mammograms, colonoscopies, flu vaccines and well-child care. It also boasts a personal electronic personal health record and comprehensive maternal health benefits for the 15,000 Wal-Mart associates who have babies each year. Wal-Mart seems to practice what it preaches.

Wal-Mart roars—and rocks—on healthcare reform. It's a dramatic turnabout for a company once known for low wages and few benefits. Maybe it's a shot in the arm that may give healthcare reform a shot at success.

– Tom DeSanto

Infection Control: A Crucial Investment

2009-06-29T17:33:00.000-07:00

Hospital acquired infection (HAI) is associated with more than 99,000 American deaths annually. The estimated 1.7 million HAIs also generate more than $20 billion of additional healthcare spending.

Several years ago, when MRSA and C. difficile infected patients and grabbed headlines, healthcare facilties initiated intensive infection-reduction programs. Many demonstrated solid success. Now HAI efforts are being cut back as a result of the economic downturn.

In a recent survey by the Association for Professional in Infection Control and Epidemiology (APIC), 41 percent of infection-prevention professionals reported that their budgets had been cut during the past 18 months. Approximately 30 percent said that reductions in staff and resources compromised their infection surveillance and prevention capabilities.

Chopping infection-control budgets to contain costs will eventually have the opposite effect on HAIs and patient safety, resulting in backsliding toward more needless suffering and death.

That extra ounce of prevention is worth many pounds of cures. Let's not wait for a new round of headlines. Investing in infection control is sound practice and good business.

—Tom DeSanto

MRSA image: WebMD

The Truth About Prevention

2009-06-22T10:31:00.000-07:00

In this weekend's Wall Street Journal, Abraham Verghese's lead article "The Myth of Prevention" provides a doctor's take on preventive care. Its tongue-in-cheek subhead (shown here) emphasizes that when medicine is a business, wellness doesn't pay.

Several conclusions offered by Dr. Verghese hit home.

Medicare is a system that pays well when something is done to a patient, but pays poorly when something is done for a patient. It pays for diagnostics, procedures and drugs, and providers earn more when they deliver them efficiency. It does not reward time spent on getting to know patients to help understand their problems and following up to ensure a proper recovery and good health.

Based on Medicare incentives, most prevention strategies are medical, not personal. We engage in expensive screenings to look for early signs of conditions throughout the population so we can intervene or conduct further tests. We're less likely to take on lifestyle modification.

Dr. Verghese cites an axiom of medical economics that appeared spent in the Annals of Internal Medicine: "A dollar spent on medical care is a dollar of income for someone." He sees doctors, hospitals, pharmacists, drug companies, nurses, home health agencies and health insurers all feeding at the same $2.1 trillion trough and fighting for their share.

Unfortunately, medicine must be run as a business. Organizations and individuals involved in the practice of medicine (or health care in general) are trapped between fulfilling their missions and meeting their margins.

Dr. Verghese believes that a medical approach to preventive care can drive up costs, instead of saving them—such as prescribing statins that end up costing $150,000 for every year of life they save in men (and even more in women).

The truth about prevention is that as long as our healthcare system rewards what we do to patients and not for them, our approach to prevention will remain medical.

What we need—and really want as individuals—is a personal approach that helps us preserve good health and allows us interact freely with doctors and other medical professionals when we're sick, so they can take time to understand us and practice the fine art of healing.

—Tom DeSanto
Image: Wall Street Journal

Phat Cells

2009-06-15T10:12:00.000-07:00

The fat cells in our bodies tend to get a bad rap. A study published this week in Nature balances that stereotype. Fat cells (adipocyctes) play a vital role in our biological mechanisms.

Bone marrow contains a large amount of fat cells. Previously they were thought to serve passively as padding. In contrast, researchers at the Harvard Stem Cell Institute and Children’s Hospital Boston discovered that fat cells are essential in regulating hematopoietic stem cell function (the formation of blood and blood cells in our bodies.)

The study conclusively defines adipocytes as the negative regulators of blood cell production (hematopoiesis). As fat-cell content in bone marrow increases, blood progenitor cells decrease. This slows the production of blood formation. The discovery correlates the increase in bone-marrow fat and decrease in blood production as we age.

The researchers are now focusing on using adipocyte-targeting compounds, currently being developed as obesity treatments, in bone marrow. By reducing adipocytes, these compounds may one day be used to accelerate blood formation in patients who have undergone bone marrow transplants.

The fat cells in our bone marrow help ensure proper blood formation. That fat is phat (great, wonderful, terrific).

—Tom DeSanto
Image: Grey's Anatomy illustration of bone marrow from Wikipedia

More Time for Improved Care

2009-06-02T12:51:00.000-07:00

America's approach to moderating healthcare costs relies on limiting the time spent in medical encounters. The opposite approach could work better. If we enabled physicians, nurses and other providers to spend more time with patients, follow up more diligently and teach them to take an active role in managing their chronic medical conditions, we'd see results.

A new AARP Magazine survey confirms that patients who are more involved in their healthcare have fewer complications and a better experience.

Readmitted to the hospital within 30 days of discharge
Less-involved patients: 28.0%; More-involved patients: 12.8%

Experienced a medical error
Less-involved patients: 35.8%; More-involved patients: 19.2%

Suffer a health consequence because of poor communication among providers
Less-involved patients: 48.6%; More-involved patients: 13.2%

Lose confidence in the healthcare system
Less-involved patients: 59.8%; More-involved patients: 15.1%

The cumulative effect of improved interaction within individual medical relationships can improve care and reduce costs. Until we can make large-scale advancements in quality and efficiency, let's think small. Empowering individual physicians, nurses and patients is a key improving care. It's about time.
—Tom DeSanto
Source: AARP Magazine, July & August 2009. Image: www.freeclipartnow.com

Love and Money

2009-05-28T11:15:00.000-07:00

Healthcare providers recently sent a love letter to the Obama administration. During Clinton-era reform attempts, they protested fiercely and loudly. Now they're pledging fervent loyalty.

"The times demand and the nation expects that we, as health care leaders, work with you to reform the health care system," wrote a group representing hospitals, health insurance companies, doctors, drug makers, medical device makers and labor. They pledge to simplify administrative costs, make hospitals more efficient, reduce hospitalizations, manage chronic illness more effectively and improve health care information technology. (Wall Street Journal)

Why all the love?

The Obama administration is intent on reducing cost increases in the American healthcare system by $2 trillion over the next decade. And this time the political and public support seem in place to make it happen. Suddenly, a lot of money is at stake, and the healthcare sector is a strong performer on Wall Street.

Average Stock Performance (Equal Weight)

Compound Annual Growth Rate between 2006 and May 15, 2009

Diagnostics +07%

Big Pharma -05%

Hospitals -06%

S&P 500 -13%

Big Managed Care -14%

(Thomson One, 5/15/09)

Cupid has many muses. For the love of money, maybe a little kumbaya will finally make reform a reality.

—Tom DeSanto

Image: www.sarahbaingallery.com

Drugs, Toilets and Teenagers

2009-05-21T17:09:00.000-07:00

Prescription medicines are turning up in unintended and dangerous places: toilets and teenagers.

Drugs consumed by Americans have risen 12 percent over 5 years, reaching 3.7 billion prescriptions and 3.3 billion nonprescription drugs in 2007. Use of veterinary drugs, including treatments for pets and steroids for livestock, has also increased. More drugs create more cause for concern.

Pharmaceuticals have been discovered in the drinking water of at least 41 million Americans. Traces enter our water supply either because drugs are not fully metabolized or are discarded improperly. Hospitals and nursing homes flush about 250 million pounds of pharmaceuticals down toilets every year. Municipal water treatment-plants are ineffective in removing cholesterol-reducing medications, tranquilizers and many other widely used drugs. Environmental studies demonstrate that even trace amounts of these compounds have adverse effects on aquatic wildlife. Laboratory studies also show that exposure causes disruption to human cellular processes.

Prescription pharmaceuticals are abused by nearly 2.1 million American teenagers. For 20 percent of teenagers, it's the illicit drug of choice, second only to marijuana. Pain relievers such as Vicodin and OxyContin are most commonly abused and 64 percent of teens who take them report getting them from friends or relatives. The risk of adverse reactions or death is high because they take various prescription drugs together and in combination with alcohol.

Pharmaceuticals need to be treated as controlled substances at all times. We can help keep drugs out of the water supply and the hands of teenagers by locking up prescription medications and discarding them properly when no longer needed. Until a better means of disposal is adopted, we can crush leftover doses, mix them into coffee grounds, cat litter or other undesirable material, bag them up and place them in the trash.

We need to tell teenagers that prescription drugs are safe when properly taken, but are as dangerous as more notorious drugs when abused. These seemingly benign drugs, flowing freely among teenagers, can quickly take their health and future down the toilet.

—Tom DeSanto

Sources: IMS Health, The Nielsen Company, Associated Press, Substance Abuse and Health Services Administration

No Mom Left Behind

2009-05-14T14:14:00.000-07:00

Births to unmarried mothers in the U.S. rose by 26 percent between 2002 and 2007, according to a new study from the CDC. Nowadays 4 out of 10 babies are born outside the traditional married-parent household.

The health implications are enormous.

Studies show that babies born to unmarried women are at higher risk for low birthweight, premature delivery and infant death. The health of the baby and mother are also dependent on available economic and social resources, which tend to be lower for this group.

Unmarried mothers now are spread throughout all population segments, so out-of-wedlock births aren't solely related to socioeconomic factors. The largest number of them are in their early 20s, instead of their teens. Social norms have shifted.

Infant mortality is a dramatic shortfall of the U.S. healthcare system. With trends moving away from better-outcome, married-couple births, we will have to be diligent in ensuring proper prenatal care for the growing number of twenty-something moms, plus well care and immunizations for their babies.

These new family units also are likely to lack resources and place additional burden on an already overstretched public health system.

With so many demands and a mandate to reduce costs, it will be difficult to institute healthcare coverage that ensures no mom is left behind. But if our hope is to provide a better life now and for future generations, we can't afford not to do it.

—Tom DeSanto

Image: Mother Holding Baby, 1986 by Keith Haring, available at art.com

Health Care Fraud and ROI

2009-05-07T11:18:00.000-07:00

Today, the Obama administration proposed a multi-year $1.7 billion increase in funding for the Health Care Fraud and Abuse Control Program. What kind of ROI might we expect from that investment?

