New Year’s Resolution #1: Preventive Care and Negotiated Costs

Happy 2011, folks!  It’s a new year of reformed eating, exercising, spending, and no-smoking habits.  It’s a new Congress with promises or threats (depending on your view) of healthcare repeal.  And with the help of U.S. Preventive Medicine, Inc., it’s a new year for Sam’s Club shoppers to reach their health goals with the “The Prevention Plan.”  Or is it?

For $99 a year, Sam’s Club shoppers can access:

a personalized, step-by-step health management program designed to help people take control of their individual health.  Via an online health assessment and at-home blood test [measuring cholesterol, blood glucose, and Hemoglobin A1c levels]… members can take the first steps in identifying potential individual health issues.  From there, a personalized plan is created to address risks.  Personal health coaching, ongoing support, a variety of tools and a plan-wide health challenge are provided through The Prevention Plan to keep members motivated to maintain a healthy lifestyle.

Although the Plan includes a 24/7 nurse line, 20 online education programs, recommended prevention screenings, and a detailed member report, it isn’t a substitute for regular health insurance… or for a primary care physician.  In a CNNMoney report, U.S. Preventive Medicine CEO Christoper Fey suggested that shoppers “[t]hink of it as what a financial planner does.   He takes all the information you provide, assesses the risk and gives you a plan on how to improve your financial health.  The prevention plan does a similar thing, but for your health.”  In the same report, a director of health policy at Families USA, a consumer advocacy group, said that she “worr[ied] about people thinking of this prevention plan as a substitute for an annual checkup at a doctor’s office.”

Participating in preventive care and services makes a lot of (dollars and) sense.  Okay, a little lame joke.  Seriously, though, why sit around when you can take measures to try to maintain your health and to prevent certain diseases from occurring?  The Patient Protection and Affordable Care Act recognizes the benefit of preventive care and services — remember, there’s that provision concerning free access to important screenings, tests, vaccinations, and the like.

Yet I’m somewhat skeptical about the benefits of paying $99 to enroll in this Sam’s Club Plan.  For starters, it sounds like the same kind of educational information and health tips can be found on other sites such as WebMD… and at no cost to the consumer/patient.  Okay, well, maybe WebMD doesn’t come with a 24/7 nurse line.  Yet after you take the at-home blood test, upload the results, and figure out your health summary, you’ll still need to consult a doctor to figure out whether any additional screenings are required.  So take that $99 and add to it the cost of your co-pay… or whatever you might pay out-of-pocket if you don’t have insurance.

Speaking of which, be sure to check out a recent New York Times article which reminds us how (most of) everything in life is negotiable, including healthcare and prescription costs.  Similarly, a NPR blog post discusses how some drug manufacturers offer coupons or subsidy cards to reduce prescription costs–but as Kate Matos mentioned the other day here at HRW, that too comes with a cost.

Contesting Depression

Social disagreement about the medicalization of experience is intensifying. Psychiatrist Allen Frances complains that the draft DSM is too quick to pathologize grief:

A startling suggestion is buried in the fine print describing proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — perhaps better known as the D.S.M. 5, the book that will set the new boundary between mental disorder and normality. If this suggestion is adopted, many people who experience completely normal grief could be mislabeled as having a psychiatric problem.

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder. . . .[This change] would give mentally healthy people the ominous-sounding diagnosis of a major depressive disorder, which in turn could make it harder for them to get a job or health insurance. . . .

Grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

Moving from the end of life to the beginning, another commentary mentions worries that quiet and listless preschoolers may be pigeonholed as depressed:

Today a number of child psychiatrists and developmental psychologists say depression can surface in children as young as 2 or 3. . . . [But c]lassifying preschool depression as a medical disorder carries a risk of disease-mongering. “Given the influence of Big Pharma, we have to be sure that every time a child’s ice cream falls off the cone and he cries, we don’t label him depressed,” cautions Rahil Briggs, an infant-toddler psychologist at Children’s Hospital at Montefiore in New York.

