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Archive for May, 2007



Upcoming IOM meeting

by Emily DeVoto

The Institute of Medicine’s Roundtable on Evidence-Based Medicine is presenting a workshop July 23-24 (in Washington, DC) entitled “Common Ground: Leadership Commitments to Improve Value in Health Care.” It’s open to the public with advanced registration.

The Roundtable panel and IOM staff present thought-provoking meetings with very practical implications. Earlier topics have included standards for judging evidence on clinical effectiveness, and the learning health care system.



Interview with Josef Woodman, author of Patients Beyond Borders (transcript)

by David Williams

Here’s the transcript of my recent podcast interview.

David Williams: This is David Williams, cofounder of MedPharma Partners and author of the Health Business blog. Medical care in the US costs a fortune. In the past few years uninsured and underinsured Americans have been venturing to places as far away as India and Singapore for surgery and other treatments. The care’s often excellent, prices are low, and even surgeons are customer service oriented. I spoke earlier today with Josef Woodman, author of Patients Beyond Borders: Everybody’s Guide To Affordable World Class Medical Tourism. Listen in and hear what he has to say.

Joe, tell me how you got interested in international medical travel.
Josef Woodman: Three and a half years ago my father suddenly announced that he was heading to Mexico to get a mouthful of teeth restored. He was 72 at the time. I had a visceral reaction. I was concerned about treatment in a shoddy clinic with rusty instruments and an untrained doctor, so I followed him out there and found exactly the opposite to be true. He had located a very clean clinic with a board certified physician, a dentist, really a quality staff, state of the art instrumentation. In fact I think the first panoramic Xray I’d ever seen in a dentist’s office was there.He saved $11, 000. That includes the cost of the trip and a month there. I came back home and found friends with the same reaction when I would tell them the story where I had gone, what I was doing. These friends had the same reaction I had when I let them know what the real story was. They would follow me out the door looking for his email address. So the publisher part of me just couldn’t resist the notion of a book on the subject. That started a three-year project which resulted in Patients Beyond Borders.
David: Interesting. So it’s interesting that you were involved more in the health care and publishing space than your father seemed to be, the trailblazer. How did he find out about the idea of going, not necessarily overseas, but going to another country to have dental work done?
Josef: He is a very practical person, and when he was quoted some price, it just dropped his jaw. I think he was quoted something like $24, 000 for this restorative dentistry. He just simply couldn’t afford it. He had been in Mexico and seen some of these clinics, and he was curious about them. Three and a half years ago he was something of a pioneer, but there were enough websites in English that he could get through.
David: Now, I sometimes hear this term medical tourism, which you use a little bit in your book but not so much. I’m wondering where that notion of medical tourists came from, and also if you have a preferred term other than that?
Josef: Well, actually the term grew out of India when the Indian government was trying to court medical travelers. That is a fairly recent term. The term medical tourism is probably not more than two years old. In fact it grew out of India after we started our research. On the one hand we were happy to see it labeled. On the other we considered it a misnomer, which is why you don’t see it much in the book. We actually mentioned the term in the book as a misnomer.We prefer international medical travel. The reason we feel it’s a misnomer is because it implies tourism and leisure time and recreational time. We feel they’re separate issues. We don’t recommend that anyone takes a vacation we think it’s best for people to take care of their bodies, take care of their health, not think of it in terms of tourism any more than a business traveler is thought of as a business tourist. You never hear the term business tourist. People have a goal. They meet their goal. They come on home, and then maybe if they saved some money, which they usually do, they can salt that away and when it’s time to a nice trip, they and their companion can go on a nice trip together. It’s separate issues.
David: Did you have a prototypical patient in mind when you wrote the book?
Josef: There are two types of medical tourists. One is the cosmetic surgery crowd and the Beverly Hills, Chevy Chase crowd. They head down to Brazil. They’ve got their own network. They spend probably twice and three times the amount they’d spend in America and come back home and brag about it. That’s a relatively low number. That’s not the crowd that we addressed.The crowd that we saw repeatedly in these hospitals were part of the 46 million uninsured and another 30 million under or partially insured. These are folks that are aging into expensive medical procedures, and they find themselves financially challenged. They’re in the middle class. They’re in the upper working class. They don’t want to have to sell their home or sell their small business just to pay for an expensive procedure.
David: So when you talk about underinsured patients, that sounds like patients that have some kind of insurance, and they’re still finding it worthwhile to go overseas?
Josef: Oh yeah. Underinsured can involve a number of circumstances. Technically anyone with a dental plan is underinsured, and there’s a 120 million Americans without dental insurance. For those who have dental insurance, they’re technically underinsured because, especially aging patients, your flesh is going to outlive your teeth. Almost no dental plan covers any of the major noncritical procedures, such as restorative surgery. So technically you’ve got so many exclusions with a dental plan that you’re underinsured.Same thing is true with, let’s say, a hip replacement, an orthopedic procedure. Unless a physician defines that as being critical care, you get to pay for that yourself even if you have insurance. It’s excluded. Also a lot of people have preexisting conditions, and that gets excluded.
David: Now, what about patients who aren’t underinsured but who are well insured? Are there any insurance companies that are actually looking to overseas providers as a way to reduce costs or to increase quality or convenience?
Josef: Well, our research shows us that so far there’s just a couple or three insurance companies with very specific plans, but look for big changes within the next year.
David: What are some of the common misconceptions that people have about international medical travel?
Josef: Well, as far as the misconceptions, there are three misconceptions that I’ve seen and that we’ve struggled with as the industry matures.One is that it’s somehow a gimmick, that you can’t get something for nothing, or for a 30%80% discount. There must be something. Either the customer care isn’t as good or you’re actually going to get your surgery in a mud hut. So that’s a fairly common misconception, which is born of typical American xenophobia shall we say. People just aren’t familiar with other cultures, and can’t believe that the healthcare would be on par in other countries.