It is estimated that 3 percent of America's health-care spending is consumed by fraud each year. In 2008, approximately $68 billion was lost to fraud. $60 billion of the fraud losses involved Medicare and Medicaid.

The Coalition Against Insurance Fraud estimates that every $2 million invested in fighting health-care fraud returns $17.3 million in recoveries.

Accordingly, the proposed investment could yield $14.7 billion in fraud recovery, representing a 7.65 percent return on investment.

The Health Care Fraud and Abuse Control Program is a reasonable short-term investment, if the increased budget is used effectively. Over the long term, rooting out fraud and abuse will pay dividends in a more efficient health-care system.

Will the government keep the $14.7 billion as part of cost-cutting measures or will America's citizens reap the savings to preserve and restore their health? Only time will tell.

—Tom DeSanto

Drug Companies: H1N1 and a New Spin

2009-04-29T11:24:00.000-07:00

The advent of the H1N1 swine flu virus is temporarily changing the spin on drug companies. The demand for life-saving remedies is getting more play than the call for cost-cutting reform.

Drug Companies as Heroes

• A vaccine for H1N1 swine flu may be in clinical trials within "a couple of months" as development is accelerated. (Bloomberg)

• The World Health Organization raised the level of alert to phase 5 and expects to reach the maximum of phase 6 soon indicating that a "pandemic is imminent." (NYTimes.com)

• On average, newer medicines increased drug costs by an average of $18, but they reduced hospital and other non-drug costs by $129. (Study by Frank Lichtenberg, Professor of Business, Columbia University, cited on the Pfizer website)

Drug Companies as Villains

• The cost of prescription drugs increased by 89 percent between 2000 and 2007, although they continue to account for approximately 10 percent of America's healthcare expenditures. (Kaiser Family Foundation)

• Expenditures on prescriptions are projected to increase to $515.7 billion, or 12 percent of America's healthcare spending by 2017. (U.S. Department of Health and Human Services)

• One crusader's Internet thread promulgates a common view. It provided a list of prescription drugs and their alleged mark-up. For example, Paxil® was claimed to have a consumer price (100 tablets) of $220.27, a cost of active ingredients of $7.60 and resultant markup of 2,898 percent.

My Spin

The current situation with H1N1 underscores the heroic innovation and productivity we all need from drug companies. As healthcare reform progresses, we must guard against a possible epidemic of drug-company vilification that could prove fatal.

—Tom DeSanto

End-of-Life Medical Decisions

2009-04-22T10:16:00.000-07:00

A friend told me that his active, healthy mother dropped dead of a heart attack at age 85. He was shocked and sad, but over time took comfort that his mother "went out at the top of her game." It struck a chord with me.

My active, healthy father was so robust that at 90 he underwent surgery to repair an aortic aneurysm. The procedure was successful, although the surgeon said that repairing his artery was like "stitching leather." My father lived until 94, finally falling victim to Alzheimer's.

What did we gain by repairing my father's aorta? We enjoyed his company for a few more years, which was priceless. He went through the transition to assisted living and then an Alzheimer's unit and finally hospice care, which exacted a huge price.

In retrospect, was taking the extra medical measures to prolong his life at age 90 worth the emotional and financial cost? Was it really what my father wanted? Maybe not. What if we had discussed it with him, far in advance and knew how to proceed?

A recent study led by Harvard researchers at Dana-Farber Cancer Institute suggests that end-of-life conversations between physicians, patients and families can be linked to better quality of life for patients with advanced cancers and lower costs for their medical care.

My father didn't have cancer, but a candid discussion about how his life might end would have provided invaluable wisdom and guidance.

Advanced directives have been around for many years, but they are not very effective. Studies by the Agency for Healthcare Research and Quality have shown that less than 50 percent of severely or terminally ill had an advance directive in their medical record. Even if they did, more than 65 percent of their physicians were unaware of it. An existing advanced directive actually made a difference in only half the cases.

It's well known that Americans spend a disproportionate amount of resources on end-of-life care. It's easy to understand why. But researchers in that recent Dana-Farber study demonstrated that end-of-life conversations could lower national expenditures for cancer care by tens of millions of dollars annually—and that's solely for cancer care.

Having those difficult conversations could improve life for the dying and preserve precious resources for the living, such as lowering America's shameful infant mortality.

My father, who was pragmatic, kind and brave, would have approved of the idea. He chose to fight in World War II and came out alive. But he had no choice in his final battle with death.

—Tom DeSanto

Falling Between the Cracks

2009-04-15T10:12:00.000-07:00

As the recession strips people of jobs and health insurance, they are forgoing vital preventive care. Recent data estimates that more than 3.7 million working-age Americans have lost their health insurance since the recession began. 500,000 of them are here in California.

The Los Angeles Times recently cited studies that estimate:

• 47 percent of Californians postponing care are considered to be in fair or poor health.

• 33 percent of Californians with chronic conditions have postponed care or prescriptions because of cost.

• 25 percent of California's uninsured have diabetes, emphysema and other chronic conditions that are not being managed.

A New England Journal of Medicine study showed that a co-pay of as little as $10 can dissuade a woman from getting a mammogram. An increase of $5 in a drug co-pay can cause older patients not to refill their prescriptions.

When people forgo or postpone medical care, they are more likely to show up in emergency rooms with severe conditions that could have been prevented. It damages their health and drives up healthcare costs.

In the long term, the prognosis is even worse. Approximately 23.6 million Americans have diabetes and the number is growing. Type 2 diabetes is already linked with higher possibility of heart attack and stroke. A new study published in the Journal of the American Medical Association links diabetes with a higher risk of dementia.

Too many people are falling between the cracks. America is only as strong as its weakest citizens. For the medical and financial health of our nation, we must find a way to care for all of us.

—Tom DeSanto

Image: www.phoenixrealestateguy.com

Nurses Needed for Healthcare Reform

2009-04-06T16:31:00.000-07:00

The prognosis for America's chronic nursing shortage remains grim.

More than 216,000 registered nursing positions remain unfilled at U.S. hospitals and nursing homes.

The nationwide nursing shortage could grow to 275,000 by 2010 and one million by 2020.

Nearly 50,000 qualified applicants were turned away from U.S. nursing schools in 2008 because of insufficient resources to educate them.

New possibilities bring some hope for resolution.

The recently enacted economic stimulus bill includes $500 million to address shortages of healthcare workers. Approximately $100 million may be dedicated to nursing.

The Nurse Education, Expansion, and Development (NEED) Act was introduced in Congress in February 2009. It would authorize capitated grants to nursing schools for much-needed nurse educators, infrastructure improvements, laboratory enhancement and equipment purchase.

In a recession, nursing offers the assurance of eventual employment opportunity. A 2006 study projected nursing employment to rise an average of 23 percent by 2016. Nursing positions in physicians' offices and home health each led the way with a predicted increase of 39 percent.

America's healthcare system cannot be reformed or realize its full potential unless we have sufficient nursing staff to care for the growing number of patients requiring treatment. An estimated 6,700 patient deaths and 4 million days of hospital care could be averted annually by increasing the number of nurses. Now is the time to take action to alleviate the nursing shortage. My wife is. She's planning a second career in nursing.

—Tom DeSanto

Image: www.reachingallyouth.org

Betting $19 Billion on Digital Docs

2009-03-31T15:49:00.000-07:00

What will it take to drive doctors to go digital with electronic health records (EHRs)?

The government is putting down at least $19 billion to start. $2 billion is slated for health IT grants, training and state programs. Starting in 2011, the remaining $17 billion is planned for Medicare/Medicaid incentives that encourage doctors and hospitals to use EHRs. If that doesn't work, penalties would begin in 2015.

The influx of billions of dollars is essential, but not enough to overcome major obstacles. It will take unprecedented participation, cooperation and ingenuity for most patients and America's health system to reap the benefits of EHRs. We have a lot to overcome.

A long path. A 2007-08 NEJM study found that only 4 percent of physicians had adopted a fully functional EHR system. Likewise, a 2009 study found that only 1.5 percent of non-federal U.S. hospitals had a comprehensive EHR system.

A checkered past. Initial forays into EHR did not go well. Many of the first systems were expensive and difficult to use. Many physicians rebelled and then surrendered.

A challenging puzzle. Dozens of vendors have already placed proprietary systems that are not compatible. Setting standards and connecting them into a shared network is a daunting task.

A fragmented landscape. Getting competing interests to cooperate across shared geography can be difficult. Issues arise around where the data is stored and who has access.

A difficult sell. Overtaxed, underpaid physicians say that any EHR that doesn't save them time and help earn them money isn't going to get their attention, let alone the dedication needed to master it.

Betting $19 billion is not enough to win, but it keeps the digital revolution in play.

Expanding successes. Some hospitals are already using EHRs in a powerful way. Regional Health Information Organizations are in the works. A government spotlight will accelerate progress.

Encouraging innovation. Technology companies, large and small, will get a boost to provide solutions demanded by the government. Entrepreneurs will fill the gaps.

Setting a national agenda. If only establishing a nationwide EHR had the cache of landing a man on the moon. Maybe once its benefits are more broadly demonstrated and understood, the whole idea will capture the public's imagination.

The benefits of EHRs are priceless. Connecting our hospitals, physicians offices and other provider sites with a common EHR system that readily shares medical information will revolutionize care. It will take a lot of time and money, but the government is off to a good start. EHRs and healthcare reform could have been off the table in these times of uncertainty. Instead, we're betting on future success.

—Tom DeSanto

Image: www.gamblingplanet.org

Denied Healthcare Coverage

2009-03-23T12:19:00.000-07:00

The flaws in our healthcare system are hitting home. More of us will see it personally in these times of job losses and economic strain. Some will lose coverage; others will be denied.

I recently applied for a family health insurance plan in the individual market. Despite excellent health, I was denied. The reason? Too many prescriptions, plus chiropractic follow-up from an automobile accident.

Okay, I'll confess. For many years, I've been taking two prescriptions to correct minor, long-term conditions. Both prescriptions are generics and not expensive. Never before has it affected my insurability.

