Here’s a Challenge for you: How can we Raise Health?

shutterstock_180808967We’ve seen the power of collective creativity and goodwill for a good cause recently, so we’re asking our health and medicine community to dig deep once more, this time for a thought experiment: Can we rebuild some of health and medicine’s most complex and critical issues – our Great Challenges – by creatively rethinking their foundations? What do we truly understand about these factors that limit health —and their possible solutions— today?

As we move into the third year of our Great Challenges program, Delegates on site at TEDMED 2014 in Washington, DC and San Francisco will be tackling these issues and more in a special area devoted to exploring the six Challenges we’ve focused on this year. Together, we’re aiming to shake up the status quo, rethink assumptions, and raise health to new heights to meet our evolving needs.

Your input will also help guide direction for the Great Challenges program in the coming year, so be sure to stop by.

Below, find 18 critical questions as determined by our community.  Answer them, validate them, reframe them. We need your input, so please respond here, via Twitter #GreatChallenges, on Facebook and Google+, or on our tumblr.

Impact of Poverty on Health

What’s the best way to invest in poverty reduction to improve health?

Are other people’s health problems everyone’s business?

How should doctors “treat” socioeconomic factors that impact health?

Reducing Childhood Obesity

How can we change our 24/7 food-everywhere culture?

Obesity risk begins in the womb. How can we deliver this message?

How much of obesity is about personal responsibility?

Achieving Medical Innovation

When should patients get to enter higher-risk clinical trials?

How can we align public and private interests to drive innovation?

How can patients be partners in medical innovation?

Making Prevention Popular

Where could health policy go farther to nudge preventive behavior?

Why do we so often do what we know isn’t good for us?

Is prevention about individuals, populations, or both? Why?

Role of the Patient

How do we empower patients to make healthier decisions?

What is the patient’s role from his or her perspective?

What is the role of healthy people  (non-patients) in healthcare?

Addressing Healthcare Costs

How do we create smart “healthcare consumers”?

What kind of system adapts to the changing needs of healthier patients?

How can we align stakeholders to reduce healthcare costs?

Special thanks to the Robert Wood Johnson Foundation for their support of this program.

New York City and Philadelphia: A Tale of Two Obesity Declines

By Risa Lavizzo-Mourey and Nancy Brown

“Severe Childhood Obesity Shows a Decline in New York City.” You might have seen the headlines earlier this month.

It wasn’t long ago that we never saw stories like that.

For decades, it was nothing but bad news – one story after another about a rapidly growing epidemic. Just two years ago, the Robert Wood Johnson Foundation and Trust for America’s Health predicted that, if trends continued the way they seemed to be going, more than 60% of adults in 13 states would be obese by the year 2030 – and have the extremely high medical bills to prove it.

But now, we’re finally starting to see signs of progress against an epidemic that was once feared to be unstoppable. Overall childhood obesity rates have stabilized. For the first time in a decade, data show a downward trend in obesity rates among young children from low-income families in many states. And, we’re seeing reports from cities and states that their overall rates of childhood obesity are decreasing: from California to West Virginia; from Anchorage, Alaska to New York City.

New York is a great example of a place taking a comprehensive, community-wide approach to reducing childhood obesity. The city has required group child-care centers to improve nutrition and nutrition education, increase physical activity, and limit screen time. “Health Bucks” enable lower-income families to maximize their purchasing power for fresh fruits and vegetables at local farmers’ markets. The city’s Department of Design and Construction provides architects and urban designers with guidelines for designing buildings, streets and urban spaces that support physical activity. Chain restaurants are required to post calorie information on menus, enabling customers to make more informed decisions. The education and health departments have collaborated on the “Move-to-Improve” program, which helps teachers incorporate physical activity through the school day.

We’re thrilled that these approaches appear to be paying off, but here’s the thing about that recent study on the most severe obesity cases: White children saw a more significant decrease than Latino or African-American kids.

This was true for overall obesity rates as well: Childhood obesity rates among White K-8 students in New York dropped from 17.6% in 2006 to 15.4% in 2010 – an impressive 2.2 percentage point decline. But the drop among Hispanic and African-American students was far less, just 0.9 and 0.4 percentage points, respectively. The disparity among upper- and lower-income students was even greater, a 1.4 percentage point decline compared to 0.7 percentage points.

This means that despite the overall progress, the disparities gap may actually be widening in New York.