Though research does not support the use of antidepressants in children this young, medication of preschoolers, often off label, is on the rise. One child psychologist told me about a conference he attended where he met frustrated drug-industry representatives. “They want to give these kids medicines, but we can’t figure out the diagnoses.” As Daniel Klein warns, “Right now the problem may be underdiagnosis, but these things can flip completely.”

Both stories foreshadow larger struggles over the meaning of “health” in risk societies where there is less margin for error or “underperformance” at work or school. Virtually any wealthy New Yorker with small children has a story about the crucial “pre-school interviewing process,” where elite schools can use an hour-long interaction with a child to decide whether or not to accept him or her as a student. On the other end of the income scale, high unemployment means that at-will employees who can’t keep up an adequate reserve of chipper and helpful “can-do” spirit are always at risk of being sacrificed in favor of some member of the reserve corps of unemployed. Business can’t survive if it’s culture is “too nice.” And hiring may end up being driven by whether an “analysis by an organizational psychologist can tell the hirer whether an applicant will have a problem with the manager or team.”

Larger social currents are feeding anxieties about these trends. Some corporate mottos appear to be “get healthy, or else:”

“We have this notion that you can gorge on hot dogs, be in a pie-eating contest, and drink every day, and society will take care of you,” says Harvard Business School Professor Michael E. Porter, who co-authored Redefining Health Care. “We can’t afford to let individuals drive up costs because they’re not willing to address their health problems.”

Hence the wellness fixation at companies as varied as IBM, Microsoft, Harrah’s Entertainment, and Scotts. Employees who voluntarily sign up for such programs often receive discounts on health-care premiums, free weight-loss and smoking-cessation programs, gratis gym memberships, counseling for emotional problems, and prizes like vacations or points that can be redeemed for gift cards.

M. Todd Henderson assures us that “corporate nannies are superior to their state analogs in some cases,” in part because “corporate policies are subjected to more instantaneous feedback from labor markets, which reduces overreaching.” As unemployment climbs and benefits end, that “feedback from labor markets” gets weaker and weaker: employees take whatever job they can find.

What’s the end result of these trends? I can’t predict, but I think Gary Shteyngart’s recent satirical novel provides one template for the workplace of the future. His protagonist, Lenny Abramov, finds that his employer has placed “five gigantic Solari schedule boards” in the office. The boards:

[D]isplayed the names of . . . employees, along with the results of our latest physicals . . . our fasting insulin and triglycerides, and, most important, our ‘mood + stress indicators,’ which were always supposed to read ‘positive/playful/ready to contribute,’ but which, with enough input from competitive co-workers, could be changed to ‘one moody betch today” or ‘not a team playa this month.’ On this particular day . . . one unfortunate Aiden M. was lowered from ‘overcoming the loss of loved one’ to ‘letting personal life interfere with job.’ (57-58)

Ultimately, moods become health problems when they seriously interfere with activities of daily living, including family, work, spirituality, and play. What Shteyngart reminds us is that the demands of work are quite flexible, and always-evolving. Without a robust societal sense of the proper claims of grief and other emotions, economic imperatives are likely to shrink them inexorably. Unlike the film Gattaca, where extant social structures somehow persist in the wake of massive changes in enhancement technology, Shteyngart’s novel describes a world where relatively small changes in self-concept, media use, and aspiration in an elite can fundamentally destabilize societal expectations.