Another common misconception is one we alluded to, which is what I call sort of the fun and sun misconception. When we first started our research the web was filled with all kinds of promotion from countries, from health travel brokers. “Get your cosmetic surgery and lie on the beach for ten days and then come on home.”

So the whole notion of medical tourism as being somehow having surgery and going on a vacation was much more popular. You don’t really see much talk about it now as the media grows up, and begins to address some of the more important aspects of international medical travel.

And the third misconception is outsourcing. And people feel that somehow medical travel is all about outsourcing. And what they need to know is most of the hospitals that were built to attract the international medical traveler in Thailand, in Singapore, the hospital that’s just being built in Dubaihuge complex of hospitals therethey don’t even have the medical traveler in mind. Most of the international medical travelers are from Europe, they’re from the Middle East, they’re from Africa, and Eastern Europe.

And so it’s really not about outsourcing. Doctors aren’t leaving this country to go practice elsewhere. And huge industries aren’t cropping up that match the traditional definition of outsourcing.
David: What are some of the mistakes that people make when they’re planning treatment overseas?
Josef: Well, that’s a good question. We sometimes refer to our book as the result of a thousand mistakes that patients have made. Fortunately, very few of those mistakes are life threatening.The main mistake a patient makes is being uninformed or being illinformed. And so to the extend that a patient is informed, they’re going to have a successful medical trip if they take the time to look into, for example, the accreditation of a particular hospital, success rates, and the number of surgeries performed, which questions to ask your physician, how to handle discomforts and complications after you get home.