In this respect, New York City truly illustrates where we are in this epidemic. Progress is possible, and happening, but this progress runs the risk of leaving some of our young people behind, and too many of those at greatest risk.

There is one notable exception to this rule—Philadelphia.  In Philadelphia, they’ve managed to reduce childhood obesity prevalence while also reducing obesity-related disparities.

 

Like New York, Philadelphia has addressed the obesity problem from many angles. The city, along with groups like the Food Trust, pioneered new financing strategies to bring full-service grocery stores back to underserved neighborhoods. The city improved food and physical activity in schools, and was one of the first jurisdictions in the country to remove all sodas and other sugar-sweetened drinks from public school vending machines.  In schools with American Heart Association Teaching Gardens, children grow their own healthy produce, and learn about the value of good eating habits. Complete streets policies make it easy and appealing for people to walk and bike throughout the city. More farmers’ markets are opening all the time across the city, and they use smart incentives to help lower-income residents afford fresh produce. Corner stores are offering healthy products and using in-store placement and marketing techniques that are boosting sales.

And guess what? Childhood obesity there fell 4.7 percent – and the biggest declines were reported for African American boys and Hispanic girls: 7.6 percent and 7.4 percent, respectively.

The challenge for all of us is this: How do we make the Philadelphia story everyone’s story, in every community?  How do we give every child in America an equal opportunity to grow up at a healthy weight?

On July 22, we’ll be addressing those questions and more at a TEDMED Google Hangout. Here’s who will be speaking:

  • Risa Lavizzo-Mourey, President and CEO of the Robert Wood Johnson Foundation
  • Nancy Brown, CEO of the American Heart Association
  • Don Schwarz, former Health Commissioner and Deputy Mayor for Health and Opportunity, City of Philadelphia
  • Elissa Epel, Associate Professor, UCSF School of Medicine
  • Lisa Simpson, President and CEO, Academy Health

Our conversation will be moderated by Richard Besser, Chief Health and Medical Editor for ABC News.

Do you have a question or comment for the speakers? A story about what’s happening in your community to promote healthy eating, or physical activity? An idea for helping kids achieve and maintain a healthy weight? We’d love to hear from you! Just comment on this post, or tweet using the hashtag #GreatChallenges.

We’re really looking forward to a lively, candid chat, and we hope you’ll tune in and contribute to the conversation!

 

Live online event: A candid conversation about childhood obesity

On Tuesday, July 22nd at 2pm ET, TEDMED will host a special live online discussion with our nation’s forward-thinking health leaders to take measure of the progress and challenges in our ongoing struggle with childhood obesity. Guests include representatives from Robert Wood Johnson Foundation, the American Heart Association, Academy Health, the University of California, San Francisco and the City of Philadelphia. Dr. Richard Besser of ABC News will moderate.

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The national childhood obesity rate has leveled off. Cities and states that have been taking on this issue comprehensively are starting to see their childhood obesity rates drop. A CDC study published in February showed that national rates may be declining among our nation’s youngest children.

This is good news, but challenges remain. Rates are still far too high overall, and racial, ethnic, and socioeconomic disparities persist.

What needs to happen to show bigger results, faster? How do we make sure all children can grow up at a healthy weight? What are some of the underlying environmental and societal causes that must be addressed? What could corporate, community and policy leaders do to further address this critical public health issue?

Click here to RSVP for the Hangout and view more information on this important conversation. We’ll be taking audience questions via #greatchallenges and will answer as many as possible on air.

Community hospital starts its own patient-centered innovation center

Nick Dawson, who moderated last week’s Great Challenges Googe+ Hangout on medical innovation, is also the new Executive Director of Innovation at Johns-Hopkins Sibley Memorial hospital. He’s helped to run a new onsite Innovation Hub, a cross-disciplinary design studio set to launch this fall at Sibley. We talked to him about the Hub and its goals.

TEDMED: What are the Hub’s goals?

Dawson: The Hub will primarily foster a culture of patience and human centered innovation for everybody in the organization to take part in problem solving, improving processes and thinking about how we do our day-to-day work. The Hub will also engage in cutting and leading edge innovation and design work in health care to improve everything from patient experience to clinical process flow. We maybe even invent new products and services.  We’ll be changing culture plus doing classic innovation and design work.