Given the current balance of power between labor and employers, the disciplinary impact of new technology is likely to rise. As Hannah Pitkin puts it, if we are not careful, the very tools invented to reduce suffering may end up increasing it, by making authorities less tolerant of human need:

We have developed astonishing techniques of communication, persuasion, indoctrination, organization. . . . Yet these extraordinary capacities somehow have not made people happy or free or even powerful. . . . We do not direct these, our alleged powers; if anything, they direct us and determine the conditions of our lives, developing with a momentum of their own in ways we cannot foresee and that are often obviously harmful to human life and civilization

The contestation of pre-school and post-death depression concerns fundamental questions about what it means to be human. Circumstances need to be better engineered to accommodate the normal range of human experience. Otherwise a Procrustean drift will result in humans better engineered to to accommodate their circumstances. As Jaron Lanier has written, “When people are told that a computer is intelligent, they become prone to changing themselves in order to make the computer appear to work better, instead of demanding that the computer be changed to become more useful” (36). Perhaps employers without “grief leave” policies should be changed more quickly than employees in search of non-medical solace.

Impact of Free Preventive Healthcare

Benjamin Franklin famously once said, “an ounce of prevention is worth a pound of cure.” The statement has that ring of truth– especially when it comes to American healthcare.  Numerous studies have shown that early detection of diseases as well as interventions for bad habits (e.g. overeating and smoking) can potentially avert thousands of deaths each year.  Additionally, reported by Reuters, these preventative cares can lead to massive health care savings because preventable diseases such as heart diseases, cancer, and diabetes account for 75% of the national health care spending.

Considering the potential of prevention, just last week, the White House laid out rules requiring health insurance companies to provide many preventative medical services at no cost to the consumer.  The NY Times reports,

The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; prenatal care; and regular wellness visits for infants and children.

Other services that must be offered at no charge include counseling to help people stop smoking; screening and counseling for obesity; and tests for infection with the virus that causes AIDS.

The rules stipulate that no co-payments can be charged for tests and screenings recommended by the United States Preventive Services Task Force, an independent panel of scientific experts. The rules apply to new health plans that begin coverage after Sept. 23 and to existing health plans that make significant changes after that date. The administration said the requirements could increase premiums by 1.5 percent, on average.

Currently, the government reports that Americans use preventive services at about half the rate recommended by doctors and public health experts.  The Obama Administration, including many experts and consumers groups, is hoping that these new changes will eventually have a huge impact and Americans will take advantage of the free preventative care.

But, how much impact would it really have?

While costs have deterred some consumers from preventive care, others have avoided doctors’ offices for other reasons.  For example, people with unhealthy lifestyles avoid checkups, not because of cost, but out of fear.  According to the NY Times,

Recent studies have shown that people who know they have health-endangering vices (like smoking or drinking) put off appointments because they do not want a healthy-living lecture. Others do not go because they feel doomed despite medical treatment. At the other extreme are the overly optimistic who are convinced they will get better no matter what. And then there are those who are embarrassed to discuss their symptoms, such as incontinence or impotence.

The bottom line for many people is fear: fear of bad news, fear of an uncomfortable test, fear of discussing something intimate.

And other people, namely men, do not regularly see their primary care physician because men generally tend to overestimate their health.  According to a survey by the American Academy of Family Physicians:

● Almost one in five men (18%) 55 years and older have never received the recommended screening for colon cancer.

● More than half (55%) of all men surveyed have not seen their primary care physician for a physical exam within the past year.

● Four in 10 (42%) men have been diagnosed with at least one of the following chronic conditions: high blood pressure (28%), heart disease (8%), arthritis (13%), cancer (8%) or diabetes (10%).

● More than one out of four men (29%) say they wait “as long as possible” before seeking help when they feel sick or are in pain or are concerned about their health.

● Despite this, almost 8 in 10 (79%) men describe themselves as in “Excellent,” “Very Good,” or “Good” health.

The “missing” men in these statistics would seem to be among those who would benefit, arguably most, from regular  checkups and screenings; unfortunately, it would seem that free preventive care will not drive these groups running to the doctor.  While the new rules will undoubtedly increase the number of people receiving preventive care, it is uncertain how much impact it will actually have as some groups will continue to avoid doctors regardless of costs.

Not So Fast With That Lipitor Johnny!