Make sure that you inform your physician before you leave, and make sure you leave your destination after your precedence with all of your medical records. And we’ve got a dos and don’ts chapter that covers most of the common mistakes that people can make.
David: Now, you have a whole section of the book that talks about the most traveled health destinations. And with the various countries, you list some of the key clinics there with their information, about them, and prices that they charge, and so on and I’m wondering how were you able to compile that information?
Josef: Well, we put a team together, an editorial and a research team, and we spent almost two and a half years compiling and writing the book. Naively we started with around 50 countries. And then we began to wonder, how in the world do we assess these countries?And long story short we began to look at the accreditation within a giving country. We discovered JCI (Joint Commission International), which is an arm of JCAHO that accredits hospitals overseas. There’s now 117 hospitals accredited abroad through an American agency. Out of say, around 1, 000 hospitals that we looked at, we vetted those hospitals in terms of in country accreditation, in terms of the cultural transparency, and the kind of experience that especially an American traveler would accept.

And then when we pared the list down, we sent surveys out to those hospitals, and depending on their answers to those surveys, if they answered them at all, we then narrowed the list down to hospitals that you see featured in the book. All of them had to have an international patients’ center where there was English spoken, they all had to at least respond to the survey, and they all had to have reliable accreditation.
David: Now, do you have a favorite destination of all these countries? I’m sure it would depend on the particular treatment that you needed, but are there any ones that stand out that you particularly like?
Josef: In general treatments for dentistry and cosmetic surgery can be handled on the Western Hemisphere, either in Mexico, or Costa Rica, or Brazil. And we recommend for people who are looking for procedures involving cardiovascular, orthopedic it may be best to endure that 24 hour, 30 hour trip to Singapore, or Thailand, or India, or Malaysia for those more invasive surgeries.
David: Now I noticed in thumbing through the list of the different countries and the different centers that it seems like some governments have been much more proactive than others in trying to attract the international medical travelers. And in particular, I noticed the contrast between Brazil and Singapore. Could you talk a little bit about that?
Josef: A lot of the success of international medical travel does have to do to the extent the governments, the accreditation agencies, and frankly the tourism bureaus want to attract that international traveler. So in Singapore, for example, the government oversees all four of the main health care networks including two of the private networks, Parkway and Raffles. These are huge medical institutions that usually don’t answer to government. Singapore’s done a great job of corralling that and bringing a lot of standardization to international medical travel.Brazil, on the other hand, the government for a number of reasons eschews medical travel, especially for the main reason people go down there which is cosmetic surgery. There’s not a lot of cultural transparency. If you don’t speak Portuguese, chances are you’re going to be out of luck, unless you go to one of the very few hospitals that cater to the international traveler.