The third prescription was Lipitor®. Without it, my cholesterol level was 210 and wouldn't decrease despite a careful diet and frequent exercise. My doctor put me on Lipitor as a preventive measure against heart disease—after trying another medication that caused side-effects. It worked well for years.

The chiropractic care was to loosen my neck muscles after an automobile accident. (I was a passenger and the driver was not at fault.) No emergency treatment was required. I simply wanted to restore my natural balance. None of the billing went through my health insurer and treatment was ending.

The remainder of my family was accepted. What's wrong with this picture?

- Two family members spend much more annually on healthcare than I do.

- Now accepted, my family members can be covered under three separate individual plans for a lot less money. So, the insurer gets to triple the administrative costs and receive lower premiums.

- I'll have to find coverage elsewhere, so the insurer loses my business. And, by the way, I've been insured by this company since birth.

- My efforts to prevent future problems actually worked against my insurability.

Obviously, the health insurance company would have done much better by simply accepting my entire family under one plan in the individual market. It's a wonderful company. Why couldn't it do better?

- Lack of complete medical data for decision-making

- Bureaucratic complexity of the healthcare system

- Lack of regulation that would preserve an optimal risk pool

- Ineffective methodologies for reimbursement

The flaws of our healthcare system are moving from being someone else's problem to becoming our own. And that's the best impetus for sweeping change.

— Tom DeSanto

Image: http://discuss.epluribusmedia.net/files/reject.jpg

Embryonic Stem Cells Multiply and Divide

2009-03-12T16:09:00.000-07:00

Many restrictions on federal funding for human embryonic stem-cell research are now history. Research and profits will multiply. Ethics and oversight will divide.

Research. At the signing ceremony, President Obama proclaimed, "we will vigorously support scientists who pursue this research. And we will aim for America to lead the world in the discoveries it one day may yield." We have a new mandate.

Profits. The embryonic stem cell market is projected to reach $1 billion per year with 10 percent growth annually.* When the restrictions were lifted, stock in leading stem cell companies spiked. California, with a $3 billion taxpayer-funded stem cell research program in place since 2004, is among the first in line for the gold rush.

Ethics. Proponents expressed hope that it will lead to therapies that will help the more than 100 million Americans with diabetes, cancer, spinal cord injuries, Parkinson's, Alzheimer's and other conditions. Opponents expressed moral objection over research that "exploits living members of the human species as raw material for research."**

Oversight. President Obama gave the NIH 120 days to draft ethical guidelines for government-funded research using embryonic stem cells. Creating policies that foster innovation while defining appropriate human embryo sources, ensuring proper FDA regulation, protecting intellectual property and ensuring adequate reimbursement is a tall order.

Congress still must act to remove a final barrier. It must overturn the Dickey-Wicker Amendment that prohibits federal funding for the actual extraction of stem cells from human embryos. The debate over use of re-engineered adult (pluripotent) cells versus embryonic cells is sure to boil over.

Pursuing the research application of human embryonic stem cells is much like the cells themselves. Opportunities multiply. Issues divide. And the debate will continue over what makes us human.

—Tom DeSanto

*Michael West, CEO, BioTime in The Scientist; **Douglas Johnson, National Right To Life Committee; Stem cell image: CIRM

Uncle Sam, Medical Expert?

2009-03-05T13:40:00.000-08:00

How much of a role should the U.S. government assume in ensuring the quality and safety of medical care?

Recent events are sure to unleash a new round of debate.

Yesterday, the U.S. Supreme Court ruled that patients injured by a drug can sue its manufacturer for damages even if the drug was granted FDA approval. Consumer advocates applauded. Drug manufacturers lamented. Lawyers smiled. No longer was the FDA deemed to be the final authority on drug safety. A precedent was set, affirming the check and balance of the tort system and Federal regulation.

Two weeks ago, the $787 billion stimulus bill provided $1.1 billion to the Health and Human Services Department to research the comparative effectiveness of drugs, medical devices, surgery and other treatments for specific conditions. Consumer advocates, labor unions and large employers applauded. Lobbyists, minority groups and conservative lawmakers expressed concern. Would the government-sponsored research truly improve quality and efficiency by eliminating ineffective care? Or would insurers and Medicare use the data to ration care and drive down costs?

New treatment guidelines from HHS, developed over broad population groups, could run the risk of producing bad outcomes in certain individuals. If that happens, would HHS, the new authority on medical effectiveness, find itself in the same boat as the FDA—with regulators wringing their hands and lawyers licking their chops?

We've cast Uncle Sam in the role of medical expert. Is he truly up to the task?

—Tom DeSanto

Down But Not Out

2009-02-27T13:54:00.000-08:00

Wham! The first healthcare reform numbers are out.

White House budget documents released February 26 outline the creation of a reserve fund of $633.8 billion over ten years to fund healthcare reform. And hospitals will take a hit.

The reserve fund would be established through savings generated from new policies, including bundling Medicare payments for hospitalizations and post-acute care ($17.8 billion), reducing payments when Medicare readmission rates exceed goals ($8.4 billion) and allocating payment based on meeting inpatient quality standards ($12.1 billion).

In response, the AHA applauded action on reform, pledged cooperation and expressed concern "about any cuts that would affect the work hospitals do for their communities during this economic downturn."

The stock market had a less cordial response.

On February 26, the HMO index of 11 major healthcare providers declined 10 percent. Major downers were Humana at 19 percent, UnitedHealth Group at 13 percent and Health Net at 9.4 percent. That was on top of heavy losses already sustained earlier in the week.

President Obama's budget document was entitled "A New Era of Responsibility." In the battle for healthcare reform, that means we'll all have to take it on the chin.

—Tom DeSanto

Sources: LA Times, Dow Jones newswire. Image: Google Images

Web 2.0 and Healthcare

2009-02-21T12:10:00.000-08:00

Web 2.0 is a revolution. It has disciples and detractors with very different views of its impact, including how it promises to reshape healthcare.

Omar Wasow, who spoke at the recent Forum for Healthcare Strategists conference, believes that as Web 2.0 transforms our social, political and economic futures, it will "put patients in the driver's seat." Web 2.0 will equip and motivate patients to move from their traditional passive role to one of active participation. It will build community among patients with similar diagnosis (and among physicians) and will be a fountain of knowledge and shared experience.

Andrew Keen, who spoke at the last SHSMD educational conference, believes Web 2.0 is destroying our economy, our culture and our values. It is creating "a cult of the amateur" in which healthcare is being undermined by unvetted user-generated content that can supplant the expert advice of physicians and other medical professionals.

How can we reconcile all the positive attributes of community and empowerment for patients with the dangers of misinformation through the Web that can erode trust in the judgment of physicians and undermine proven treatment protocols?

Personally, I have friends with chronic illnesses who find hope in online patient communities and rely on the Internet to keep up with healthy behaviors and advances in treatment. Other friends and family with health concerns search in hope only to find conflicting information that lacks authority and authenticity.

Another pitfall is that the Web also removes the intimacy of in-person relationships. How much can we trust the advice of others who don't know us and lack factual knowledge about the full condition of our health?

The advent of Web 2.0 presents an enormous opportunity for healthcare leaders to step up and set an agenda that fosters all the benefits of community while certifying information to be reliable. However, the Web is still very much the wild, wild west. It provides a forum for many competing factions. Any group that exerts control on a grand scale is labeled as acting in its own self-interest. Even on the local level, many healthcare providers create web landing pages on procedures and physicians as a marketing tactic. Where do we draw the lines?

The full repercussions of Web 2.0 are largely unknown. We have the challenge of shaping the outcome.

—Tom DeSanto

Image: www.startupordown.com

"Top Docs" Litigation Unfortunate

2009-02-19T10:10:00.000-08:00

Virtua Health and Cooper Health System, competitors in South Jersey, are going to court over claims made about having the most "top docs."

How sad. Because everyone loses.

Four years ago, I wrote an article that appeared in Healthcare Marketing Report entitled "Healthcare Quality Ratings: Where Do They Fit In Your Marketing Efforts." I also spoke at several universities on the subject. I can't help but offer the following excerpts:

"In our sound-bite-oriented, everybody-loves-a-winner culture, healthcare ratings can be a bit like the standings for baseball or football. Even if you're not a fan, you like to see your home team near the top. ...Much like sports, it really is about winning: making the list and being the best."

"Depending on the level of competition, health systems tend to line up on one side of the ratings or the other. They either promote them proactively to build market share or apply them defensively to protect it."

"In my opinion, the promotion of healthcare quality ratings is multiplying far more rapidly than consumers' ability to understand their true meaning and value. By jumping into the ratings game too quickly or too often, marketers risk jading their audiences and diluting the power of their messages. Ratings are an asset. Consider their use wisely."

The article also featured a worksheet to help marketers assess ten factors to help them make effective decisions about promoting quality ratings in their marketing communications. Please contact me if you would like one.

The current litigation is so unfortunate. Two organizations give themselves black eyes. Consumers become even more cynical or indifferent. Trust in our already beleaguered healthcare system continues to erode.

—Tom DeSanto

Image: i116photobucket.com.../kipese/winner-win.jpg

Branding is More than an Advertising Campaign

2009-02-06T11:49:00.000-08:00

The process of creating your brand is the engine that will ultimately drive your ability to deliver and sustain it.

Often marketers focus first on developing a campaign to define and communicate the brand without developing the relationships that bring the brand to life. Many consecutive steps are necessary. Here I offer ten, all beginning with "C." Note that "Campaign" is #8.

1. Collaborate. Engage people across your organization to "birth" or "adopt" the brand. They will become the proud parents who protect and nurture it.

2. Consider. Your brand is NOT merely about your organization. Consider others first and get them involved. How do your various constituents perceive you? What exactly do you offer them? How does that compare to other choices they can make? What do they need, feel, expect, feel, want or hope for?

3. Capture. In light of your constituents' viewpoints, dig deep to capture the unique truth of how your culture, services and aspirations meet your constituents' needs, thoughts and emotions.

4. Clarify. Work together to distill your organization's unique truth into simple and inspiring ideas, words and visuals.

5. Communicate. Share your discoveries with all branding collaborators in a way that they will make them their own. Then, don't merely inculcate the brand internally with meetings, posters and guidelines. Infuse your brand throughout your organization. Give communications materials to collaborators and send them out to interact.