Sibley's Innovation Hub features new perspectives: Pictured: Nick Dawson and Joe Sigrid

Sibley’s Innovation Hub features new perspectives: Pictured: Nick Dawson and Joe Sigrin


TEDMED: Why now?

Dawson: There are some pragmatic realities. Healthcare costs have risen. Clinical quality, despite really well intentioned and impactful work, can be improved.  We may not have enough providers the future,  Above all, it’s become part of our collective discussion to question if we are delivering truly human centered healthcare and meeting the needs of our population, making them healthier and keeping them from being admitted to the hospital and from having serious chronic conditions. We’re having that conversation as country, and we ought to have that conversation within health systems.

TEDMED: Do recent statistics about poor outcomes in the U.S. fuel the fire, despite all the money we spend on healthcare?

Dawson: They are disappointing, and I’m certainly one to help beat that drum and say we need to be doing a better job. At the same time, [numbers] can be misleading because we really do some things incredibly well.  We pioneer techniques and procedures and we’re innovative as a medical community. For example, laproscopic procedures were developed in part right here at Sibley Hospital. A lot of new drug therapies come out of American pharmaceuticals.  So, while we do need to be having a serious discussion about outcomes, we should be proud taht we do have a high performing healthcare system.

TEDMED: You’ll have an embedded innovation team. Who’s on it?

The idea of “team” is loosely defined for us. Dr. Chip Davis, the CEO here at SIbley, and his team deserve the credit for championing the Hub’s vision, and having it be the first community hospital in the nation to have an embedded, well-thought through and resourced innovation center.  There are two of us running the Sibley Innovation Hub, myself and a colleague, Joe Sigrin, who is our Innovation Experience Advisor, and an advisory board.  We’re also developing a physician advisory board to provide clinical direction, and then we have the goal of trying to create widespread culture change. If we’re successful in our job, the whole organization will be part of the team and will be doing mini-projects and even full blown design on their own. We have a wonderful space I which to going to grow that army of design thinkers. It’s a space for everybody that comes into Sibley, whether they’re staff, medical staff or patients.

TEDMED: Will patients be involved?

Dawson: One of our driving goals is including patients in the process, and not just as end users, but as part of the design team.  Frankly, that’s the only way innovation is going to work. Once you co-design, it just feel so right.  It’s the only way that makes sense.

TEDMED: Who or what do you credit with launching a design revolution in healthcare?

That’s a fun one to ponder. There are the IDEOs and the Stanfords; we’ve seen design and innovation centers in many large academic institutions. They gave prominence to the idea.

Another partner, though, and one who ought to get more credit, is patients, those who have said, ‘My health and my condition, and my experience and my interaction with my doctor — that’s my responsibility, and here’s what I’m going to do to own it.  I may have to hack the system.’  They’re designing for themselves ultimately.

And then there are nurses.  All you have to do is shadow any nurse and they have hacks and workarounds for everything.  They don’t call it design thinking, but they have empathy for their patients and their peers and they’re always thinking about how to make things just a little bit better. We see that in doctors, too. Some doctor said, ‘I’m going to try this laproscopic thing, and I’m going to invent a prototype for it.’

There’s a culture in health that who has always existed.  It’s just now becoming a formal process.

– Interview by Stacy Lu

Reshaping the healthcare workforce: Two case studies

Healthcare is calling for all hands on deck.  Most pundits are anticipating a primary care shortage thanks to greater usage of primary care under the Affordable Care Act.  And with the rise in demand comes increased costs from an already bloated system.

What’s the remedy?  Among suggested strategies on how to add workers, like making it easier and less expensive to train doctors, are innovative initiatives that address the problem from inside out:  Making better use of the staff already in place – like allowing nurse practitioners to practice independently – or adding help at the clinician or community level.

Following are two case studies of care systems that have overhauled delivery with significant results.

Union Health Center: Modeling the A-ICU

Audrey Lum, Chief Clinical Officer of Union Health Center (UHC) in New York City, began reforming Union’s health care team along with Union administrators following a 2005 white paper from the California Health Care Foundation talking about how to serve the highest-cost patients – those with chronic health conditions – who were also under- or uninsured, low-income and not eligible for Medicare or Medicaid. Could these patients be better served, while reducing overall health costs at the same time?