India, for example, is a huge proponent of medical travel. In Thailand they saw it as one of the solutions to the falling baht in the late ’90s, and they identified medical travel as a big revenue source and targeted the many expatriates in Thailand and in Bangkok to come to Bumrungrad. That’s how Bumrungrad got it’s start, was through marketing to the expatriate crowd. Then they discovered lots of Europeans and Middle Easterners coming over. After 2001 when folks in the Middle East weren’t welcomed in the United States, Bumrungrad was flooded with those folks. Now they’re marketing to a more Western audience including America.
David: Well, one of the things that really struck me in reading the book was the way that physicians overseas, even some of these surgeons, are quite accessible. It mentioned something that was a real shock to me, which was that they would typically want to communicate by cell phone with a patient even when the patient was first in the country and then after the surgery and to follow up on them. Can you talk a little bit about what somebody might expect in terms of how they work with an overseas physician compared to what they’re used to in the US?
Josef: Yeah, I have to tell you if I hadn’t seen this with my own eyes and actually hadn’t been a medical traveler myself, I just wouldn’t have believed it. My first experience was when I traveled to India. There was a couple from Wisconsin that I interviewed and followed for months after they returned home. They were consulting regularly with one of the top surgeons in Asia, a man named Vijay Bose in the Apollo Network in Chennai in India.I actually thought that this man was almost a charade for what he perceived as a reporter when I was there. I found out later that he spends probably 25 percent of his time talking to his patients directly on the telephone, preprocedure and postprocedure. These guys just live with their cell phones in their hands, with text messaging and voice. They have a very close tie with their patient. In addition, most of them are more than willing to talk with a US physician should there be any discomforts or concerns or, God forbid, complications upon a patient’s return.
David: Now one question I was going to ask that you made me think about was how does physicians in the US feel about their patients going overseas? It sounds like the overseas physicians are willing to follow up with the US physicians. Is the patient likely to get written off by their US doctor if they go overseas for treatment?
Josef: I feel bad for physicians. I feel like they’ve got a raw deal in the US. They now find themselves unable to compete in a way that they would probably like to. They find themselves rushed and forced into a lot of decisions outside of their control by their hospitals, by the insurance bureaucracy. It’s a tough place to be. So many physicians are either uninformed about health care overseas and just the quality of the health care and the quality of customer service, or they’re competitive and intimidated, or both.So a patient who queries his or her physician or specialist is not likely to get a lot of support, and that’s understandable.
David: Now, other than reading your book, are there some other resources that you recommend for patients who are considering international medical travel?
Josef: If I were a patient, I would certainly start with JCI and get familiar with some of the better hospitals. JCI has a listing of hospitals throughout the world that have received their seal of approval, their JCI accreditation. There are some good websites. They won’t give you alpha to omega information, but you can piece it together. There’s a site called medicaltourism.com. There’s Medical Nomad. It’s medicalnomad.com. Those folks have compiled information for the medical traveler. No doubt there’ll be more books after this one broke its ground, after “Patients Beyond Borders.”
David: Now, Joe, what’s going to be next for you after writing this book and getting highly involved in the whole international medical travel area? Is there a “Patients Beyond Borders II”? Are you moving on to something else? What do you think?
Josef: Well, certainly there’s a second edition. We had to get the book out, and we culled the information down to 22 destinations in 14 countries, which gives people a really good start for the common procedures. However, there are specialty hospitals. There are centers of excellence within the hospitals that we featured that we’re learning about.So in the second edition, which we expect to be at least 50 percent bigger than the first edition, we want to go deeper. People don’t need more hospitals. They need better information about these centers of excellence. So if they had a certain type of cancer, they know which two or three hospitals have the very best cancer centers. We want to dig deeper into research. And of course there are more hospitals emerging.
David: I’m been speaking today with Josef Woodman, author of “Patients Beyond Borders: Everybody’s Guide To Affordable, WorldClass Medical Tourism” published by Healthy Travel Media. Joe, thanks very much for speaking with me today.
Josef: Oh, thank you. It was good to be here.



Banking and Healthcare: Odd Bedfellows?

by Scott MacStravic

It is not often that there is a convergence between healthcare and financial services, but one appears to be already happening. It is based on an odd coincidence relative to the size and growth of two separate but closely related markets: 1) the market for “wellness” or “healthy living” services; and 2) the market for healthcare investment/spending accounts.

The size of the wellness/healthy living market has been estimated at $1 trillion by two different authors. One estimated that this level would be reached by 2020. [T. Haws “The New ‘Healthy Living’ Marketplace” www.hospitalconnect.com/hhnmag Jan 25, 2005] The other believes it will reach that size by 2010. [P. Pilzer “The Wellness Revolution: How to Make a Fortune in the Next TRILLION DOLLAR Industry”, New York, NY, John Wiley & Sons, 2002]

Precisely the same market size has been estimated for the health spending accounts (HSAs) that are part of consumer-directed health plans (CDHPs). [G. Ahlquist, et al. “The Next Trillion-Dollar Opportunity” Booz Allen & Hamilton eInsights June 2001] This market size is also predicted to be reached by 2010, based on an expected creation of 50 to 100 million new retail accounts reflecting the shift to defined contribution benefit plans and personal ownership of health spending accounts.

The financial services industry is already gearing up for its role in these converging markets. This convergence is based on the fact that the best way for consumers to protect and grow their trillion dollars of pre-tax HSAs that can only be spent on healthcare is to protect and improve their own health. The insurance segment of this market is already offering health insurance plans that are geared to healthy and health-focused consumers, those willing to commit to managing their own health and interested in coverage that depends on their acting accordingly.