6. Cultivate. Nurture and grow the brand with your internal and closest external constituents until it blossoms. Then it will be bright, fragrant and ready to be delivered.

7. Coordinate. Solicit staff ideas about how they can "be the brand." Coordinate their actions, turn them loose and keep them going.

8. Campaign. Now you can promote your active and sustainable brand with a carefully crafted and segmented campaign.

9. Continue. Keep strengthening the relationships among the original brand collaborators and those who most enthusiastically embrace it. Keep your campaign consistent, but always relevant and fresh.

10. Calculate. Powerful branding requires careful planning. Think ahead five or more years and calculate how to get there. Go back to step one. Branding never ends.

—Tom DeSanto

Image: David Friedman, www.kosmic-kabbalah.com

Obama's Newest Healthcare Numbers

2009-01-30T12:37:00.000-08:00

The new administration is putting on its thinking cap. The $819 billion stimulus package just passed by the House includes:

$ 87 billion to help States cover Medicaid costs

$ 29 billion to help unemployed people buy private insurance

$ 20 billion to implement healthcare technologies such as EMR

$ 11 billion to extend Medicaid coverage to the newly uninsured

= $117 billion for healthcare

Economic turmoil is leading us to pump money into the healthcare system to cover the millions who are losing their jobs and most likely their coverage. Out of necessity, we're diverting resources from reforming the system to preserving access to it.

Hopefully, the $20 billion earmarked for technology will spur further development and adoption of regional health information organizations so we can share data to improve the efficiency and quality of care.

Today the Senate approved $32.8 billion to bring coverage to 4 million more children through the State Children's Health Insurance Program. President Obama plans to sign it into law.

We're spending more on healthcare to cover more people. The GDP is shrinking; healthcare spending is growing. It doesn't bode well for sustainability. But, for now, our choices are limited. Providing care in lieu of making progress on reform is the right thing to do.

—Tom DeSanto

Image:www.weeklystandard.com

Inaugural Numbers

2009-01-21T22:05:00.000-08:00

44th president of the United States

37.8 million U.S. television viewers

28ºF temperature at noon

20 January 2009, a great transition

18-minute 37-second inaugural address

3AM my son leaves American U to attend

1.5 million people pack Washington, DC

1 new leader with a mandate for change

0 arrests despite the huge masses of people

Innumerable: a new spirit of unity and hope

U.S. government photo

The Consumer Mindset

2009-01-12T18:00:00.000-08:00

Consumer spending is falling toward its lowest level since 1942.

Consumer confidence is falling toward depths not seen since the 1990-91 recession.

Both are good reasons to take another look at the workings of the consumer mind.

We are caught up (or down) in what economists call "the paradox of thrift." As consumers worry more and spend less during times of financial strife, their collective cutbacks keep money out of the economy and make matters worse for everyone.

Two main forces trigger consumer purchases: feelings and logic. As marketers, we provide sensory, tactile and emotional stimuli to attract consumers and their business. We also promote rational criteria such as performance, convenience and pricing. The mix, of course, varies according to the product or service. But when the feeling turns to fear for the future and the logic to financial self-preservation, all bets are off.

Research has demonstrated that emotions are the essential catalysts in the purchasing process. People who have lost emotional function due to brain injury can experience a total impairment of their ability to make decisions about purchases. They simply cannot shop.

The vital role of emotion has led marketing researchers toward medical investigation. Consumer subjects now undergo functional MRIs to detect their cognitive versus emotional brain activity as they react to descriptions of brands, products and services. Increased activity in the brain's pleasure centers is thought to reveal a propensity to purchase. EEGs are also being considered as a more portable technology for "reading consumers' minds."

Other more conventional studies reflect consumers' need for logic. With new and unfamiliar products, consumers seek categorization. The opportunity to choose from smaller, better-defined subsets improves decision-making and ultimately satisfaction with their purchase.

Consumers who already have an emotional bond to a company, product or service spend much less time in the shopping mode. They proceed directly to purchase without lag time or additional consideration. Their choice is already "precategorized" and in a sense preprogrammed. That is the power of branding.

When consumer spending and confidence are down, the importance of making a strong emotional connection with consumers is paramount. Unfortunately, marketers' spending and confidence seem to careen down the same slippery, treacherous slope as consumers'. Our emotion turns to fear and our logic to self-preservation.

Let's not lose heart or lose our heads. Instead we must use them both to develop innovative, highly practical ways to retain our customers' loyalty and empower them to choose our products and services.

Some economists are talking about a full recovery around 2010. That's too long to wait. When the chips are down, it's time to fall up.

—Tom DeSanto

Sources: The Christian Science Monitor, www.csmonitor.com/2009/0109; Penton Media,Inc.; The Economist, December 20. Image: Cover of Shel Silverstein's book of poems and drawings, "Falling Up"

2009: Think Microbial

2009-01-06T09:29:00.000-08:00

Happy New Year. I'm proclaiming 2009 the "Year of the Microbe."

By year's end, the Human Oral Microbiome Project is slated to identify and name the 600 varieties of microbes that reside in our mouths. That's in addition to the 1,000 species already identified in our guts.

Tiny microbes are a huge part of us. Our bodies have 10 trillion cells of our own and 100 trillion microbes that call us their home. Our microbes weigh almost as much as our livers.

The DNA in our resident microbes contains 60,000 genes, double the amount of our own. That extra endowment of genes from microbes allows us to do things we couldn't do on our own. Scientists already know that microbes help us synthesize vitamins and break down fiber we can't digest. As knowledge emerges from microbiome studies, we'll likely discover that it's just the tip of the iceberg.

In the future, medicine may very well analyze and work in cooperation with our resident microbes to influence our health and heal our disease. In 2009, we can learn from the success of our own microbiome.

Challenging times and dwindling resources demand new approaches. Let's think microbial. If our organizations take smaller, well-planned steps and harness the power of interdependence, we can accomplish great things. Our 100 trillion microbes can't be wrong.

—Tom DeSanto

Source: "Life on Man," Alun Anderson, The World in 2009 from The Economist, Image: www.genome.gov

Santa and Sanity

2008-12-23T10:40:00.000-08:00

Last Saturday, I heard a holiday skit on A Prairie Home Companion® that tickled my funny bone and wrenched my heart.

It was about how Santa Claus started to suffer from claustrophobia. He was seeking help before Christmas so he could go down chimneys and deliver presents. These few short excerpts will give you some idea of how the story went.

Therapist: "Claustrophobia is very common, Santa Claus. Especially in a chimney environment."

Santa: "Help me over this chimney anxiety. I'm terrified of them. It feels like an MRI machine."

Therapist: "What if instead of a threatening thing—you saw the chimney as a big welcoming hug?"

Santa: "Because it's not." "...it's a long dark hole with hot coals at the end."

Therapist: "Time is up. See you next week. Or wait a minute, no—I'm taking off next week. I'll see you in two weeks."

Santa: "Two weeks and it's all going to be over."

Therapist: "... do the best you can."

Santa: "That's all you can do for me? How about medication?"

Therapist: "Medication isn't recommended when you're operating a sleigh."

Santa: "Please. Give me some meds. Look— (HE SINGS) I'm making a list. I'd sure like some Wellbutrin or Valium. Santa Claus is begging you, please." "...I'm making a list and asking you twice. Some Percocet would be nice."

The skit ended when the next patient, Rudolph, came in for treatment for nasal shame.

I smiled, but then the plight of a friend came to mind.

For years, he had suffered from depression and other issues, but had reached a contented equilibrium after intermittent counseling and medication. In September, he was let go from his job after decades of dedicated service. Nearly sixty-years-old and suddenly out of work, he suffered an emotional setback. Through COBRA coverage, he picked up health benefits. It was expensive, but he made it happen. Before long, he reached his lifetime maximum benefit. Now he can no longer afford counseling and medication. Like Santa in the skit, he has to find a way to meet his commitments and get on with his life.

This year, I'm asking Santa to bring us better mental health coverage. Hope he makes it down the chimney.

—Tom DeSanto

Excerpts from A Prairie Home Companion® with Garrison Keillor, "Santa," December 20, 2008. Image from www.quiet-storm.net.

Genomics and Economics

2008-12-22T18:00:00.000-08:00

As advances in genomics accelerate, so does the advent of rapid tests that unlock secrets. Sequencing a complete genome has progressed from rarified science to a race to profit. Its possibilities extend from translational research labs to consumer's living rooms.

As proficiency increases, pricing decreases. And demand soars.

Gene sequencing promises to revolutionize diagnosis and treatment by spurring the development of new drugs and therapies. According to FierceBiotech, sequencing cost a million dollars in 2007. By mid-2008, the cost dropped to $60,000. One company intends to set the price at $5,000 in 2009. Its CEO considers that the "tipping point." Effective application of sequencing data could cut billions of dollars from the cost of clinical trials and speed results.

At the other end of the scale, a company aspiring to be the "world's trusted source of personal genetic information" offers a $399 home testing kit. It was named TIME Magazine's 2008 Invention of the Year. Now the average joe can discover why he's not so average in his health and ancestry.

The widespread application of genomics is becoming increasingly feasible. Incredible knowledge will be gained. Incredible amounts of money will be made. My hope is that as market forces drive the application of new discoveries, we won't squander the possibilities.

—Tom DeSanto

Image from 3dscience.com, Zygote Media Group

The Other Healthcare Disparity

2008-12-15T16:38:00.000-08:00

Women pay more for health insurance coverage than men do. Conventional wisdom says that childbearing and higher utilization of medical services justify the difference. A recent study by the National Women's Law Center (NWLC) challenges that assertion.

When all else is equal and maternity benefits are excluded, women still pay more for health insurance coverage. A 40-year-old woman's monthly premiums can range from 4 to 48 percent higher than those paid by a 40-year-old man with identical coverage.

Within each state, the additional premium cost for women can vary widely. For example, the difference women in Little Rock, Arkansas, pay for the best-selling health plans can range from 13 to 63 percent. If the costs were based solely on gender rating, they would be more consistent. NWLC suspects gender bias.

In the group insurance market, women are better protected from higher costs. However, in the individual insurance market they often face difficulty in finding maternity coverage. If they do, they are subject to exorbitant premiums and/or out-of-pocket costs. Otherwise, they are priced out of health insurance and are relegated to the ranks of the uninsured. Women who need individual coverage tend to work at low-paying jobs and may be heads of households. They need help. Eliminating gender rating could be a first step in the right direction. Maine, Montana and New York already prohibit gender-based rates.

