First Do No Harm @HHIOrg @ChildHealthUSA

October 2, 2015

CHW LogoThe theory of evolution by natural selection, the telephone, the fortissimo E flat major chord at the beginning of Beethoven’s Piano Concerto #5.  All of these are now seemingly mundane things that at first were the product of true genius.  To that list I would add the concept that health care does, but should not, cause harm.  When I was in school 30 years ago, that concept didn’t really exist, the idea that hospitals and physicians could do anything other than good – perhaps as a result of gross incompetence, but not as a byproduct of normal operations..  One of the people who understood and helped raise awareness that providers must acknowledge and control their inherent potential for harm has now been recognized for the genius of that insight.  Gary Cohen, founder of Healthcare Without Harm, was announced this week as a recipient of a 2015 MacArthur Foundation “genius” award.

Cohen began with a grass-roots campaign to eliminate mercury from use in healthcare over 20 years ago.  Given its ubiquity in thermometers, sphygmomanometers (blood pressure cuffs), and other devices, that might have seemed quixotic.  Yet mercury has now essentially disappeared from hospitals.  More broadly, Cohen and his colleagues saw this as just one example of the ways in which health care organizations were major contributors to environmental degradation, with the potential to undermine, directly (e.g., mercury, toxic cleaning chemicals) or indirectly (e.g., power plant emissions) the health and well-being of their patients, workers, and communities.   Healthcare Without Harm brought together all of those stakeholders to not only advocate but also to create solutions.

As noted in the MacArthur Foundation citation, Cohen “led a paradigm shift in the perceived responsibility of health care providers, from a narrow, patient-centered duty of service regarding individual health to a broader obligation to also ‘do no harm’ to surrounding communities, their residents, and the global environment.”  Like the patient safety movement inspired by Don Berwick among others, Healthcare Without Harm and the Healthier Hospitals Initiative (also co-founded by Gary Cohen) are helping hospitals and providers to see their positive responsibility to minimize the negative effects of their activities, and to make the necessary systemic changes to do so.  Hippocrates urged us not to harm the individuals under our care; Cohen urges us not to harm everyone else.  It’s nice to have that recognized as a stroke of genius.


September 25, 2015

CHW LogoIt is sadly not uncommon, in a market economy, for a seller to take advantage of those with a desperate need in order to maximize profits.  War profiteering is one familiar example.   US Marine General Smedley Butler, in his 1935 book “War Is A Racket,” decried military contractors who, in the heat of World War I, jacked up their profits to as much as 1700%.  This seems completely outrageous.  So what do we make of Turing Pharmaceuticals, a start-up run by a former hedge fund manager, which bought the rights to a 62-year old drug called pyramethamine (used to treat parasitic infections including malaria)?  Turing raised the wholesale price of the drug, which costs about a dollar a pill to manufacture, from $13.50 (already a 1350% profit margin) to $750 (75,000%).

A slew of such multiple-order-of-magnitude price hikes in medications has occurred in the past couple of years.  High prices for pharmaceuticals are often defended on the basis of the expense of research and development, and the fact that so many prospective new drugs fail.  But how can one argue that in the case of a drug that has been on the market for six decades, during which time the pretty tidy 13-fold markup must have paid off the R&D costs?  Which, by the way, were incurred by someone else.

Medication prices are an important driver of the high cost of health care in the US.   Prices for pharmaceuticals in the US are more than twice as high as in the next highest nation.  And remember, unlike clinic visits or hospital stays, where there may be important differences that obscure such comparisons, here we are comparing apples to apples (or aspirin to aspirin): it is by and large the same drugs available in Milwaukee as in Milan or Munich or Madrid.

Every other nation controls its costs in one of two ways.  In many countries, where the government is the largest purchaser of medications because of some form of nationalized healthcare, it simply leverages that bargaining power to negotiate better prices with the pharmaceutical companies.  Interestingly, the government is also the largest purchaser of drugs in the US, too: between Medicare, Medicaid, the military, and the veteran’s health system.  However, when the Medicare drug benefit was created in 2003, Congress explicitly prohibited the agency from negotiating prices.  Another approach is to set price limits on approved medications, as is done, for example, in Switzerland.  While this might reek of big government, the Swiss are hardly known as regulatory fanatics.  Moreover, this is tolerated despite the fact that two of the largest drug companies in the world are based in Switzerland, where the pharmaceutical industry accounts for 6% of GDP (compared with only 1% in the US).  These companies can still make a very handsome profit, and support their research and development, but at about half the cost to the public as in the US.