This convergence is also supported by those employers that recognize the full value of employee health – not merely in reducing sickness care costs, but in reducing absenteeism and presenteeism, improving employee productivity and performance. These employers are contributing to employees’ motivation and ability to manage their health, and thereby their HSAs. And the insurance plans that employers choose are increasingly joining in promoting employee wellness in order to attract and retain employer clients.

Financial services firms will be enjoying the opportunity to hold and manage the trillion dollars that consumers put into these accounts. They will compete for consumers’ accounts by offering both traditional interest on the savings, and transaction management when they are spent for eligible healthcare services. Healthcare providers will find themselves being paid through such accounts, and the credit or debit cards associated therewith.

Those firms that hold and manage these accounts may even be willing to partner with healthcare providers that are already in or move into the proactive health management (PHM) market. Since PHM services are designed to reduce the incidence and prevalence of disease and injury causes for depletion of HSAs, it is in these firms’ as well as in consumers’ best interests that PHM services be widely adopted. We can imagine the possibility that the firms holding HSAs will even be willing to pay higher interest or offer other advantages to consumers who adhere to healthier lifestyles.

Those who predicted the $1 trillion size for HSAs predicted that the leadership for the convergence between financial and healthcare industries will come from banking and investment firms, not healthcare insurers or providers. But there is no reason for insurers and providers to wait for such leadership. A partnership approach, particularly in local healthcare markets, may prove to be the best way to promote the mutual benefit of health and financial service firms, as well as the benefit to employers, consumers, governments and society as a whole that healthier people would deliver.



Health Wonk Review

by Emily DeVoto

Check it out at The Sentinel Effect; it’s a compilation of the best blogging on health care policy from the past two weeks. Our own David Williams is included.



How Much Global Influence Does the US Have In Health Care?

by Scott MacStravic

Fred Fortin’s discussion of “Soft Power” suggests the potential for the US to lead by example in the healthcare arena, whereas it has lost influence to a significant degree in other areas, thanks to dropping behind on environmental issues and championing democracy.  Given the amount of money the US spends in healthcare, and its leadership in technology applied thereto, the potential might seem great.

The problem is that our “lead” in healthcare seems to be mainly in our proven ability to spend far more per capita than any other nation on earth, while getting far less return on our investment in terms of the health of our population.  The one area where we might offer leadership is in proactive health management (PHM), where we have a large industry devoted to reducing the incidence and prevalence of disease and injury, as well as managing existing chronic diseases in order to reduce their crises, complications, and worsening over time.

All other nations in the world share problems related to out-of-control increases in the incidence and prevalence of disease and injury, either infectious diseases in underdeveloped countries, or chronic diseases in developed.  The reason we have not created leadership in this arena is that we have not proven to be cost-effective in doing anything about the problem.

Our government keeps coming up with the same conclusions, and publishing them for all the world to read, that disease management, as practiced here, has not proven to work.  Moreover, the majority of PHM investments are still evaluated in terms of reducing the rate of increase in healthcare costs, where many other countries in the world, as well as many employers in this country, have long since added the far greater returns that are being achieved in improving workforce productivity and performance.   Besides, preventing chronic diseases will clearly save a lot more money than managing them.

The rest of the world is often leading the US.  Because insurers, employers and the government (plus taxpayers, of course) share the burden of paying for sickness care, most of the wellness, risk reduction and disease management efforts we have been involved in for the past few decades have been aimed at controlling sickness care costs.  They have usually been piecemeal, rather than strategic, and looking for short-term rather than lasting payoff.

In Europe, plus countries like Australia, South Africa, etc. that are equally well “developed”, governments often bear the burden of sickness care costs.  This does not mean that employers are unconcerned with employee health, however.  For one thing, many employers bear part of the burden, or offer private health insurance for workers when use such fringe benefits to recruit and retain the talent they need.  And for another, they have found that healthier/happier employers are significantly more valuable to their employers than are unhealthy/unhappy ones.