Currently, approximately ten states have some provision for limiting gender rating. Our state-by-state approach to regulating health insurance enables inefficiencies and inequities to continue. As the Obama administration takes on healthcare reform, I would hope for a plan that addresses disparities for all citizens, regardless of socioeconomic status, race—and gender.

—Tom DeSanto

Image from Wikimedia Commons

Balancing Medicine and Marketing

2008-12-08T10:10:00.000-08:00

Recently a friend who works in healthcare marketing told me that she will soon undergo a bilateral knee replacement.

I asked if she would be taking advantage of a recent development, knee implants designed especially for women.

After researching the possibility and discussing it with her surgeon, she found no advantage to the female-specific knee and decided that most likely the whole idea was based more on marketing than on medicine. There's truth in her conclusion.

Two recent studies showed support for the idea that marketing (specifically the need to sell services and generate revenue) does influence medicine more than we would like to admit.

A study of 377,000 patients in an HMO in Washington state found that between 1997 and 2006 the number of CT scans doubled and MRI scans per patient tripled. The average cost increased from $229 to $443. Instead of replacing older tests, the new ones were ordered in addition. Why? Better medicine? Protection from litigation? And perhaps the need to generate revenue to pay for all the new equipment.

The CyberKnife delivers radiation with amazing precision. Its first application was to treat inaccessible tumors in the spine and brain. Most recently, it's being promoted as an alternative to the many therapies for prostate cancer. The jury is still out on the effectiveness of treatment. However, we do know that each machine costs around $4 million dollars and urologists can receive approximately $1,200 in Medicare reimbursement for each procedure. "Unfortunately, it often comes down to the money," said Louis Potters, chairman of the American Society for Therapeutic Radiology and Oncology's Health Policy Council. "Prostate cancer is so common that it represents low-hanging fruit in terms of revenue opportunities."

Adoption and proliferation of new technologies is essential to bringing patients greater opportunities for recovery and restored productivity. It is also driven by the real economics required to support the advances.

Medical professionals and marketers alike need to maintain a delicate balance. Quality of care, cost control, hospital/clinic solvency and the overall integrity of America's healthcare system depend on it.

— Tom DeSanto

Sources: Reuters Limited, washingtonpost.com, photo: watership kennel/in knees of a solution

Medical Travel: Exporting Patients

2008-11-28T15:56:00.000-08:00

A few weeks ago, the Los Angeles Times ran an inauspicious feature in its business section. Several articles told readers how they can save money by seeking medical treatment in foreign countries. The problem? In a time of consumer-driven healthcare, that healthcare might very well be driven to other countries.
- The Deloitte Center for Health Solutions reports that 750,000 Americans traveled abroad for medical care in 2007 and projects the number will reach 6 million by 2010.
- Nearly 200 healthcare institutions outside the U.S. have been certified by the Joint Commission International.
- Patients Beyond Borders, Josef Woodman's complete guide to "affordable, world-class medical tourism" is now in its second edition. It lists 40 destinations outside the U.S. that provide quality and innovation at a much lower cost.
The cost comparisons provided by Woodman are mind boggling. A heart valve replacement with bypass that costs $75,000 to $140,000 in the United States is just $9,500 in India or $25,000 in Israel or $50,600 in the United Arab Emirates. If quality is equal, we're in trouble.
Deloitte estimates that domestic healthcare providers lost $16 billion to medical travel in 2007. Compared to $2.4 trillion in domestic healthcare spending, it's not much. But the upward trend promises to continue. Much will depend on what happens as the new administration tackles healthcare reform.
Now more than ever, the mighty U.S. healthcare industry is facing global competition. Few, if any, would argue that we provide the best medical treatment for those who can afford to pay. Will we succumb to competition and begin exporting patients—and jobs—in large numbers? Possibly.
The challenge for the U.S. healthcare industry is to compete globally on quality, cost and patient satisfaction. The opportunity for entrepreneurs is to get into the patient export business. By building high-quality global networks and making travel easy, they could deliver excellent outcomes at costs that open-minded payors, employers and individuals can't resist.

—Tom DeSanto

The Truth Abut Blogging

2008-11-15T14:18:00.000-08:00

After six months and 25 posts, I've learned some harsh realities abut blogging.

A blog is a tumbleweed. It lives in a vast, uncharted wilderness. You must provide the moisture to sustain it and the wind to keep it moving. A blog can easily become dry, lifeless and still.

A blog is a spouse. You will not find fulfillment and joy in blogging unless you love it, are committed fully to it and have realistic expectations for it. A blog can easily end from boredom and neglect.

A blog is a lottery. You play it regularly and hope to hit it big. You check the numbers and shake your head. 30 hits one day; none the next. It makes no sense. But you don't want to stop.

A blog is a drill sergeant. It demands the discipline to go beyond reading, thinking and sharing to obeying the regimentation, schedule and protocols of blogging. Duty calls and you must hop to it.

A blog is a personality inventory. You can learn a lot about yourself and readers can learn more about you than you could ever imagine. A blog can reveal everything from narcissism to altruism.

A blog is a reservoir. If you love to write and have something to say, a blog collects and stores a wellspring of ideas that quench your thirst to share and hopefully serve to refresh others. (At least that's my ideal.)

To tell the truth, there are a great many things I'd rather do than blogging. For now, I'm choosing to make it a part of my life. Will other commitments crowd it out? Only time will tell.

—Tom DeSanto

Image: www.pierce.ctc.edu

Obama elected. Reform expected.

2008-11-10T20:09:00.000-08:00

Americans went to the polls and cast their vote for "change" and "hope."

But how much change can we hope for?

For our healthcare system, not too much, not too soon.

The problem? We all know the numbers: double-digit cost inflation and premium hikes; $2 trillion annual spending with questionable results; and 71 million Americans either uninsured or underinsured.

Obama's proposed solution? Three more numbers: $2,500, how much the plan is slated to save the typical family each year; $50 to $65 billion , the annual cost of the plan when fully phased in; and $100 billion, the upfront cost expected for bringing coverage to most of the uninsured.

And how about those other numbers? A 25% loss in value of the U.S. stock market; 5% inflation; and possible double-digit unemployment.

Beyond the numbers, how about words? Quality, affordability and universal coverage. I'm not sure the American people agree on what they truly mean or realize how difficult it will be to bring them into satisfactory equilibrium.

Bob Blendon from the Harvard School of Public Health offers the final word on numbers: 60 percent. That's the majority of Obama voters who expect him to do something major to improve healthcare.

Of all the factors influencing the success of healthcare reform, overinflated expectations may be the most difficult to control.

Our country voted for "change" and "hope." Let's be real. Let's look forward to even the most incremental of change and not lose hope.

— Tom DeSanto

Rx for Falling Hospital Philanthropy

2008-11-02T09:54:00.000-08:00

Giving to U.S. hospitals fell 50 percent between 2005 and 2007 according to a study recently released by the Association for Healthcare Philanthropy. Fewer available dollars require more effective methods.

My prescription: Optimize the internal relationships that drive fundraising campaigns.

Running a campaign, particularly a capital campaign, involves a huge cast of characters, on the inside and outside. It demands Herculean amounts of energy, strict management of expectations and endless endurance. Myriad decisions must be made in short order to meet sequential goals for creating communications. Much too often, fundraising and marketing/media/PR people are left scurrying to meet impossible deadlines.

To avert anxiety and do the best work possible, people in fundraising and communications must break down silos and proceed with one accord from the very beginning. This requires mutual respect for the invaluable experience and talent each group offers—and demands the graceful surrender and sharing of power. (And that can make it a difficult challenge.)

Early in the planning stages, get to know each other well—beyond the cursory meetings—and establish free-flowing channels of communication. Create a process that works efficiently for everyone involved. Define objectives and assign very specific tasks. Designate shared responsibilities that cross silos. Set clear deadlines and hold each other accountable. Proceed with transparency, honesty and a singular sense of purpose. Avoid an "us" and "them" mentality at all costs.

Too many times I've seen fundraising campaigns lose their momentum and mojo because the internal relationships were dysfunctional. With hospital philanthropy falling, all of us must rise to the occasion.

—Tom DeSanto

Healthcare Quality Ratings: Sight Unseen?

2008-10-30T15:53:00.000-07:00

Healthcare ratings continue to proliferate. But fewer Americans recall seeing and using them.

Between 2006 and 2008, the percentage of Americans who reported that in the past year they "saw" and "used" comparative health quality information for health insurance plans, hospitals or doctors dropped by 6 percent. (From 20 to 14 percent)

This finding came as part of the Kaiser Family Foundation's 2008 Update on Consumers' Views of Patient Safety and Quality Information. In the same study, the percentage of Americans who said they "saw" that same type of information fell from 36 to 30 percent.

The implications are huge.

As government continues to gather and publish data in the hope of driving efficiency and cost savings through informed free-market forces, fewer citizens are participating.

As health insurers increasingly generate information to empower consumer-driven healthcare, awareness and use are diminishing.

As hospitals and health systems seek to differentiate themselves based on quality data, not as many consumers are noticing.

Why are fewer Americans tuning in?

In 2006, in an article published in Healthcare Marketing Report and in speaking engagements, I warned of factors that would undermine the effectiveness of quality ratings: exploitation and overexposure in marketing, too many sources with no standardization, needless complexity with lack of interpretation, or oversimplification that betrayed the underlying data. The result would be a lack of understanding by consumers, resulting in tune out. It seems to be coming true.

Providing comparative healthcare information and encouraging its use is essential. The two-year downtrend shows that we have lot of work to do. Consumers can't gain insight from comparative healthcare quality information if ratings go sight unseen.

— Tom DeSanto

FDA: Fix Deficient Activity

2008-10-28T11:14:00.000-07:00

First, Vioxx faced withdrawal despite FDA approval.

More recently, an impurity in an active ingredient that came from a Chinese factory caused Baxter International to recall its total production of various types of heparin. More than 60 people died from allergic reactions in the aftermath.