Indeed, if the real reason for high drug prices is to support R&D, it would appear the US is subsidizing new drugs for the rest of the world, which would be problematic enough.  But even Martin Shkreli, the CEO of Turing who engineered the Daraprim price hike, admits it’s really just about making his company as profitable as possible.  That sounds like profiteering of the kind Gen. Butler warned about.  As far back as the Civil War, the False Claims Act (still on the books) was passed to prevent such behavior, and contractor malfeasance in the Iraq War led to the War Profiteering Prevention Act of 2007.  When will we see a Pharma Profiteering Prevention Act?

Through A Glass Darkly

September 18, 2015

CHW LogoTransparent (\tran(t)s-ˈper-ənt). adj.

  1. allowing light to pass through so that objects behind can be distinctly seen
  2. free from pretense or deceit; easily understood

The buzzword in healthcare today is transparency, and especially price transparency.  The foundation of market-based reforms, including but not at all limited to the passage of the Affordable Care Act, is the concept of consumerism:  the notion that people with good information about quality and cost will make choices based on value.  There is a great deal of debate about every word in that sentence, but for the moment let’s focus on cost.

Cost, like beauty, is in the eye of the beholder.  To a consumer, the relevant question is “How much of my money will I have to give you to get your service?”  Ideally, this would be answered before the purchase.  How many of us go into a store, load up the cart, and then wait for the bill to arrive a month later?  In some settings, like a grocery store, pricing is easy.  Buying a car, on the other hand, may be more complicated.  There is the sticker price, but no one really pays that.  You negotiate a price with the dealer, and then you might also negotiate a price for a trade-in.  In all those cases you also need to account for taxes, and perhaps some fees.  But at the end, perhaps with pencil and paper and a calculator, you can figure out what the item will cost before you commit to buying it.

In healthcare, the complications are exponentially higher.  There is the sticker price (also known as the “charge master price”) which again, no one ever pays.  Then, depending on the insurance you have, there is an already-negotiated discount on that sticker price.  How much of that discounted price is coming out of your pocket in turn depends on the insurance terms: whether you need to pay a fixed amount per service (co-pay); whether you have to pay a percentage of the charge (coinsurance); and whether there is a minimum amount per year that you must pay before the insurance even kicks in (deductible).  But the biggest obstacle to transparency is the fact that it’s very difficult to know in advance what items are going to be in the cart.

Let’s take one of the simplest things I can think of: a sore throat.  How much does it cost to take care of a sore throat?  Well, you’ll need a provider to ask you some questions and examine you.  Then, it needs to be determined whether it is caused by a bacteria (which would be treated with antibiotics) or a virus (which needs only medication for symptoms).  Not everyone needs a test for the bacteria, since the likelihood of a strep throat correlates with the exam findings.  And then even for cases where there is a bacterial infection (strep), the choice of antibiotic might be affected by whether the patient has allergies.  So the answer to how much will it cost is – it depends.  Not very satisfying.  And that’s the easiest one!

As a provider, I could look at an expected resource use based on prior experience.  Of the last 100 people who came in with sore throat, 60 needed a strep test, 30 were diagnosed with strep, and of those 28 got penicillin and 2 something else.  I can then calculate an average price.  If that’s what I subsequently charge, some individuals (someone who doesn’t need a strep test or antibiotics) might pay more than they would under the old system, while those who need both a test and a prescription might pay less, but at least they would have a guaranteed price up front.

Some providers have started to do this with some other common conditions and procedures, such as joint replacements for adult patients.  But there are unfortunately few conditions that lend themselves to this kind of calculation, as there are simply too many “what ifs.”  This is particularly true in pediatrics, for several reasons.  First, there is more natural variation.  A sore throat in a 2 year old is different than in a 7 year old which is different than a 15 year old.  Second, the number of children with most conditions is fairly small, making it hard to do this sort of estimate.  Pediatric providers are also at a disadvantage because a general hospital might decide to offset that uncertainty by cross-subsidizing pediatric care from their much larger adult business.  Say for example that the average adult sore throat costs $70, but for kids it’s anywhere from $60 to $100. Charging $70 across the board for both adult and pediatric patients undercuts the provider that only cares for kids.  Pediatrics becomes a loss leader.

One of the reasons so much health care is paid for under an insurance system is because it is so difficult to know the costs up front.  But with high deductible plans and increasing cost sharing, patients are becoming consumers, and buying healthcare is more like buying a car.  I am skeptical, however, that despite all the talk about “transparency” that costs in health care will ever be distinctly seen, much less free from pretense or easily understood.   An unsuccessful quest for transparency may undermine the push toward consumerism.  Single payer, anyone?