European firms, particularly those in the UK, have found that employee health and well-being efforts pay off in significantly reduced absence rates, as well as reduced productivity impairment when at work (“presenteeism”).  Dramatic reductions in turnover have been achieved, along with on-the-job injuries and sick leave costs.  And those that have looked have often found positive impacts on revenue as well.

Healthier/happier employees tend to deliver higher quality products and services, increasing customer satisfaction and loyalty.  Their enthusiastic recommendations of their firms’ products and services, along with the word-of-mouth “advertising” by more satisfied customers have been credited with significant increases in new business and added revenue.  While many other factors in the handling of employees contributes to these same results, any health improvement effort that does not is likely to miss a substantial amount of value already being delivered.

Until and unless the US qualifies to and actually takes a leadership role in the measurement and management of all the factors that affect employee productivity and performance, it will not be entitled to such a position in proactive health care, any more than it is in reactive sickness care.  While our country enjoys one of the highest productivity levels in the world, that is more due to technological innovations and working employees harder than most other countries.  When it achieves such pre-eminence via managing employee health and happiness better than anyone else, it may justify a leadership position in proactive health as well.



Is China Complying with New Pandemic Strategy?

by Fred Fortin

China continues to be in the international spotlight when it comes to being in compliance with the World Health Organization’s (WHO) new strategy on international reporting of infectious diseases.

Last week the WHO’s 60th World Health Assembly finished up with more than 2400 people from its 193 Member States, nongovernmental organizations and other observers attending. One notable accomplishment was the adoption of the revised International Health Regulations (see my earlier post). As I indicated, these regulations are designed to give the WHO broader authority in helping countries deal with the international spread of infection disease.

In another effort, on the final day of the Assembly, that seemingly reaffirms the IHR, those gathered passed a resolution — “Pandemic influenza preparedness: Sharing of influenza viruses and access to vaccines and other benefits”. The resolution, among other things, urged WHO members

“to continue to support, strengthen and improve the WHO Global Influenza Surveillance Network and its procedures through the timely sharing of viruses or specimens with WHO Collaborating Centres, as a foundation of public health, to ensure critical risk assessment and response, and to aim to ensure and promote transparent, fair and equitable sharing of benefits arising from the generation of information, diagnostics, medicines, vaccines and other technologies”

It requests the WHO Director-General to take a number of actions to ensure that the proper framework, procedures and financing are in place to accomplish these goals. This also includes establishing an international stockpile of pandemic vaccines and creating a working group to draw up new rules for the sharing of flu viruses by WHO collaborating centers and reference laboratories.

On the heals of the Assembly’s action came the announcement by China’s Health Ministry that a 19-year-old soldier hospitalized on May 14 had contracted the H5N1 bird flu. Henk Bekedam, the WHO’s representative in China, said the case was China’s 24th of 25 human infections that occurred without a reported outbreak among poultry.

“That is not a good record. I have to say that is still confirming that in China the animal surveillance system needs to be strengthened because this human case is a very clear reflection that the virus is still circulating,” Bekedam told reporters.

Repeated concerns over delays by Chinese health authorities in providing information on bird flu and other emerging diseases like severe acute respiratory syndrome, or SARS, continue to be expressed. The WHO was said to be pressing China’s Health Ministry for more information.



Prevalence of Traditional Chinese Medicine in China

by Fred Fortin

Any health care reform effort in China has to take into consideration the widespread prevalence of Traditional Chinese Medicine (TCM). At a recent China-U.S. health care conference, China’s Zha Dezhong, Deputy Director-General of the Department of Medical Administration, State Administration of Traditional Chinese Medicine, presented the following statistics. I thought you might find these numbers interesting. As usual the scale of any numbers coming from China is always a bit startling.