Having previously described my diet, proclivities, and the thoroughly reasonable fear I had regarding the battery of tests I would have to undergo this week at the Cardiologist’s, I am pleased to say that I did so well that my doctor no longer thinks I will need to take Lipitor. My valves seem to all flap when they’re supposed to (echocardiogram), and the nuclear stress test showed no obstructions whatsoever. But the clincher was that the calcium scan showed zero calcium. Yes, zero.

Given the high correlation between the presence of arterial calcium and propensity for heart disease in a country where heart disease is the number one killer (about every 25 seconds an American will have a coronary event) and a major medical expense, I wrote previously how it seemed penny wise and pound foolish for health insurers to not pay for calcium deposit screening. This test can offer actionable insight years  prior to the onset of ultimately costly symptoms. There is, reasonably speaking, savings of more than one kind to be had in this kind of knowledge: if  one knows, one can act in accord. I paid the $318 out of pocket. Now, it seems, despite the ostensible risk factors which may have counseled otherwise, I have spared my insurer the cost of a lifetime’s worth of Lipitor. And myself the burden of a lifetime’s worth of pharmaceutical dependence.

There’s a J.D. at the end of my name, not an MD, so I do not give medical advice. But I will say that the whole battery of tests was painless, congenial, and took about 4 1/2 hours spread over two visits– which is not a lot of time to invest in dispensing with the ominous unknown. Of those one every 25 seconds in America who have a coronary event, one every minute will die. Testing will help tell you where you stand, and you never know, you just might get some peace of mind.

New Breast Cancer Screening Recommendations Cause Controversy

Rarely do medical recommendations or clinical guidelines receive such immediate and passionate attention as those released this month by the U.S. Preventive Services Task Force (USPSTF), an independent panel of doctors and scientists who make recommendations to the Department of Health & Human Services.  In a striking detour from prior recommendations by the Task Force and those of the American Cancer Society (ACS) that women over 40 receive a mammogram every one to two years, the Task Force now recommends:

• “against routine screening mammography in women aged 40 to 49 years”;
• “biennial screening mammography for women aged 50 to 74 years”;
• “against teaching breast self-examination (BSE)” (emphasis added).

In a radio interview on the new guidance, Dr. Bruce Calonge, chair of the Task Force, was asked about the USPSTF recommendation against routine screening for women in their 40′s and “the possibility that some women may die as a
result of not having routine mammograms.”  Calonge’s astonishing answer:

“what women really need to understand in that decade is that overall reduction in mortality, which is for all comers in that age group, only about 15%, because breast cancer is relatively rare in that age group, that benefit is really quite small…”

Although he claimed that cost analysis had no place in the Task Force’s recommendations, later, focusing on early detection generally, he repeated,

“I think one of the things that is important to say… that mammography’s benefit is only a 15% reduction in mortality.”

Kathleen Sebelius, HHS Secretary, has clarified that the federal policy on breast cancer screening has not changed, despite the Task Force’s recommendations.   In response to concerns that patients who seek mammograms before the age of 50 would not be covered by health insurance, Sebelius stated that she “would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.”  Despite such assurances, if past experience is a guide insurance companies will use these criteria to determine coverage.

A number of professional and advocacy groups have responded to the Task Force’s November 16 recommendation.   The ACS continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40.  The American College of Radiology issued a frankly titled statement, “USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year” and labeled the recommendations “cost cutting.”  And the American Congress of Obstetricians and Gynecologists continues to recommend a screening mammography every 1-2 years for women aged 40-49 years and every year for women 50 and over, as well as to recommend BSE.

So what would the task force’s mammography recommendations mean for patients?  The changes to the recommendations extend beyond the age at which they recommend beginning mammography screening.  For example, the 2002 USPSTF recommendations explained, “[t]he precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences” (emphasis added).  The elimination of the term “preferences” and the focus on “patient context” and the “patient’s values regarding specific benefits and harms” indicates a move toward evidence-based medicine, whereby a patient’s inclinations and personality are taken less into consideration or play a less significant role in predicting outcomes.  In a November 17 New York Times article, the author asks,

Are you the sort for whom shivering in a paper gown, enduring discomfort and waiting a week for results is so unnerving that you are thrilled for a decade-long reprieve? Or are you that woman who gets an extra breast sonogram with your gynecologist even when it is not medically indicated? Do you trust scientists or prefer your own gut?