Your Brain on $20,000 a year @ChildHealthUSA @AmerAcadPeds

September 11, 2015

CHW LogoAs part of the war on drugs, there were a series of public service announcements that showed an intact egg with the caption “This is your brain,” next to a fried egg captioned “This is your brain on drugs.”  I doubt it was any more effective than the ”Just Say No to Drugs” buttons people wore in the 80s (or the “Whip Inflation Now” buttons that people wore in the 70s, for that matter), though it did make for some great comedy fodder, like the breakfast platter captioned “This is your brain with a side order of bacon.”

In any case, there is growing evidence that poverty in early childhood is far more damaging to the brain than most things done to it later in life.  An article in the current issue of JAMA Pediatrics could be accompanied by a picture of a fried egg with the caption “This is your brain on less than $20,000 a year.”  Researchers examined data on a diverse group of almost 400 children enrolled in an NIH study of brain development.  These children had serial MRI images of the brain and standardized cognitive testing.  The study found that key regions of the brain were smaller – and cognitive scores lower – among children in families earning less than 150% of the federal poverty level ($36,375 per year for a family of 4).  These brain areas are known to undergo a long period of postnatal development in the early childhood years, and are linked to cognitive abilities that affect learning.  The gray matter volume in these brain regions was 3-4% less than normal among children in the <150% FPL group, with an even bigger gap (8-10% smaller volume) for children in homes earning less than 100% of the poverty level.  This is after accounting for differences in race and ethnicity, birthweight, and parent’s education level.

One strength of this study is that potential participants with high risk criteria known to affect brain development – e.g., risky pregnancy or newborn history, family psychiatric history, lead exposure, etc. – were screened out.  Many of these are more common among the poor, so they need to be accounted for in most studies of this type, but in this study there was more of an apples-to-apples comparison.   While this strengthens the conclusion that poverty causes arrested brain development, it likely underestimates the effect, since the stress of poverty might have an even more profound effect in the presence of some of these other risk factors.

The authors conclude that “households below 150% of the federal poverty level should be targeted for additional resources aimed at remediating early childhood environments.”  A key question then is what type of remediation?  There are other studies showing that both caregiver support style and stressful life events in early childhood – again, both associated with poverty – are associated with change in brain structure.  Classes or coaching to promote better parenting might be expected to help.  But the formidable stress of living in poverty can only be alleviated by, well, alleviating the poverty.

MKE Deserves Better Bicycling @BikeFed

August 31, 2015

CHW LogoLet me start by saying I love Milwaukee, and I will never root for the Minnesota Vikings.  But I visited Minneapolis for the first time this past week, and must admit I was smitten.  Admittedly, it was summer (technically – the weather was definitely Octoberish); I know the winters are even harsher than here along the shores of Lake Michigan.  What struck me most was that, despite a lot of similarities to the Cream City, Minneapolis had a much more vibrant feel, reflecting its reputation as a magnet for millenials.  The total urban population is similar, the number and type of Fortune 500 companies are similar, the number of major league sports teams,  the latitude, the northern European heritage, etc., etc., etc.  Why is Minneapolis so hip, and Milwaukee, well….?

At the considerable risk of over-reaching based on a 72 hour visit, I would pose that a significant factor is the infrastructure.  Specifically for transportation.  Minneapolis has light rail, a system of bike paths that resembles Madison on steroids, and robust bike and car sharing programs.  Not that Milwaukee isn’t trying.  But young professionals simply don’t want to be tied to cars (heck, even an old professional with any sense wouldn’t want to be tied to a car), and in Minneapolis they don’t have to be.

The bike trails were mind-blowing.  We could park our car when we arrived and not get in it again until it was time to leave town 3 days later.  Now, I do love Milwaukee’s Oak Leaf Trail, which basically circumnavigates the county.  But it’s hard to get anywhere in the middle.  It’s great for recreation (at least the segments that have been maintained – a good bit of work is still needed!), but limited for commuting.  The Hank Aaron State Trail is an increasingly well-used commuter route that essentially parallels I-94, but again, the reach is pretty limited.  In Minneapolis, there are trails for both fun and work.  One of the paths, clearly meant for commuting, we nicknamed “the superhighway”:  2 bike lanes in each direction, separated by a median, and a separate pedestrian path.  That is serious infrastructure!  And they clear snow in the winter; people commute by bike year round despite the 50+ days of below-zero temperatures.

Not surprisingly, Minneapolis is one of the top-ranked large cities for bicycle commuters (4th of the 70 largest cities, with 3.7% of commuters traveling by bike), while Milwaukee is sadly behind at 26th (1.1%) – just behind Anchorage!  It seems likely that this is one factor in Minneapolis’ slightly lower rate of obesity.  More striking is that in Minneapolis, 17.1% of residents are considered Pathphysically inactive (no exercise in the prior 30 days), compared with 24.4% of Milwaukeeans.  Interestingly, there is a strong inverse correlation between the percentage of bicycle commuters and bicycle fatalities.  I don’t know whether this is a direct cause (i.e., more cyclists increases familiarity among drivers and makes it safer for the cyclists), or indirect (better infrastructure makes cycling safer and more attractive), but I’ll take Minneapolis’ 40% lower rate of cycling deaths.