  • There are 3009 TCM hospitals accounting for over 16 percent of all hospitals in China.
  • There are 35,053 TCM outpatient departments and clinics, or nearly 17 percent of all outpatient departments and clinics in China.
  • 92 percent of urban community health centers and nearly 55 percent of community health service stations are able to provide TCM services.
  • 75 percent of the 40,907 town hospitals have TCM departments.
  • 50 percent of the 58,209 village clinics across China can provide TCM services.
  • Among the 864,168 rural doctors, 267,305 practice some combination of TCM and western medicine.
  • There are 19,533 practicing TCM “pharmaceuticalists” in China.
  • 234 million people were treated in TCM outpatient departments (No indication of time period).
  • Over 6 million people were discharged from TCM hospitals making up nearly 13 percent of all discharges in China (No indication of time period).


Obama on Healthcare

by Tony Chen

Today, Obama unveiled his stance on healthcare. Politically, this is significant because (1) it’s really the first time he’s provided a detailed glimpse into his policy mentality on anything; (2) healthcare has been Clinton’s pet issue up to this point; (3) healthcare has been deemed by some as the “theme of the Democratic primary.” While still fuzzy on total numbers, his strategy would mandate employers to provide (or fund) health insurance, create a new system for uninsured coverage, and establish a new “National Health Insurance Exchange” aimed at regulating insurers. It’ll be funded by eliminating tax cuts (capital gains and inheritance) for the wealthy. Under this plan, big pharma, managed care, big business, and the wealthy are the losers. By 2012, Obama promises a truly universal healthcare solution.

What’s missing in all the candidates’ policies are exactly the issues that we’ve been discussing here at World Health Care Blog. It’s not sexy (unless you are at a healthcare policy analyst party) to talk about investing in preventive health or managing the chronic diseases that will ravage our country for the next 50 years. It’s not appropriate or relevant to talk about personal responsibility and good lifestyle decisions in healthcare on the campaign trail. Is there a candidate out there who is willing to take on healthcare politics AND health politics?

By the way, here’s an excellent rundown of every candidate’s voting record regarding healthcare. And here’s AAFP’s summary of every candidate’s stance on healthcare.



American Hospitals and their Priorities

by Scott MacStravic

The American Hospital Association recently published a report on how the aging of the “baby boomer” generation will affect our healthcare system over the next 25 years. Not surprisingly, the news isn’t good. In general, it predicts dramatic growth in chronic diseases, with the prevalence of diabetes, for example, increasing from 30 to 46 million by 2030, that of arthritis from 46 to 67 million, an increasing “epidemic” of obesity, with 21 million obese in the boomer generation alone, costing Medicare one-third more than lighter patients.

Falls are predicted to rise, with one-third of adults 65+ falling each year, and 20-30% of those suffering moderate to severe injury as a result, including decreased mobility and independence, where boomers intend and expect to be even more active in their retirement than those now enjoying their post-working years. The net result will be the doubling of physician visits and hospital admissions, and the creation of severe shortages in physicians, nurses, and hospital beds.

The report notes that current healthcare expenditures for those with no chronic conditions average $850 per consumer; $2241 for those with one such condition, $4256 if two; $6178 if three; $8518 if four; and $12,699 if five or more. It predicts that 56% of all hospital inpatients will be 65+ by 2030 compared to 35% currently. This will be the result of the continued shift toward outpatient treatment among younger patients, and increasing illness among, as well as the percentage of the population 65+.

The shortage of registered nurses is expected to reach 1 million by 2030, with 130,000 more specialists, particularly those in chronic diseases and treatment of elderly, such as orthopedists to treat all the joint and other orthopedic injuries that will arise, plus 60,000 primary physicians. Hospitals are already responding and proactively anticipating the dramatic increase in need by building new and expanding existing facilities, joining with the educational system to train more nurses, and preparing for more obese patients, for example.