The paper offered a solution: the Ambulatory Intensive Care Unit (A-ICU), which uses nurses, medical assistants, health coaches, community health workers, pharmacists, dietitians and others working at the very top of their capabilities and licensure as the front line of patient assistance and coaching, to allow physician and nurse practitioners to do more of what they’re best at: diagnosing, prescribing and managing care of complex cases.

Audrey Lum and Troy Trygstad discussed their patient home models on a recent Great Challenges Hangout about rethinking the healthcare work force.  Watch a recap:

UHC was the perfect petri dish for its experiment, a health center with diverse patient base and unique history. Established in 1914 by the International Ladies’ Garment Workers’ Union, its patients are mainly still union members – laundry workers; porters; doormen – and unions subsidize their care, including operations costs. Around 30 percent of their patients are privately insured.

The center created health care teams staffed by physicians, patient care assistants, two health coaches, assistants and support staff. Teams work off of patient education templates created by clinicians, with input from all.

“It’s about educating patients and helping them learn how to take care of themselves.  If you have a chronic disease, you live with it 365 days a year; you only go to the doctor when you’re very sick. How could we incorporate the preventative part of that in our care model?” Lum says.

Hiring culturally proficient health coaches and assistants helped make patients feel comfortable; the staff seem to be de facto community health workers. Staffers speak Spanish, Chinese and Creole, among other languages.

“They’re in the same neighborhoods and they shop in the stores, so there’s that separate connection. It speak to the relationship model of,  ‘We’re in this together. Let’s get better as a team,’ “ she says.

Results are good. A 2014 case study review found that the total per member, per month costs for UHC as of 2013 were 17 percent lower than non-UHC patients, and that emergency room costs were 50 percent less. Patient time in the office decreased from 2 hours to an average of 48 minutes.

Training workers was an investment, Lum allows. It takes up to nine months for assistants to complete, with time dedicated specifically for staff to train with nurses and nutritionists. Union had the help of a grant from The Hitachi Foundation to set its change in motion. Still, the results beg the question: Why aren’t more practices doing this?

“It takes a lot of effort, and it takes a lot of time. People don’t realize that when you give a lot upfront, you get it back at the end.  But when you’re trying to see as many patients as possible and get your fees-for-service, you want instant gratification,” Lum says.

Community Care Workers Calling

In the Community Care of North Carolina (CCNC) model, the patient home extends to the front door. In 2008, the state initiated a population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. Today, the community-based program establishes a medical home for more than 1.4 million patients.

Under the program, care managers follow patients, including home visits, with a special eye to medication adherence, reporting back to a primary care medical home; 90 percent of primary care providers in the state – and every hospital – participate, as do local health and social services departments. Physicians oversee care and share data on a dedicated network.

“We need health workforce reorganization to move from ‘when a patient who has a problem, they come to me’ to ‘a patient has a problem and we’re going to manage it no matter what.’ It becomes more about what happens outside of an encounter with a physician,” Trygstad says.

CCNC patient admission rates are consistently 40-50% lower than non-CCNC Medicaid patients. In a study of patients hospitalized during 2010–11, CCNC found that those who received transitional care were 20 percent less likely to have a readmission the following year compared to clinically similar patients who received usual care.  As measured in 2011, resulting four-year savings to the state for hospital costs and other services were estimated at nearly $1 billion.  In fact, North Carolina is the only state with consistent declining growth rates in medical spending over a decade.

Oregon, Colorado and Oklahoma have similar programs, but Troy Trygstad, Vice President of Pharmacy Programs for CCNC, says:

There were three key ingredients in the primordial goo in North Carolina that resulted in this DNA. There’s a strong historical culture of primary care and public health and population management by virtue of a strong emphases on rural health, supported by medical centers and big universities.

The second thing is that it happened early enough that a lot of the traditional barriers of entry weren’t established. There are certain stakeholders in health system that want to do care coordination and control infomatics, and they’re not going to be interested in an organic provider model that can take on risk.

The third thing is true championship. If you didn’t have strong personalities going to battle over time you wouldn’t be able to maintain [a program like this].

Live event: Can rethinking the healthcare workforce help drive down medical costs?

There’s no shortage of news, or worry, about the coming scarcity of healthcare workers. But is there really a problem? What if we’ve got enough hands, but just need to align tasks better?

shutterstock_172496525According to a study from the Annals of Family Medicine, one doctor can reasonably help 983 patients in a year working solo. As part of a team and delegating some tasks to others, that same doctor could potentially reach 1, 947 patients.