Oh, Milwaukee, we have better beer, better ball teams, better beaches.  It sure would be nice to have better bicycling.

The Fine Print @ChildHealthUSA @HHIorg @NonGMOproject

August 21, 2015

CHW Logo

Today’s supermarkets in many ways are something out of a 1960s science fiction story.  Bar code scanners and payment via cell phone (not to mention the cell phone itself) are just two things that would have seemed a bit far out back when I was watching the original Star Trek.  But that’s nothing compared with genetically modified organisms (GMOs), those agricultural products that arise when genes are transferred between species.  GMO corn and soy, for example, contain a gene from a bacterium that makes the plant resistant to herbicides.  The idea of taking a gene from a soil bacterium and transferring it into a corn plant seems so routine now, it’s hard to remember how mind-blowing it was not too long ago.

All of the available evidence (which is considerable but by no means exhaustive at this point) suggests that the products of this genetic engineering themselves pose no harm to human health.  That’s good news.  But it’s more complicated than that.  There remain important ethical and ecological issues.  And, as discussed in a recent editorial in the New England Journal of Medicine, there are potential indirect health issues that have not been previously considered.  For instance, the “Roundup-ready” GMO corn and soy (which make up the vast majority of those products in the US today) allow farmers to use large amounts of the herbicide glyphosate, which has now been shown to be a likely carcinogen.

At the very least, people should be able to choose whether they want to purchase a product that contains GMOs.  For myself, I choose not to because I don’t want to support the use of toxic herbicides, or the corporate agriculture system.  Others may doubt the evidence of the safety of the products themselves (which for the record I don’t), or may simply be squeamish about moving genes between species.  The idea that consumers should be allowed to choose – and need to be informed to be able to do so – is behind the move by several states to require labeling of products that contain GMOs.  64 other countries already do so, including the entire European Union and Brazil, a country with a substantial GMO-based agricultural sector.  The US Congress, however, recently passed a law proscribing a federal requirement for such labeling, and also prohibiting state or local governments from enacting any such requirement.  This prohibition has been pushed by Big Ag, using the argument that they shouldn’t be required to label products that are shown to be safe.

That’s beside the point.  We label the fiber content of clothing – no one is claiming cotton or silk are unsafe.  It’s just that I should know what a shirt is made of so I can decide which one I want.  If something is unsafe we shouldn’t be labeling it, we should be removing it from the shelves.  Labeling isn’t about safety, it’s about consumer choice.

During those 1960s Star Trek episodes, in the New York area, I frequently saw commercials for Syms, a men’s clothing store.  Sy Syms, touting his low prices, would say “An educated consumer is our best customer.”  That concept wasn’t too far out then, and it shouldn’t be today.  I wish Monsanto and its subsidiary, the House of Representatives, saw it that way.

Go Outside and Play

August 7, 2015

CHW LogoOne of the great joys of Wisconsin summer is that it is possible- indeed, desirable – to spend essentially all of one’s time outside.  Hence one of our goals for the past week, when my 9-year old twin nieces were visiting from Florida (where the same cannot be said of summer), was to spend as much time as we could in the outdoors.   Clean air, exercise, fresh food – perfect antidote to stress, right?  Well, it turns out, recent studies have begun to provide an explanation for how it works.

  • Researchers at Stanford found that walking in a quiet natural area produced an elevation in mood, and a decrease in blood flow to an area of the brain associated with brooding and depression, compared with walking in an urban area. Remaining unclear are how long the exposure needs to be (it was 90 minutes in this experiment), and which elements (quiet, greenness, odors, or a combination) are responsible for the effect.  It certainly boosts the case for a wellness trail on the medical campus.
  • Numerous studies have shown that moderate exercise leads to long term benefits in terms of stress reduction and improved mood. More recently, English researchers demonstrated that even a 30 minute walk at lunch time produces an immediate increase in energy level and decrease in stress.
  • Some of the most provocative work is in the area of psychoneuroimmunology, which studies the interplay between the microbiome and mental health. Among the intriguing findings are that numerous molecules produced by gut bacteria are psychoactive, and that changes in the intestinal flora are associated with a variety of psychological features including mood, stress, and cognition.

They may not have known why, but our mothers were spot on when they told us to get the heck outside and play.   On the other hand, right now we’re getting ready to go to State Fair.  I’m not sure what cream puffs and deep-fried stick-based foods do to the microbiome, but it can’t be good.  We may have to go for a very long walk in the woods to recover.


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