Plumpy'Nut

The NY Times ran an important op-ed yesterday by Susan Shepherd, a pediatrician and medical advisor to Doctors Without Borders. The core of her message is that as the farm bill progresses through Congress, we should focus not only on the quantity of food that is produced and that we export for relief to underdeveloped nations, but on its quality as well.

Dr. Shepherd describes the difficulties in treating children who are victims of severe malnutrition, particularly in areas like Africa and South Asia where milk and clean water can be scarce.

Families USA Health Action 2008: An Alternative Plan

Families USA is an impressive organization that has built a formidable platform over the year through its base, consumers. But to achieve the reforms it advocates for, it must leverage that platform with the one group that has enough strength and motive to bring meaningful reforms to fruition: large employers.

A wonderful meeting (Full disclosure: They brought me in to blog my impressions.), The Families USA conference that ended Saturday brought together some impressive Congressional politicians - Nancy Pelosi, Tom Daschle, Ken Salazar, Blanche Lincoln - and true health care experts - Don Berwick, Tony Fauci - with "consumer advocates" from around the country.

I thoroughly enjoyed the people at the conference. They were, for the most part, knowledgeable about health care and committed to driving a better system. (My favorites were a group of California Gray Panthers, all of whom were VERY up on the issues). There were also bright young people relatively early in their careers, and representatives from community health advocacy organizations around the country, all fervently dedicated to a better, more equitable health system.

My concern was that I believe this group under-appreciates the influence of health care lobbies over Congress and the policy process. They WANT things to change for the better, and they advocate for approaches they KNOW are more logical and reasonable than the way health care is currently done. So why WOULDN'T we do it that way?

The answer, of course, is because it would damage Congress' largest contributors. Almost every politician I heard speak patronized this crowd, making a point to tell them that their input was vital. Would that it were so. If it were, Congress wouldn't take the money it does from health care interests throughout the continuum, and shape policy for their benefit rather than ours. And, please note, the lobbying rules didn't change substantially when the Democrats retook control.

Families USA's leader is a warm, brilliant, articulate guy (and great dancer!) named Ron Pollack, who has guided this organization for years and made it into the health care consumer advocacy powerhouse it is today. He has a clear, unifying, noble vision for how American health care ought to be delivered and financed, evidenced by the caliber of speakers who agreed to talk at this conference.

Unfortunately I don't believe we can get there by relying on consumer advocates. Ardent and well-intentioned as they may be, they lack a power base, and simply cannot compete with large corporations for the attentions of Congress. I hope I'm wrong about this, but this is why I doubt that meaningful reform will take place after the elections. Even if we get a President who is disposed to real change, getting there will require that Congress go along, and they're beholden to the health care industry.

Families USA has built a formidable platform. There's no reason why, quietly, discretely, this group couldn't reach out to certain non-health care business leaders and groups, explain how their interests align with those of non-HC business - we all seek a more stable and sustainable health system that allows the nation to be healthier and more economically competitive - and facilitate a new coalition that could overwhelm the power wielded by the health care sector. After all, they're 1/7th of the economy. Non-Health Care business is 6/7ths.

They're just looking for someone with a compelling reason and a plan to come together, and help us all resolve this issue so we can get on with other equally pressing matters that face the nation.

Families USA Health Action 2008: Tony Fauci on Global Health

I first met, heard and came to admire Tony Fauci several months ago at the Aspen Health Forum. Dr. Fauci heads the National Institute of Health's National Institute of Allergy and Infectious Diseases. In addition to his spectacular medical contributions, he is, equally importantly, a passionate and wonderfully articulate explainer of the importance of infectious disease and global health to common people. Unfortunately, I was called unexpectedly out of the meeting for a call, but here are my notes on his comments. They provide a clear view of the value of his work.
Plagues and epidemics have shaped societies since the beginning of civilization. Gradually, though, and with progress in hygiene and the management of disease, the dangers from infectious diseases to ordinary people have been significantly lessened, though the idea that we're home free is seductive and illusory. In 1967, Surgeon General William Stewart testified a little prematurely that "the war on infectious disease has been won."

Still, 26 percent of deaths worldwide today result from infectious disease. This occurs in two major patterns. The Matrix of Infectious Disease represent a relatively stable number of deaths that occur each year. Emerging and Re-Emerging diseases - AIDS, SARS, and others - are much more variable and represent significant potential for unprecedented devastation.

The war between microbes and humans is ferocious, and depends on our mutual strengths. Microbes that cause infectious disease have extraordinary capabilities to mutate and replicate to persist, emerge and re-emerge. Humans can plan and implement strategies and tactics.