In the meantime, the U.S. Supreme Court took the first steps toward removing manufacturer liability when products meet FDA approval. In Riegel vs. Medtronic, it ruled that when the FDA approves the safety of a medical device, individuals have no legal recourse if something goes wrong. A similar case involving pharmaceuticals is due to be heard soon.

Is the FDA up to the task of protecting us? Several statistics depict a dire situation:

- As of September 30, 12 out of 16 of the advisory committees in the Center for Drug Evaluation & Research were without chairmanship and had 83 vacancies. (Source: The RPM Report)

- The number of FDA inspectors who certify that manufacturing plants meet current GMP standards has decreased by 25 percent since 2002. (Source: GAO)

- More than half of the clinical trials used to support FDA approval remain unpublished in peer-reviewed literature for at least five years after approval has been granted. (Source: www.sciencebasedmedicine.org)

Apparently the FDA is deficient in maintaining leadership, staffing and transparency. Many agree it's time for fundamental restructuring.

Representative John Dingel (D-Michigan) is vocal about FDA shortcomings and believes that congressionally mandated change is needed. He is holding oversight committee meetings to take FDA leaders to task about making improvements. Dingel also is formulating an overhaul plan that he hopes to enact by year-end, or that may become a model for action under the new administration.

In a post on this blog on August 8 entitled "Our Healthcare Conundrum," I cited a candid assertion made by the FDA's Dr. Steven Gutman: "The health system will explode in three to four years and that will fix it." As I look at the FDA's current state, I understand his comment as coming from inside the volcano. But, as an optimist, I'm convinced that we can alleviate some pressure from the magma chamber before it blows.

Maybe we really can make progress in retooling the FDA into a organization that facilitates innovation while protecting us from harm. By more clearly defining the FDA's role and responsibilities, establishing strong leadership and accountability, and by providing the required resources, we can fix deficient activity.

— Tom DeSanto

Disco Redeemed

2008-10-17T09:31:00.000-07:00

Who knew? I thought Disco was deadly. Now it has the potential to save lives.

Researchers at the University of Illinois confirmed that listening to or singing Stayin' Alive by the Bee Gees can help people perform CPR more effectively. At 103 beats per minute, it sets the appropriate tempo for chest compressions.

The American Heart Association recommends a minimum of 100 compressions per minute for CPR. Tuning into Stayin' Alive helped study participants reach 109 to 113 compressions. At that rate, recipients of CPR are more likely to survive.

I guess it's time to dust off my "Disco Sucks" tee shirt and trade it in for one that says "Disco Saves."

— Tom DeSanto

Improving Communication with Patients

2008-10-15T11:14:00.000-07:00

The Institute for Healthcare Advancement (IHI) has published a list of the 10 most common errors made when communicating with patients. I've translated the problems into solutions.

10 Best Practices for Communicating with Patients

1. Explain and write instructions at a fifth-grade level.

2. Speak and write in common terms, not medical jargon.

3. Recommend only Internet sites with clear information that supports the physician's advice.

4. Keep font sizes at a minimum of 12 point.

5. Use only simple, literal graphics to support medical instruction.

6. Help patients understand what you say by having them explain it back in their own words.

7. Recognize cultural differences and respond with sensitivity.

8. Talk slowly and allow time for questions.

9. Provide information in the patient's first language.

10. Explain prescription instructions carefully to avoid misinterpretation.

According to the IHI, billions of dollars in unnecessary healthcare expenses can be attributed to misunderstanding between patients and providers. Beyond that, the cost of continued illness from noncompliance — and the frustration and alienation it causes — is immeasurable.

Taking time to apply 10 common-sense communications practices can make a huge difference.

— Tom DeSanto

The Paradox of Change

2008-09-30T18:40:00.000-07:00

Healthcare practitioners face a paradox of change.

Technologies, regulations and market dynamics sweep us along.

Inefficiencies, rising costs and inequities hold us back.

Our healthcare system is changing constantly, yet not changing at all.

Once again Americans are demanding more from the system.

In response we embrace the vital role of change agents.

We seize acute opportunities and battle chronic challenges.

From most infinitesimal details to the elephant in the room,

we are consumed by change—and the lack of it.

— Tom DeSanto

In the October issue of Healthcare Marketing Report, I write more about change.

Purpose-Driven Annual Reports

2008-09-30T05:27:00.000-07:00

Your annual report is a mighty ambassador. Are you using it to its full potential?

Properly planned annual reports can be workhorses in branding, marketing, recruitment, philanthropy, employee engagement, lobbying, immunization against loss of tax-exempt status, and many other important pursuits.

Often annual reports are seen as a yearly obligation and a burden. If we step back each year, plan ahead and engage them in our overall strategy, annual reports can be invaluable.

Analyze your audiences and current communications challenges and then examine the possibilities for all that your annual report could accomplish. Set clear objectives and communicate them internally, long before you begin seeking input for content. This guidance will help protect your organization from becoming narcissistic and bombastic when generating content. It will also drive your report toward fulfilling its intended roles.

More than a decade of conceptualizing, writing and judging annual reports has taught me a major truth: A disciplined process that engages organizations in providing content based on a well-defined purpose yields excellent, effective annual reports.

— Tom DeSanto

Diagnostics: Essential In Medicine and Marketing

2008-09-22T22:09:00.000-07:00

Each year 10 billion in-vitro diagnostic tests are conducted in the U.S. , an average of 33 tests per citizen. The approximately $40 billion we spend on diagnostic testing accounts for less than 5 percent of total healthcare expenditures, but influences 70 to 80 percent of decision-making.

Effective diagnostics, properly applied and interpreted, are critical to outcomes. Medicine is increasingly dynamic and complex. It demands new approaches and insights.

The same is true for healthcare marketing.

Effective diagnostics and interpretation are critical to positive marketing outcomes. The small percentage of expenditure invested in research, strategic analysis and planning is perhaps the most important of all.

— Tom DeSanto

A Voice for Frustrated Physicians

2008-09-15T18:22:00.001-07:00

As individuals, and in healthcare organizations, physicians command respect and have a strong voice.

As a group, and in the healthcare system, the opposite seems true.

The science of medicine continues to advance. But the art of medicine — and the ability to prosper while practicing it — continues to decline.

We all know the problems: paltry reimbursement, myriad bureaucracy, insufficient time for patients, astronomical insurance costs, crushing debt for medical graduates. The list goes on. And so do the struggles.

Who would want to be a doctor, especially a general internist? These primary-care physicians tend to care for the elderly and chronically ill, and earn one of the lowest starting salaries among physicians.

USA Today reported that only 2 percent of 1,177 respondents to a survey of students at 11 U.S. medical schools said they plan to go into general internal medicine. The long hours, lower income and grueling work deterred them. No wonder. Those already in practice may be having second thoughts.

My general internist recently was asked to leave a group practice. Why? He spent too much time with patients and it complicated reimbursement. He's cared for me over a decade with insight, skill and remarkable dedication. But that's not how medicine is practiced any more. So, he's worn out and frustrated. And he's not alone.

I'd say doctors are mad as hell and they're not going to take it anymore. But they haven't really flexed their muscle because they've been unable to unite with a single voice in real time—until now.

Since July, more than 7,300 of the nation's 600,000 practicing physicians have signed an "Open Letter from America's Physicians," a manifesto for change. They've come together on Sermo, a physician-only online network that boasts a membership of 70,000 doctors.

Sermo was designed for physicians to exchange clinical insights, review cases, influence the biopharmaceutical industry and help improve patient care in real time. Now it's giving doctors a unified voice. (See www.sermo.com/doctorsunite)

Online grassroots movements can erupt with great power. Let's hope this one gathers momentum. Sermo is Latin for "conversation." That's the first step toward abeo, Latin for "change."

— Tom DeSanto

Health Care or Healthcare?

2008-08-30T05:37:00.001-07:00

Is it "health care" or "healthcare?" We've all seen it spelled both ways.

Here is a quick review of the preferences of a dozen voices in the industry.

"Health Care"

American Hospital Association
American Medical Association
Centers for Medicare & Medicaid Services
NCQA
The Joint Commission
U.S. Dept. of Health & Human Services

"Healthcare"

American College of Healthcare Executives
Healthcare Advertising Review
Healthcare Marketing Report
Healthcare Strategy Institute
Modern Healthcare
Society for Healthcare Strategy and Market Development

Merriam-Webster and The New York Times use "health care." Hits on Google: "health care" 55.5 million, "healthcare" 12 million. I prefer "healthcare," but use it either way based on the client's culture. Sometimes I also use it hyphenated as a compound adjective, such as "health-care system."

What's your Vote?

Which version does your organization use? I'm adding an informal poll to this blog that will remain open indefinitely. Please take a moment to weigh in. (See right column.)

Later note: "healthcare" won by a large margin.

—Tom DeSanto

Death Rates: Of Patients and Hospitals

2008-08-25T08:13:00.000-07:00

The news on death rates is out. It promises to drive U.S. hospitals toward further improvement in clinical performance. Eventually, fewer hospital patients will face unnecessary death. In the meantime, some hospitals may begin a slow death.

Without a doubt, the federal government has taken a giant stride in measuring and reporting hospital performance. The Hospital Compare website now posts reports based on deaths that occur with 30 days of admission among the 35 million Medicare beneficiaries.

Upside

The improved reporting method:

uses heart attack, heart failure and pneumonia deaths to reflect overall performance
compensates for differences in the acuity of patient populations
retains simple categories for comparison
delivers a 95 percent confidence level that each hospital is in the right category.

Downside

The new comparison data:

assigns most hospitals to the "as expected" category, making comparisons difficult
does not account for DNR orders of deficient follow-up care outside the hospital
runs the risk of patients and consumers "over-interpreting" mortality rates
places 115 hospitals, deemed to have higher than average death rates, on the spot.

Flip Side

Transparency around death rates is likely to improve performance and cull hospitals unable to reach posted standards. It's a new round of survival of the fittest.

If patients and consumers react strongly and stay away from hospitals that have higher death rates, the resulting loss of fiscal resources not only will make it difficult to make improvements, but also hasten the demise of hospitals already in the red.

Likewise, if physicians, nurses and staff lose faith in their hospital's ability to reach higher performance standards, their response will slow progress in achieving them.

Every hospital has highly trained physicians, nurses and staff who are dedicated to providing the absolute best care they can with available resources. The sad truth is that all that extraordinary talent, dedication and technology is undermined by a healthcare system that is an outmoded hodgepodge of ineffective governance, finance and information-sharing.