As Ed Salsberg, a research professor at the George Washington University Center for Health Workforce Research and Policy, said:

How we use workers also directly impacts costs, efficiency and quality. If we only allow highly educated practitioners to provide certain services…we are likely to drive up costs and may limit access. If we allow a lesser-educated caregiver to provide services, it may be beyond their skills and training. So how do we know who is qualified to provide what services?

What needs to happen on all fronts to make that work? How can we handle rural and under served areas? Who should play bigger roles: Nurses, pharmacists, technicians? What would that mean for costs? What are our future healthcare needs, and how can we meet them?

Join a TEDMED Great Challenges live event this Tuesday, May 20 at noon ET with Salsberg and others on the forefront of rethinking the healthcare workforce. Kick off the conversation today by tweeting your questions and comments to #GreatChallenges and we’ll discuss them on air.

Better outcomes for engaged patients may start with an empathic doctor

An engaged patient, one who is knowledgeable about his condition and feels confident in his skills to help manage his own care, may in turn contribute to improved outcomes and reduced costs for himself and for the system.  There are even ways to measure their ability to take a stake, including the Patient Activation Measure (PAM).

On last Tuesday’s Great Challenges Hangout, we gathered a team of thought leaders to explore PAM and how well it measured patient engagement. Of course, getting patients to take a more active role is a two-way street; well-managed care involves solid clinician-patient collaboration.

What, then, can providers do to make this happen, and who tracks how well they do it?  We’re not talking about best-doctor magazines or web site rankings, but an across-the-board measure of how doctors succeed in relating to patients – a “doctor activation measure,” as one of our Community Members called it in his tweet.

As it turns out, there’s no universally used rating for clinician engagement. But there is one trait that has, in study after study, shown to positively affect patient engagement and outcome: empathy.

Clinician empathy leads to greater patient satisfaction, increased compliance and better outcomes. It boosts job satisfaction for providers.  It may be particularly helpful in cases of chronic illness; In one study, patients with diabetes had measurably better outcomes when their doctors scored higher on the Jefferson Scale of Empathy, a tool that measures patients’ perceptions of physician caring. A recent systemic review and meta-analysis concluded that the patient-physician relationship had a small but measurable effect on patient health outcomes.

Yet with so many patients seen in limited time increments, and the increasing specialization of medicine, how can doctors get – and remain – empathetic?

Here’s the neat part:  They can be taught. Researchers as Massachusetts General Hospital gave residents three 60-minute empathy training modules. The courses explained the neurobiology of empathy, showing physiological responses to dismissive comments. Based on another scale, the Consultation and Relational Empathy (CARE) measure, the group with training showed higher scores than those without.

Understanding how our brains process and respond to verbal and physical cues is key to shaping behavior, says Helen Riess, a psychiatrist who developed the modules and led the study. As grounded in science as clinicians are, they can forget their autonomic nervous systems may lead them to act in ways they don’t intend.

That doesn’t mean a physician needs to or should feel deeply emotional about a patient’s outcome. More important is an awareness of how actions might be perceived.

“Empathy has cognitive, emotional, behavioral and moral components. Sometimes we really feel for another person; another time we cognitively understand what they’re going through, but we may not feel it because we’re tired. That still leaves us a choice to behave in a more empathic and caring way,” Riess says.

Empathy among med students tends to erode in the third year.  Perhaps this is where intervention can begin; as this blog has reported, some schools, including Harvard Medical, are exploring ways for doctors to learn to see patients holistically, including a curriculum called the Longitudinal Integrated Clerkship in which students follow a patient’s case from beginning to conclusion.

In the end, showing empathy can start with measures as sitting down to listen to a patient and making eye contact.

“If you can learn empathic behaviors and be respectful and kind, that’s really what the patient is going to remember at the end of the day,” Riess says.

 

 

N is for Nutrition: Can schools help prevent childhood obesity? An online live event

What kind of role can and should schools be taking to help keep kids at an optimal weight?

Image courtesy of The Kitchen Community

Image courtesy of The Kitchen Community

According to a Kaiser Permanente survey published last summer, some 90 percent of Americans expect schools to take the lead in any community effort to reduce childhood obesity. This makes sense, after all – the vast majority of school-age children spent most of their waking hours at school, and most partake of school lunches. Further, the Centers for Disease Control pointed out in a report about how schools can promote kids’ health, research now shows that a healthy body is critical to a healthy mind. In our age of winner-take-all standardized testing, no stone can be left unturned.