Over time, it has become clear that global health exerts enormous influence on nations' economic development and stability. As a result, interest in global health has galvanized within major organizations like the UN, the G-8, the US Government, major philanthropies (like the Gates and Clinton Foundations), NGOs and so on. The topic has achieved visibility in the mainstream media, giving it credibility and a spot in the popular consciousness.

AIDS is currently the most frightening and pervasive infectious disease, with 90 percent of cases in low- and middle-income developing countries, and 2/3 of the cases in Africa. The US has spent more than $210 million on global attention to this disease over the last several years, mostly stemming from The President's Emergency Plan For AIDS Relief, or PEPFAR.

Most governments act in their own interests, but as our understanding of what constitutes and impacts those interests matures, so does our appreciation of how we must respond. The US has undertaken a major, strategic role in global health precisely because it appreciates the role that disease plays in the stability of international relations and regional development.

Dr. Fauci's contributions and perspective are refreshing because they clarify the role that health activism plays in economic prosperity and peace. Here in the US, we are so often turned inward, and focused on issues within our own system. By leveraging our science, wealth, and the tremendous variety of other resources we have accumulated here in our nation, Dr. Fauci and his colleagues are engaged not only in a vast humanitarian enterprise that seeks to reduce misery throughout the developing world, but he is one of our most effective international diplomats, conveying that we want to share what we've learned in helping improve the world's health, financial stability and political stability.

Families USA: Don Berwick on Everything

Through patience, an ability to articulate need and solutions, and diplomacy, Dr. Berwick has facilitated tremendous quality advances in hospitals across the country. And that lends him enormous authority to urge the process on. At the Families USA meeting, he described his vision.

One of the pleasures of the Families USA Health Action conference was that the speakers represented a nice blend of top politicians and genuine health care experts. Tony Fauci MD, the wonderful head of NIH's National Institutes for Allergies and Infectious Diseases, who talked about Global Health, was followed by the equally impressive Don Berwick MD, the Founder and leader of the Institute for Healthcare Improvement. I've heard Dr. Berwick speak several times and am always delighted by his cogent, comfortable, sensible presentations.
I can think of several people who, if they gave one, deserve a health care Nobel Prize for the positive impact they've had on millions of people through their work to change the industry. Dr. Berwick is one. (Others include Jack Wennberg MD, the founder of the Dartmouth Atlas, and David Eddy MD, who leads theArchimedes Project and who coined the term "Evidence-Based Medicine.")

As fate had it, I was delayed coming into Dr. Don Berwick's talk, and arrived just when he had covered the quality improvement goals of health care - that it should be safe, effective, patient-center, timely, efficient and equitable - that were defined by the 2001 Institute of Medicine report, Crossing The Quality Chasm.

Dr. Berwick's talk was peppered with interesting, mildly provocative observations.

    - More than any other physical test, skin color (that is, race) is the best predictor of health status.Sad but true.

    - Our health system's performance is limited by human frailty. To improve, we need to identify those frailties and build dikes around them. That is, fortify processes that are vulnerable to human error.

    - American health care STEALS from other important societal functions that desperately need the money it consumes. Other industrialized nations - he pointed to Sweden as possibly having the best health system currently - provide care to all their citizens for 60% or less than what it costs us. Maybe we should be spending 9% of Gross Domestic Product, but 16+ percent is outrageous, based on the fact that most developed countries do a better job for far less. Whatever we spend on the greedy health care industry, we're unable to spend on other things that also matter tremendously: education, infrastructure, the environment.

    - We drive low value in American health care. As the Dartmouth folks have demonstrated repeatedly, demand is driven by supply. As a rule, we don't make clinical choices based on data-backed determinations of value. (I believe that will change as Health 2.0 ramps up.)

But the most important message of Dr Berwick's presentation was his explanation of what he calls the Triple Aim. This ideal here is to transition our health system to a state of "simultaneous, integrated work to improve the patient’s experience with care over time and the health of a defined population while containing cost per capita of health care."

In other words, manage the health of populations while improving the experience of individual patients. At the same time, reducing the cost of care for each patient.

I wholeheartedly agree that these are the goals of a truly effective and efficient system. They're also wholly elusive given the current structure and political realities of American health care. Dr. Berwick is  aware of this. In an earlier presentation on the same topic - see here for a copy - he lays out a list of system characteristics that are necessary to achieve these goals. All are tall orders that America's health care industrial complex would fight. They include

    • Population budgets
    • Discipline of a cap on total budget
    • Population view of health status and care needs
    • Measurement capacity
    • Capacity to integrate care experience through time and space
    • Capacity for proactivity
    • “Memory”of the person
    • Capacity for system redesign and execution
    • Leverage to mold the environment.
Still, its very worthwhile to have this kind of vision, this level of specificity, and the drive to continually frame our current progress against them. Through patience, an ability to articulate need and solutions, and diplomacy, Dr. Berwick has facilitated tremendous quality advances in hospitals across the country. And that lends him enormous authority to urge the process on.