With the publication of death rates and subsequent media push, hospital communications teams have a lot of explaining to do. Updates from Quality Advisory offer help. But these communicators will need to offer hope.

— Tom DeSanto

Our Healthcare Conundrum: Innovation vs. Access

2008-08-08T12:17:00.000-07:00

Medical innovation advances while access to medical care declines. How can the U.S. drive innovation and expand access?

To me, a first step might be to get the government's purveyors of advancement and access working together.

The Food and Drug Administration (FDA) evaluates the efficacy and safety of new interventions, but not their effectiveness in alternative clinical settings or cost implications.

The Centers for Medicare & Medicaid Services (CMS) has a mission "to ensure effective, up-to-date healthcare coverage and promote quality care for beneficiaries."

Why can't the FDA and CMS collaborate early on to ensure the clinical and reimbursement viability of new diagnostics and treatments?

I posed that question to Dr. Steven Gutman, Director of the Office of In Vitro Diagnostic Device Evaluation and Safety at the FDA, at a recent conference. He confirmed that the agencies currently work completely separately and that past efforts for collaboration have not been successful. Another overture is taking place currently, but he is unsure what the outcome might be.

As usual, the wheels of bureaucracy turn slowly, even in the face of evidence for change.

To fund biomedical innovation in 2007, the U.S. government provided $28 billion to the National Institutes of Health and $593 million to the National Science Foundation.

At the same time, 47 million Americans, almost 16 percent of the population, did not have any healthcare coverage—which means they could not directly reap the benefits of medical advancements.

Innovation is essential, but the high cost of new interventions is not always covered by a Medicare system that struggles for solvency.

Back in 1999, the RAND Corporation corporation recommended that "it would be beneficial, then, for policymakers to consider how their decisions may effect medical innovation indirectly through the effects of those decisions on private technology adoption, along with the more obvious direct effects of their decisions about coverage and payment under public health insurance programs."

A decade later, we're still not getting there. What's the answer?

Dr. Gutman provided a candid assessment at the conference. He said, "I have a perverse view that the health system will explode in three to four years and that will fix it."

No one, including Dr. Gutman, truly wants to see an explosion. But we could use a little fireworks. Maybe then our health system can break down more silos and reach a more acceptable equilibrium between innovation and access.

—Tom DeSanto

System Branding, Family Style

2008-07-30T06:30:00.000-07:00

Developing a strong central brand across a large health system is like organizing a family reunion. If you think of your system as a family, the branding process goes like this:

Decide who to invite into the process.
Plan what you want to do and its cost.
Talk to everyone you can.
Learn their good and bad points.
Figure out how everyone is related.
Find out what they all have in common.
Distill out what makes them special as a family.
Express this unique quality clearly.
Get them together and smooth out differences.
Celebrate who you are and what you do.
Excite everyone enough to brag about the family.
Keep everyone up to date and keep celebrating.

This process will make sure that your brand is alive and active when you invest in marketing communications to promote it.

Think family. We all have members who are different, cranky and maybe even weird. But we need to bring everyone into the fold and build each other up. That's what a strong central brand is all about.

—Tom DeSanto

Kids and Statins: Another Magic Bullet?

2008-07-20T19:00:00.000-07:00

The American Academy of Pediatrics' recent proposal that statins can be prescribed for children as young as 8 years old is another sign of a disturbing trend.

Traditionally, a major role of medicine was to protect us from potentially fatal diseases, such as pneumonia, dysentery and tuberculosis.

More recently, medicine seems to be shifting toward protecting us from ourselves. We find it easier to use medical science to offset the consequences of unhealthy behaviors than to change them.

For example, statins have proven successful in lowering LDL cholesterol in adults over 50. More than 36 million people take them every day. However, as LDL levels decline, obesity soars. Why? Many people believe that they no longer need to exercise and watch their diet when taking statins. Americans now spend more than $20 billion a year on them.

When statins are prescribed for children, we may find ourselves on the same path—taking the easy way out by treating the symptoms instead of the cause.

Looking beyond behavior change to treat obesity, people turn to many other remedies. The U.S. weight-loss market (medical and otherwise) continues to expand and is projected to hit $61 billion in 2008.

Bariatric surgeries are becoming more commonplace as well. The number performed annually has grown ten-fold since 1998. Gastric bypass and banding surgeries are predicted to surpass 200,000 in 2008. At an average cost of $30,000 per procedure, spending will reach $6 billion. The growth is sure to continue. Only a small fraction of eligible candidates have been treated and procedures among teenagers are increasing.

There is nothing inherently wrong with using statins, weight-loss programs and surgery to treat obesity. Many people find them effective and they can save lives. But our culture leads us to take shortcuts. We demand the magic bullet. And medicine is willing and able to provide it at a cost.

As we ask ourselves what our healthcare system is delivering for the enormous sums of money we spend, we should think about what we're asking medicine to do. Should it be curing our ills or compensating for our behavior?

— Tom DeSanto

In Healthcare Marketing We Trust?

2008-07-09T13:54:00.000-07:00

By nature, basic marketing processes run contrary to creating the empathy and trust so essential for effective healthcare communications.

In marketing discussions, we talk about patients and families in terms of targets, volumes and responses. Healthcare relationships become service lines, outcomes, appointments and margins. This desensitizes us to the deep emotions around health and healing.

In marketing research, we seek insight by studying patients and community members in aggregate and labeling them based on demographics, psychographics and ZIP+4. This devalues individuality.

In marketing communications, we speak to people indirectly via brochures, newsletters, advertising and emails that direct them to call centers, websites and sometimes telephone message trees. This removes immediacy.

In marketing programs, we apply CRM software to remember personal data, track contacts, send email blasts and gauge the value of potential customers. This replaces intimacy.

Often we stay "in touch" without really being in touch with people's perceptions and feelings. No doubt marketing communications are an imperfect substitute for the face-to-face interaction so critical to building trust.

How can we compensate? With periodic reality checks.

Let's take more breaks from our computers, data, projects and meetings to visit briefly with patients, families, visitors, nurses, physicians and patient-care staff.

Let's keep in mind how healthcare experience have shaped our lives and those of loves ones and friends.

Finally, let's remember that healthcare marketing is an experience and calling unlike any other.

In marketing we trust, but building trust goes far beyond marketing.

— Tom DeSanto

Diabetes Demands Decisive Action

2008-07-02T09:01:00.000-07:00

Last week the CDC issued the latest statistics on diabetes. The number of Americans with diabetes grew 15 percent between 2005 and 2007. Nearly 24 million people (8 percent of the population) now have the disease.

The increase may be attributed in part to better detection, but the situation remains dire. Another 57 million Americans are likely to be prediabetic and at risk, particularly due to obesity and sedentary lifestyles.

Approximately 3 out of 5 people with Type 2 Diabetes commonly suffer at least one serious comorbidity such as heart disease, stroke, eye damage, kidney disease or foot problems that can lead to amputation.

The personal cost is incalculable. And the monetary cost is enormous. In 2006, America spent an estimated $22.9 billion on medical costs directly related to diabetes complications.

New statistics on diabetes are yet another call to action for hospitals and health systems.

How well is your organization doing with outreach for diabetes awareness, diagnosis, treatment and management? Could you take a more proactive and effective approach? Have you bundled services around the needs of diabetics and improved access to care?

It is estimated that in 2007 nearly 25 percent of Americans age 60 and older had diabetes, either diagnosed or undiagnosed. As a starting point, that group could benefit greatly from decisive action on diabetes.

— Tom DeSanto

Genetic Testing Boom Ahead?

2008-06-26T19:35:00.000-07:00

After 13 years of Congressional debate, the Genetic Information Nondiscrimination Act (GINA) finally was signed into law last month.

This landmark legislation removes a significant barrier to genetic testing by protecting Americans from discrimination based on their individual genetic profiles.

Health insurers will be prohibited from denying coverage or increasing premiums based solely on genetic predisposition toward a specific disease. Employers will not be allowed to consider genetic information when making decisions about hiring, placement, promotion and firing.

"Americans can finally take advantage of the tremendous potential of genetic research without the fear that their own genetic information will be used against them," said Representative Louise Slaughter (D-NY), who first introduced the legislation in 1995. Cosponsor of the bill, Senator Edward Kennedy (D-MA), said, "This bill paves the way for every American to benefit from the vast potential of this new age of personalized medicine."

Will GINA unleash a boom of genetic testing and therapies?

Not immediately. GINA's health-insurance provisions are predicted to take effect in about one year, followed by the employer provisions six months later.

In the meantime, commercial genetic testing labs and manufacturers of in vitro diagnostic (IVD) products may accelerate their efforts in anticipation. The most recent issue of IVD Technology stated, "Industry analysts believe GINA will remove public apprehension about getting genetic tests, which will encourage IVD manufacturers to continue developing such tests."

According to the Genetics and Public Policy Center at Johns Hopkins University, tests currently exist for nearly 1,500 diseases and conditions. Many are available to consumers on the Internet.

That raises the question as to what people can actually do with the information they gain from genetic testing. Doctors can monitor patients and begin diagnostic and preventive care earlier to save lives. They can also more accurate determine dosages of certain medications, such as blood thinners. Couples with hereditary conditions can make decisions about having children. And people genetically predisposed toward a disease can learn about it and make long-term medical, personal, legal and financial plans.

The present value of genetic testing has been put in perspective by Francis Collins, director of the Human Genome Project. He explained, "Genetic testing offers us a great opportunity to practice preventive medicine in a way that focuses more specifically on what each of us ought to do for our health. It is a great new model, but right now we don't quite know how to implement it."

Do I believe that GINA will generate a genetic testing boom? Not yet. In the short term I predict:

• A bit of a "gold rush" by companies selling direct-to-consumer tests

• More scrutiny and regulation of genetic test procedures and results

• Continuing debate over "civil rights" regarding genetic information

• More doctors prescribing and more patients accepting genetic tests

• Optimism and opportunity to strengthen the emerging IVD industry

• Healthcare organizations touting their capabilities in genetic testing

GINA is a great leap forward on the road to personalized medicine and the wondrous possibilities of genetic therapies.