For those and other reasons, a growing number of schools are taking part in a drive to do just that. Fresh, nutrient-filled food is increasingly on the menu. The Federal government has stepped in by instituting new standards for school lunches. Education about good nutrition and its relationship to a healthy body weight is on the rise.

Can school gardens harvest health?

Some schools are going a step further by growing fresh edibles on school grounds, and asking kids to help harvest them. The movement had a visible beginning some 17 years ago when chef Alice Waters started her Edible Schoolyard project in Berkeley, Calif. Research so far suggests that “garden-based learning” may increase students’ knowledge of nutrition and promote healthy eating habits, as well as teaching team-building skills and an appreciation for the environment.

Image courtesy of The Kitchen Community

Image courtesy of The Kitchen Community

A number of local and national initiatives have, er, sprung up with plant-based missions.  The Kitchen Community, an initiative based in Boulder, Colo., makes the school garden the basis of an outdoor classroom that includes benches and artwork.

“It’s fundamentally changing the built environment and using that as a catalyst towards experiential learning and imaginative play. We know that will raise test scores, and we know the impact will be profound on what kids eat and how they eat,” says Travis Robinson, Managing Director.

So far, Kitchen Community has helped create 155 school and community center “Learning Gardens” with an additional 11 community gardens across the U.S. Installing the Gardens, however, isn’t an inexpensive or quick endeavor, and involves much involvement with school and community facilities managers.

Cheryl Moder, director of the San Diego County Childhood Obesity Initiative, says the group takes a policy, environmental, and systems approach to obesity prevention, working to improve access to healthy, fresh food and promote physical activity.

The Initiative’s work with school gardens allowed community members to help with gardening, and in some cases to have plots on school property.

“It helps increase the sustainability of school gardens.  All too often once the project champion leaves the school plot goes fallow,” says JuliAnna Arnett, who manages operations and food systems for the Initiative.

The group works with partners in multiple sectors to prevent and reduce childhood obesity through a variety of strategies, including healthy and local food procurement for hospitals and schools, while also focusing local efforts around two overarching strategies: Reducing consumption of sweetened drinks and increasing safe routes to healthy places.

How are efforts like these making a difference? Join this week’s live online Google+ Hangout this Thursday at 2pm ET to discuss these issues and more. Tweet questions to #greatchallenges and we’ll answer as many as we can on air. Participants include Great Challenges Team Member, Melissa Halas-Liang, and our guests for this discussion: Cheryl Moder and JuliAnna Arnett from the San Diego County Childhood Obesity Initiative, Travis Robinson from The Kitchen Community, and Laura Hatch from the Alliance for a Healthier Generation. Amy Lynn Smith will return as our moderator.

What To Do With Transparent Pricing In Healthcare

By Dan Munro

The snowball started with Steve Brill’s epic Time cover story, “Bitter Pill” (subscription required). In some ways, it’s been an avalanche ever since, and the whole topic of pricing transparency in healthcare has become front-and-center to the much larger healthcare debate. In many ways, I think we’ve made more progress on healthcare pricing transparency this year than the preceding 10 or maybe even 20 years.

Until recently, we’ve all been held captive to a system that had no real obligations and refused to openly share the cost of any service or procedure with us as patients. Walk into any of America’s 5,000+ hospitals and ask the cost for a full knee replacement. At best, you’ll get a quizzical stare. At worst, you’ll be asked, “How much you got?”

According to this 2013 study from Brigham and Women’s Hospital, there are about four million Americans living with a total knee replacement, and we average more than 600,000 full knee replacements per year. How can anyone, anywhere –with any remote credulity– say that we either don’t know or can’t tell you the cost of this high-volume procedure? The corollary would be like saying that McDonalds hasn’t the foggiest idea of their cost for a potato, bun or meat patty, and that we’re not allowed to know the price of a hamburger until after it’s served. It is laughably absurd, except that it’s all so tragic and represents (in aggregate) about 18% of our GDP.

Until fairly recently, the U.S. healthcare system has been perfectly content to revolve around the employer as benefits provider and the innocuous and relatively small patient co-pay. Even after full implementation of the Affordable Care Act, the bulk of Americans (about 48%) will continue to get their health coverage through their employer. Another 27% will continue to get their health coverage through Medicaid or Medicare. Those two groups alone represent about 75% of the U.S. population (~ 321 million in 2016).

