I'm still in Laos - with a plane-worth of reading to do to catch up. Regular posts will begin next week, although I'll try to send something from the 8000 mile ride back.
Of note, the April Harvard Business Review includes an infographic I wrote (with much editorial assistance from Gardiner Morse of HBR) on the causes of health care cost increases, and a few potential answers. Here is a URL for a "teaser." Subscribers can view the entire article on line, and Harvard-affiliated readers can access this through the Harvard Library - but the April issue won't be available until next month. Many of the topics here will be familiar to readers of this blog.
For nonsubscribers, the issue has an interview with Atul Gawande (recent author of The Checklist Manifesto, noted in the column on the right), and articles on improving the delivery of care by Richard Boehmer of HBS and Tom Lee of Partners and Harvard Medical School. I'm looking forward to seeing my copy!
Selected URLs
6:01 PM
indigo
I'm traveling - so not doing full postings.
A few articles of note
The Boston Globe reports that Harvard Pilgrim has identified which providers are paid the most for different services. This is not risk adjusted - but the differences are far larger than you'd expect to be eliminated by risk adjustment.
The New York Times reports that more physicians are dropping out of Medicaid because of fee cuts. The article also points out how difficult it is to care for Medicaid patients when many cash-strapped states eliminate vital benefits? How do you treat a Medicaid beneficiary with an infected tooth when dental is no longer covered? Not well, obviously.
The LA Times reports that the number of uninsured in California continues to rise rapidly - now approaching a quarter. The issue of how to pay for health care for the uninsured grows larger by the day.
A few articles of note
The Boston Globe reports that Harvard Pilgrim has identified which providers are paid the most for different services. This is not risk adjusted - but the differences are far larger than you'd expect to be eliminated by risk adjustment.
The New York Times reports that more physicians are dropping out of Medicaid because of fee cuts. The article also points out how difficult it is to care for Medicaid patients when many cash-strapped states eliminate vital benefits? How do you treat a Medicaid beneficiary with an infected tooth when dental is no longer covered? Not well, obviously.
The LA Times reports that the number of uninsured in California continues to rise rapidly - now approaching a quarter. The issue of how to pay for health care for the uninsured grows larger by the day.
Childhood Obesity Month
8:59 PM
indigo
I'm long overdue for a posting - and I've been thinking a lot about childhood obesity lately.
I'm not the only one - Michelle Obama is evangelizing to take action to increase activity and decrease kids' caloric intake. There are efforts to impose sweetened beverage taxes in New York and elsewhere. And this month's Health Affairs has a whopping 80 pages in the March issue on this topic. (Health Affairs just changed to a larger format. The new version looks absolutely beautiful, and allows printing useful color graphics like the one at the top of this posting.
I'd like to mention two efforts, both from the Boston area, to address childhood obesity. Health Affairs published a study of a multidisciplinary team approach to childhood obesity at Boston Medical Center. The team included a pediatrician, a nutritionist, and a case manager - and was based at community health centers. It incorporated health care IT, and children and their parent(s) attended sessions every 1-2 months for six sessions and early results suggested that of the 174 children who had at least two visits, 80% made at least one improvement in lifestyle (less screen time, better nutrition, more exercise) and 50% had a lower BMI. This is preliminary - and it's exciting, because so little about treating childhood obesity seems to work.
The other effort is not based on the medical model, but is rather based on a public health model. Shape Up Somerville,
Here are two paragraphs from the Boston Globe describing the program:
Pedestrians in this city of 77,500 stride onto bright, recently striped crosswalks. Bicyclists, who until this year navigated traffic aided by a single bike lane, enjoy 2 additional miles of designated lanes, and almost 4 more are planned. In school cafeterias, fresh produce has replaced canned fruits and vegetables, and the high school retired its fryolator. The Neighborhood Restaurant now serves wheat oatmeal waffles with bananas in addition to bacon and eggs. Budding salsa dancers step-two-three in a new Recreation Department class that costs just $10 for two months of twice-a-week lessons.
These scenes might seem to be mere background noise to the bustle of a diverse city of artists and immigrants, laborers and lawyers. Yet changing the background noise has placed Somerville in the vanguard of communities putting environmental and policy changes - rather than exhortations to modify individual behavior - at the center of their fight against obesity.
Essentially, the idea is to make it easier for people to live healthier lifestyles - not merely to pester them to improve their individual behavior. Shape Up Somerville has one excellent statistic - the Tufts University researchers who helped set up the program say that kids have gained 15% less weight (one pound) compared to a control group. That's a big deal with huge potential implications.
The real social question is which of these approaches is sustainable. We will need the medical model for a select few children - but we need to set up more public health approaches. And yes, let's tax sweetened beverages too!
I'll be taking a break from Managing Health Care Costs for the next two weeks - I'm now in Los Angeles on my way to Hanoi to cycle to Luang Prabang Laos. If you're interested in reading about this adventure, I'll post at 2wheels2laos.blogspot.com (assuming I find internet cafes!).
The cost of doing nothing, part two
3:03 AM
indigo
The Boston Globe had a two-part series on the cost of health insurance for local governments in Massachusetts that began on Sunday.
Health care costs went from 8% of local city and town budgets in 1999 to 14% over 2009. This creates a real crisis of crowd-out – that 6% of the budget now used to pay for health care is no longer available for the other things cities and towns do – largely schools, police, fire departments, and roads. Cities and towns provide a great illustration of the threat posed by massive health care cost increases.
The Globe articles focus on the role that unions and local town politics have played in the burgeoning health care costs. Some municipalities don’t force eligible retirees over 65 to use Medicare as primary insurance ($5m bill for Boston alone), many offer “Cadillac plans” that have very low copayments, and some even still offer indemnity health insurance plans. Few have joined the state’s purchasing agency, the Group Insurance Commissioner (GIC). State law makes it easy for a single union to stymie a town’s transition to the GIC, and even requires a municipal vote to require transition to Medicare. Many towns offer lifetime health coverage to those who have held office or been on commissions for as little as 10 years. Government retirees and employees vote, and therefore these requirements are difficult to meet even if the alternative is to close the library, lay off teachers, and stop repairing the potholes.
The Globe has editorialized about the need to reform state laws that make it difficult for cities and towns to address these cost increases through cost-shifting to current and former employees.
This series is another good example of how our current system with its rapidly increasing costs is unsustainable. Suggested changes in state law are prudent – but a real solution to this crisis will require meaningful health care reform that will lead to lower rates of health care cost increase.