—Tom DeSanto

Photo: www.whitehouse.gov

Vacations and Morbidity

2008-06-19T04:41:00.000-07:00

Often we're dying to go on vacation. But can vacations actually help us from dying? Maybe so.

Are Vacations Good for Your Health? The 9-Year Mortality Experience After the Multiple Risk Factor Intervention Trial by Brook B. Gump, PhD, MPH, Karen A. Matthews, PhD

"There are a few possible mechanisms through which vacationing might have protective effects on health."

"First, vacations may reduce stress by removing ongoing stressors (e.g., avoidance). The health benefits of stress reduction are well documented..." [especially for cornary heart disease]

"Second, vacation may reduce stress by reducing potential stressors and anticipated threats, providing a period of "signaled safety." Anticipated threats are known to have adverse effects as great as, if not greater than the threat itself."

"Finally, annual vacations may provide a unique opportunity for behaviors having restorative effects on anabolic physiological processes, such as social contact with family and friends and physical activity, in the context of reduction of stress-initiated metabolic effects."

It's official. And yes, I'm on vacation now. Off to the beach! (And a healthier life)

— Tom DeSanto

Healthcare Expectancy

2008-06-12T05:55:00.000-07:00

"Life expectancy" brings to mind the idea of "healthcare expectancy." How long we expect to live has a lot to do with what we expect from our healthcare system.

Yesterday the National Center for Health Statistics released the latest life expectancy estimates. A child born in the U.S. in 2006 is likely to live approximately 78 years if mortality trends remain consistent. It's a new American record for predicted longevity, but as everything in healthcare goes, there's a flip side.

The U.S. still ranks behind about 30 other countries in estimated life span. (Japan holds first place with 83 years.)

Disparities remain: white women lead the list with 81 years, followed by black women with 77, white men with 76 and black men with 70.

These new statistics will stir debate over our return on investment as the nation that spends the most, by far, on healthcare. But the verdict depends on what we expect.

Overall, I believe our nation does not receive the level of care merited by our enormous expenditure. In individual cases, however, such as my nephew who overcame childhood cancer and is now a remarkable, robust 20-something, we receive priceless miracles.

Our "expectancy" for life and healthcare is skewed. We expect a long and healthy life. If that isn't our lot, we expect medical miracles to save us, restore our vitality and preserve us from serious illness. For ourselves and loved ones, we're all too willing to go to extraordinary measures to prolong life, even in its last days and against very steep odds.

As long as we insist on expecting so much from life and healthcare, our healthcare system will continue to fall short of our expectations. We will not lead the world in life expectancy. And all our citizens will not get the care and support they need to have long healthy lives.

We're at yet another crossroads for healthcare reform. As we examine the system, we'll also need to examine our expectations.

— Tom DeSanto

Boomers: Crisis or Catalyst?

2008-06-07T11:25:00.000-07:00

We all know that the Boomer generation, by its sheer numbers and projected utilization, will change our healthcare system forever.

But will Boomer's burgeoning medical demands foment a healthcare crisis? Or will they use their clout to demand and drive much-needed reform?

Recently I saw a television commercial for "Divided We Fail." It led me to a grassroots campaign that's growing rapidly right under our feet.

AARP has joined forces with organizations that represent 53 million Americans to fight bipartisan gridlock over healthcare reform. They've put together a communications arsenal that includes everything you'd expect and a lot more. A distinctive brand and icon. Invitations to sign a pledge. Town meetings. Personal stories of healthcare strife. A stirring anthem sung by Aretha Franklin. Voter registration. Opt-in for e-newsletters. YouTube. V-cards. E-cards. And links galore, all at www.DividedWeFail.org.

The July/August issue of AARP: The Magazine shouts a battle cry for healthcare reform. The article calls out provocative statistics on American healthcare:

$500 billion is spent annually on unnecessary care.
30,00 Medicare recipients die each year as the result of unneeded care.
50% of surgeries, test and procedures are not backed by scientific evidence.

They're rallying the readers of the "world's largest circulation magazine" to take a stand and make a difference.

As the presidential election approaches, the Divided We Fail movement will surely spread like wildfire. The other half of their motto is "together we can do anything."

I agree. Intuition tells me that collectively the Boomers will become a catalyst for change long before they become a burden of catastrophic proportions.

What do you think? Will the Boomers help sink the system or save it?

— Tom DeSanto

Road Trip!

2008-05-29T18:30:00.000-07:00

The unofficial start of summer brings to mind road trips. Remember the chaos of car packing and choruses of "are we there yet?"

Branding is a lot like a road trip. It's an adventure, often filled with drama and detours. How do you stay on course?

Branding Is A Trip: Tom's Ten Tips

Explore the possibilities and learn everything you can in advance.
Agree on your destination and what kind of trip you'd like to take.
Set a robust and varied, yet realistic and efficient itinerary.
Map out everything: start to finish and every stop along the way.
Know the cost of everything, including incidentals, and allow for more.
Secure the resources you need and tell everyone to pack lightly.
Respond patiently to whiners and stay the course.
Be prepared for delays, detours and possible disaster.
Look all around you, take it all in and share your thoughts.
Revel in who you are and all that you're doing.

Branding is an ongoing journey. Enjoy the trip.

— Tom DeSanto

Serving the Survivors

2008-05-26T09:56:00.000-07:00

Memorial Day. Honor the dead. Remember the living.

Advances in battlefield medicine, response time and transport save the lives of more soldiers than ever before. From the Iraq war alone, more than 30,115 men and women have returned home with injuries.

Likewise, medical advances allow us to save more lives here at home. For example, five-year survival rates across all forms of cancer increased an average of 16 percent between 1975 and 2003. And they continue to rise dramatically.

However, studies show that survivors, whether from war or life-threatening disease, fall short in sustaining behaviors that guard their health and promote well-being.

As healthcare practitioners and communicators, we can make a huge difference. Survivors' medical, psychological and social needs are immense and their numbers are growing. Let's find new ways to extend our reach far beyond treatment with much-needed information, support and advocacy.

The best way to honor the bravery of survivors is to help them live the best lives possible. We're already making progress. May they inspire us to do even more.

— Tom DeSanto

Doctors on Angie’s List®: Disrespect or Discussion?

2008-05-23T08:46:00.000-07:00

Kiplinger's calls Angie's List "a virtual backyard fence—with talk about the dry cleaner, the drywaller and everything in-between." That discussion now includes doctors. Angie's List is soliciting members' feedback on medical professionals so it can compile ratings in 55 categories, ranging from allergy/immunology to vascular surgery. (They eventually plan to double the number of categories.)

Does inclusion of doctors on Angie's list signal decreasing respect for the training, experience and skills of physicians? Or as Kiplinger's suggests, does it represent a revival of individuals making very personal decisions based on neighbor's recommendations?

Angie's List members grade medical professionals and facilities on price, quality, responsiveness, punctuality and professionalism using an A through F scale. The questionnaires cover courtesy, comfort, communication and other aspects of the patient experience. From the consumers' view, it makes perfect sense. Most people assess healthcare encounters based on how well their providers relate to them and whether their overall experience was comfortable and convenient. Medical skill, outcomes and especially price seem less important.

While grading physicians in tandem with tradesmen seems to indicate eroding respect, providing a forum where patients can share their experiences is vital to improving healthcare.

Not long ago, managed-care gatekeepers limited open discussion and selection of physicians. The addition of out-of-network options and now advent of healthcare consumerism is changing all that.

Adding medical categories to Angie's List revives and amplifies people's ability to see opinions from neighbors. To its credit Angie's List advises members that its ratings should be used solely to gain perspective on healthcare decisions.

So, is Angie's List dissing docs? Not intentionally. Is it opening discussion? Definitely. Is there a downside to all this? Perhaps.

Patient-experience ratings sites are proliferating rapidly and have overtaken efforts to quantify and publish accurate, useful outcomes data. The best healthcare decisions are made when we balance our physicians' advice with information on service experiences and outcomes.

Angie's list has earned a rightful place among healthcare information resources. But it's vital for people to understand that is is not the only list to consult before choosing a doctor.

— Tom DeSanto

Is Consumerism the New Managed Care?

2008-05-20T20:57:00.000-07:00

Back in the 1980s, many promises came with the advent of managed care. Reduced utilization. Free preventive care. Practice guidelines that improve outcomes and increase efficiency. Lower healthcare costs.

In theory, managed care seemed to be the right prescription, but it never fully lived up to the high hopes we ascribed to it. Although managed care temporarily put the brakes on skyrocketing healthcare costs, it never became the solution for double-digit healthcare cost inflation.

Why? In simplest terms I'd say managed care became overly rigid in its controls and then gradually loosened its grip in response to widespread discontent. The idea of healthcare restrictions runs against the grain of American culture. People like getting free physicals, immunizations, well-baby care and wellness classes. But they detest limitations in their choice of physicians and balk at obtaining pre-authorizations.

By 1988, the United States was spending nearly $500 billion per year on healthcare ($2,400 per person.) In 2007, the amount surpassed $2.3 trillion ($7,600 per person.) The problems remain the same. Excessive cost. Low efficiency. Inequitable access.

The new hope for our ailing healthcare system is the advent of consumerism. Since exerting control didn't work, maybe free-market forces will. Publish medical outcomes and costs. Drive quality through transparency. Have people shop for healthcare with out-of-pocket dollars. Maybe we really can reduce spending. Consumerism a great idea in theory, but will it live up to its promises?

Intuition tells me that healthcare consumerism is likely to fall short of expectations. Healthcare is neither a commodity nor merely a service. It is delivered in complex relationships and subject to individual patient's biological and emotional identities. The stakes in many healthcare purchasing decisions are higher and more profound than any other item in the consumer marketplace.

I agree that people might comparison shop for simple diagnostic services and basic care, such as the kind now being delivered in supermarkets and pharmacies. They also are likely to review outcomes data as it becomes more readily available and easy to understand. Quality and price may well become true criteria for decision-making, and the result would be a reduction in healthcare spending.

However, I don't believe American consumers will contemplate the price of treatment in life and death situations. And that's where the costs and stakes are the highest. Life is priceless. That belief, just like freedom, is deeply ingrained in our culture.

Consumerism is a reasonable answer to runaway healthcare costs. But, much like it was with managed care, we can't expect it to be the answer.

— Tom DeSanto