Dan Munro will moderate a live, online Great Challenge discussion about transparency in health care pricing on Thursday, October 10 at 2PM ET.  Find out more here.

Dan Munro will moderate a live, online Great Challenge discussion about transparency in health care pricing on Thursday, October 10 at 2PM ET. Find out more here.

Brill’s article definitely sent shock waves through the $3.5 trillion healthcare industry, but it was anecdotal evidence. It wasn’t really indicative of a systemic problem. Like Mayor Vaughn in the movie Jaws, we found it too easy to say “a few bathers were injured” and that the small beach community of Amity was not infested with a man-eating shark. “Amity, as you know, means friendship.”

All of this lurched another big step forward earlier this summer when the Government released payment history for 100 procedures at more than 3,000 hospitals around the country [Government Drops Big Data Bombshell On Hospital Industry].  The Washington Post included a revealing chart of charges at two hospitals in Florida that are literally fewer than 2,000 feet apart.

The evidence was clear, and now voluminous, accumulated over several years from about 60% of the hospitals in the U.S. There was simply no discernible logic to acute care pricing. It wasn’t state, regional or even local; it wasn’t an inpatient versus outpatient facility and it wasn’t a different procedure. In other words, there was no reason for such a wide variation in cost.As a contributing factor, something else also kept happening year after year. The cost of insurance for access into the healthcare system kept escalating. Then the actual benefits started to be less generous. Deductibles kept increasing. Services like dental, vision and mental health were completely stripped out and companies were still choking on their annual commitment to employee health benefits. This scene – as described by one CEO – played out faithfully for many employers – each and every year.

“When an employer sits down with his health care providers – the broker, the health plan, the physician, the hospital, the drug and device firms – everyone in the room wants it to cost more – and they’re all positioned to make that happen.” Lynn Jennings – CEO of WeCare TLC – Top Ten Healthcare Quotes for 2012

Even big, bellwether companies like Microsoft began to buckle under the toll. For the first time in its storied history, the global software giant could no longer simply extend rich healthcare benefits without an employee contribution. At a surprise “town-hall” style meeting in 2010, Microsoft informed its sizable employee base and then released this statement.

We can confirm that Microsoft has begun to evolve its employee health care benefit. There will be no changes for the next two years, but in 2013, employees will contribute to their health care.”

That’s the backdrop. But the scenario is changing rapidly. Today, there are a host of new companies like Castlight Health, PokitDoc, and Clear Health Costs that have jumped in to fill the void of healthcare pricing. Castlight Health, founded in 2008, is arguably the oldest and could easily be one of healthcare’s next IPOs. In the course of about five years it has raised over $180 million in venture funding. Castlight isn’t really a B2C solution as much as a B2B (employer/employee) one, but there are others targeted directly at all of us as patients.

The questions and challenges, however, cascade quickly from there.

  • What is the larger objective? For healthcare to mirror a consumer-centric, retail model?
  • What value does pricing alone have when it’s untethered from either quality or affordability?
  • As a consumer I’m definitely motivated to find the best healthcare I can, but what if it’s way beyond my reach financially?
  • Will this spawn a kind of healthcare lending industry like education and mortgages?
  • What real difference, if any, can pricing make in an emergency situation? NB: Hospital admissions through the ER represent about 50% of all hospital admissions (here)
  • In healthcare, demand will always exceed supply. Are we, in fact, building unrealistic expectations around the capacity of transparency alone to lower pricing?

A few things are becoming crystal clear. As evidenced by this banner headline in the Wall Street Journal last month, “Walgreen to Shift Health Plan for 160,000 Workers,” our healthcare system is moving away from a defined benefit model of healthcare coverage to a defined contribution model. In that model, more choices will become available, and served with consumer convenience, including price. That price may be untethered from quality (or personal affordability), but it will be transparent. The last remaining question could well be: What do we do with it?

Dan Munro is a freelance writer and Contributor at Forbes. He writes regularly about the intersection of healthcare IT, policy and innovation at Forbes.com. Read more from him here, and follow him @danmunro.

 Opinions expressed by our guest bloggers do not necessarily reflect TEDMED’s.  