The AHA has long included a significant commitment to prevention and proactive health in its official mission. Its website includes a vision statement that calls for: “…a society of healthy communities where all individuals (emphasis mine) reach their highest potential for health.” This vision is echoed on the <a href=”http://www.ama-assn.org”>American Medical Association’s website</a>, whose members are “Physicians Dedicated to the Health of America”, to: “…improving the public health through promoting healthy lifestyles.”

After describing what the AHA apparently considers the inevitable increase of disease and injuries it will be forced to treat by 2030, it mentions, pretty much as an afterthought, that its members are sponsoring community fitness and nutrition programs, as well as classes and screening programs, along with end-of-life management efforts. But it does not mention the potential for proactive health management (PHM) efforts, including those sponsored by governments, insurers and employers, to substantially reduce the cataclysmic increase in chronic disease and injuries that it predicts, nor how much hospitals might do so as both employer and provider.

There are an increasing number of hospitals actively engaged in PHM efforts with their own employees. By improving their employees’ health, they can at least mitigate the severe shortage of most of the clinician categories of workers upon which they depend by making them more productive. By the same token, by engaging in PHM as a revenue-generating service for other employers in their markets, hospitals can mitigate the increasingly stingy payments they receive compared to the ever-increasing costs of sickness care services.

Physicians have been proving the value of PHM efforts in retainer medicine, such as the 150 or so MDVIP practices operating in 16 states. Their patients generally use less than half the amount of inpatient hospital and ER services as do patients in traditional practices. As these kind of practices grow, and primary physicians in traditional practices gain bonuses for managing their patients’ health, primary practice should become a more attractive career choice, and the explosive growth in demand that hospitals are counting on in their futures may not pan out.

Some hospitals are “hedging their bets”, or at least gaining an alternative source of revenue by offering PHM to employees already. Northwestern Medical Center in Chicago, for example, operates a Wellness Institute offering such services. Mayo Clinics Health Solutions offers a wide range of PHM services to over 70 employers, as well as an executive health program aimed at maintaining and improving the health of leaders.

Just recently, U.S. Preventive Medicine, Inc. in Texas, announced that in addition to its Centers for Preventive Medicine programs for consumers, it is offering a Prevention Plan that its hospital partners can offer to local employers. Both programs generate revenue not available through traditional sickness care nor community-benefit flu shot, screening and similar proactive health programs aimed mainly at those who are medically underprivileged.

It is logical and appropriate that hospitals seek to improve their images as essential providers of sickness care, that deserve adequate payment for their vital services, and the ability to expand their capacities to meet increasing demand. But it is equally logical that they look for more ways to be truly part of a “Health System” that is not focused 95% on sickness, but somewhere near halfway focused on promoting and protecting health.



Mirror, Mirror, Who has the Best Health Care System of All?

by Fred Fortin

Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care”, The Commonwealth Fund, May 2007, by K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea.

For those who have not seen news of this recent report, it is an important study to digest and think about. Briefly, its panel of distinguished authors find that while the U.S. health system is the most expensive in the world, their data and analysis show it to be consistently under performing relative to several other countries (Australia, Canada, Germany, New Zealand, the United Kingdom). The dimensions studied included quality, access, efficiency, equity and general health with the overall ranking of the six nations placing the U.S. dead last. The study is sobering and instructive.

The public yawns that have typically accompanied these kinds of studies in the past are gone. With the U.S. entering into a collective learning moment about health care due to the presidential campaign, reactions to the study have been an almost universal steady drum beat of criticism of U.S. health care (some samples here, here, here and here) with few exceptions. Yet, most health care policy wonks will not be surprised either by the ranking (not the first time) or by the primary issues (lack of universal health care being a big one).

Given the media attention the study has garnered, I hope we pay similar attention to the authors’ urgings to engage the international community.

“While many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, the U.S. could improve the delivery, coordination, and equity of the health care system by drawing from best practices both within the U.S. and around the world.”

There’s a pride in America, and in American health care as well, that make these tough words to hear. But we need to take a listen.

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