Families USA Health Action 2008: Tom Daschle on Reform

Former Senator and Majority/Minority Leader Daschle gave the opening address on the 2nd day of the Families USA Health Action conference. Mr. Daschle has a new book coming out in March on America's health system and our past efforts to fix it.


I was honestly impressed with Mr. Daschle's grasp of the sweep of health care problems and how they play out. Mostly importantly, he was clearly aware of the deep challenges associated with getting meaningful change, given the industry's control of Congress and the policy-making process.

"One of the biggest tactical mistakes we've made, the opponents of health reform have defined the debate. As a result, we've lived under a number of myths. Perhaps the biggest myth of all is that the US has the best health system in the world. So before the debate can begin, we need to all understand the same basic facts. We need to understand how we got here and where we need to go."

"Incremental change in our system is no longer a viable option. Instead we need comprehensive reform. In growing numbers the American people are demanding that we do something. Our goal should be to build what current and retired members of Congress have today, and make that available for all Americans."

Here are some elements of his platform.

- Establish an autonomous oversight body for health care comparable to the Federal Reserve for our monetary sector. We need to give this group the ability to control costs, starting with chronic disease, which represents the largest block of costs to the system.

- Investments in information technology would result in quantum leaps in efficiencies and quality improvements.

- Pooling would aggregate the risks/costs for small business and individuals.
- Negotiate drug pricing. Build on and leverage the purchasing volumes that government already  is responsible for.

- Prevention. Wellness, easy access and early intervention clearly saves enormous dollars.

- Comparative Effectiveness. As the Congressional Budget Office and Institute of Medicine have recently pointed out, an autonomous national institute that could use large data sets to identify the approaches that work best would clarify and unify clinical practice throughout America, and would have significant impact on both quality and cost.
- Transparency. We cannot fix our problems until we can see them more clearly.

- Medical Malpractice. Make it easier for physicians to make the best decisions, and protect them from frivolous legal actions.

- Patient-provider interactions. Take advantage of technology to smooth the flow of communications between patients and the health system.

- Universal Coverage. Increase access through health vouchers and coverage.

This is a much more thorough list than Ms. Pelosi offered, and Mr. Daschle seemed more aware of, sensitive to and committed to the political challenges represented by the relationship between Congress and health care special interests. While none of his recommendations are novel or particularly surprising, there is no question that Mr. Daschle's experience, access to governmental and business power, and clarity about what needs to be done represent important potential in the ongoing effort to actually get real change accomplished

Families USA Health Action 2008: Nancy Pelosi's Opening Address

The featured highlight address at the opening session of the Families USA conference is by Nancy Pelosi, Congress' first woman Speaker. In person, Speaker Pelosi clearly comes across as a brilliant and warm woman, a friend of Families USA, and she was introduced as a champion of social justice and equality in the 110th (2007) Congress, passing the first minimum wage increase in a decade and making college more affordable for working families. While I'm not certain this is true, I heard comments beforehand that this speech was slated as a major health care policy statement by the Speaker.

Four Big Trends

Four relatively little-noticed trends will have profound, positive impacts on health care. Health 2.0 is using the Web to bring patients much better knowledge and data about all aspects of health care. The lawsuit by the advocacy group Consumer Checkbook to get HHS to make Medicare physician data public has the potential to make physician performance profiling easy. Come October, 2008, Medicare and most commercial health plans will stop paying hospitals for avoidable errors like "never-events." And though its slow, we're making steady progress toward the establishment of a national health care "comparative effectiveness" agency.

Leveraging The Doctor As A Trusted Authority

I was on the phone with my good friend Bill Bestermann MD yesterday.  Dr. B, a preventive cardiologist who is passionate about the underlying mechanics of cardiovascular disease and the horrific toll the American diet and lack of exercise is taking on everyday people, lives in spectacularly beautiful, rural Kingsport TN. He told me he was driving through town, channel surfing on his radio, and he happened upon the station that broadcasts information for the local schools. They were announcing the menu in the school cafeterias. He said it was appalling. "Honeybuns and processed foods. It was all the stuff I tell my patients to avoid."

On Practical Reforms

Now that health care reform is once again an active, visible issue in state governments and the presidential campaigns, the ideas are flying fast and furious. Predictably, some ideas are better than others.