 

Examined Lives: Why healing health starts with racial equity

By Gail Christopher

At the time my three-month old baby died, I could think of nothing but our family’s sorrow. We had lost a dear, beautiful child. What can you do but grieve?

It was only later that I realized that I was a statistic.

In fact, as I looked back, I could recall a number of early deaths in my community. When I was 15, my best friend’s mother was rushed to the hospital before she was due. It was a shock to us all when she died during delivery. This was, we thought, a healthy woman.

Then I remembered my parents’ best friends. The couple had a daughter named Alicia. Alicia also died during childbirth, along with her baby.

What was going on here? Why were these maternal and infant losses so prevalent in families of color?

I made the decision to do something to change these statistics, and began pursuing a career as a holistic doctor.

As I would come to learn, there were gross inequities between whites and African-Americans in birth and maternal health outcomes.

When I graduated from naturopathic medical school in the mid-1970s, I set up a private practice in Chicago. At the same time, I established a company that worked with social service agencies to deliver holistic wellness and well-being services to underserved communities.

Gail Christopher

We focused on getting women to eat healthfully, to get exercise, to manage stress. They did the things that are key in the holistic healing world. And these women began having healthy babies.

It actually became a joke in our community. Women referred to me as “the fertility doctor,” because I saw so many who were expecting, or who couldn’t get pregnant, or who had had babies and lost them. Of course, I wasn’t a fertility doctor. I was making sure that they got the whole health care they needed. Healthy pregnancies followed.

So this was my work: Helping women, children and families become healthier. Helping communities understand and improve disparities in outcomes. Helping reshape the statistics.

And yet I also knew that truly eliminating these differences in outcomes would mean dealing with something much bigger.

To genuinely eradicate health disparities—as a nation—we have to confront the undergirding dynamics that contribute to them. That means addressing African-Americans’ continued exposure to discrimination and lack of opportunity.

That’s hard work: structurally, politically, emotionally.

Challenging the dynamics of discrimination means reaching back through deeply entrenched roots and history. It means reconfiguring the DNA of this country’s belief system.

At a "Save Our School" rally in Cleveland, Ohio, high school junior Gail C. Christopher addresses her classmates as they convene to save their high school from demolition.

For hundreds of years, that belief system has held that it is OK for people to be valued differently based on physical characteristics. We have never as a country dealt with that belief.

Of course, we’ve had a civil war and a civil rights movement—but those dealt with the consequences of that belief rather than the belief itself. We’ve also known that race is a social, rather than biological, construct. But simply pronouncing something false is not dealing with it.

Today, at the W.K. Kellogg Foundation, we’ve put a priority on achieving racial healing and racial equity in this country. This work specifically and openly challenges the historical belief in racial hierarchy.

At the same time, we also work to to equip people with the innate and external resources to mitigate the effects of that historical belief.

It’s a both-and approach.

Dealing with it requires intentional strategies.

Let’s imagine a young boy growing up in a community much like the one where I used to practice. It’s an impoverished neighborhood. He’s enrolled in a failing school system. He’s harassed by police. And he or may not have the benefit of two parents or an extended family.

This child is continually exposed to overwhelming stress responses, something Dr. Jack Shonkoff at Harvard University calls “childhood adversity.” Childhood adversity is a predictive factor in all manner of chronic diseases later in life. And so we see our long racial history playing out across the health of individuals and particular communities from a very young age.

For this boy, and for his children, we have to tackle both the current situation and the historical context.

At the bare minimum, he needs balanced nutrition and social support to cope with the vicissitudes of his body’s adaptation to the stressful environment. People need optimal food for optimal health. The W.K. Kellogg Foundation funds organizations working to improve access to fresh, healthy affordable food for vulnerable children.

Dr. Gail Christopher, with her children Heather and Hassan.

At the same time, we also fund organizations working to acknowledge and dismantle structural racism—the policies and practices that continue to create barriers for children of color.

Which takes us to an evolution of my earlier question: How do we address the early death so prevalent in families of color?

Addressing these health inequities demands that we address inequality more broadly. We must create an environment that supports equity and opportunity while mitigating the effects and consequences of exposure to discrimination.

In other words, I realized that to change the statistics—to change the conditions that resulted in so much premature death in my community growing up—we must bring a racial healing and racial equity lens to our nation’s health discussion.

Until we do, we’re just putting Band-Aids on the hemorrhage.

Click here to read more about the Great Challenge of the impact of poverty on health.