These concerns seem more like preferences than medically-supported decision-making factors.   The 2009 recommendations instruct that “the patient’s values regarding specific benefits and harms” be taken into account — but do not explain how far “patient context” be considered.  The recommendations do not apply to women with “known underlying genetic mutation or a history of chest radiation.”  Beyond these two exceptions, how will doctors and patients make individual decisions to start regular, biennial screening mammography?  The recommendations should be appreciated for confirming — to an extent — that the decision to begin regular screening mammography is individual.  The doctor and patient, in collaboration, should consider the patient’s risk tolerance, family history, and any other applicable factors.  Sebelius recommends that patients “[k]eep doing what you have been doing for years — talk to your doctor about your individual history, ask questions, and make the decision that is right for you.”  It is unclear how the Task Force’s recommendations could affect the decision to begin mammography in an educated and reasoned way.

The Task Force’s self-examination recommendation is also worrisome.  The USPSTF states that “there is moderate or high certainty that [BSE] has no net benefit or that the harms outweigh the benefits.”  However, discouraging the use of self-examination — a short, free, easy, and non-invasive process — might seem astonishing to many, particularly those who have known someone for whom a BSE has been the means by which breast cancer was first discovered.  Appreciating the concern about BSE leading to higher incidences of biopsies, additional screenings, and false-positive test results, with the increasing focus on disease prevention, this recommendation seems, at best, counter-intuitive, particularly when taking into account those who are uninsured and may not pursue other methods of breast cancer screening.

Urgency, Medicalization, and Sick Days

The US media have recently coalesced around a narrative asserting that US health care costs too much in the aggregate because citizens are demanding too much health care. But the “too much demand” narrative must be balanced by an awareness of high prices in the US, as Ezra Klein has pointed out on the provider side, and Uwe Reinhardt notes on the insurer side. Reinhardt cited a study that found that, in comparison with West Germany, “in 1990 Americans received $390 per capita less in actual health care but spent $360 more per capita on administration.”

Nevertheless, there are legitimate concerns that citizens of the developed world are demanding (or having foist upon them) “too much health care,” as Charles J. Wright argues in the Literary Review of Canada. For example, Wright observes that

The recent analysis of all the available evidence from multiple studies published in the British Medical Journal shows that if 2,000 women are screened with mammograms regularly for ten years, only one single woman’s life will be prolonged, but 500 will have at least one false positive and ten will be diagnosed with a “cancer” that would never have become a real disease if it had been left alone. . . . The diagnosis and treatment of non-disease is also popular in some areas of psychiatric practice. Among the hundreds of diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (known as the psychiatric bible) published by the American Psychiatric Association, dozens would be considered by most people as normal variants of the human condition but for the relentless attempts by the pharmaceutical industry to have them known as common diseases treatable by drugs.

Wright examines many causes for overmedicalization, but I think he misses one very important one–health concerns as a trump card over other social needs. In the US particularly, shrinking middle class incomes, weak unions, and high unemployment make it extremely difficult for the average worker to demand much in the way of vacation time, and there is virtually no political movement to guarantee such time. But there is momentum on both the federal and the municipal level to get sick days, in part because of the public health consequences of “presenteeism“–sick workers who spread flu and other disease when economic necessity forces them to go to work. While laissez-faire business interests can smear virtually any other pro-worker law as an intolerable burden on business, it is intuitively obvious why stopping the spread of disease is in everyone’s best interest.

Whatever happens as a result of this year’s health reform debate, I believe it has done some crucial normative work. After a long campaign by advocates of “consumer-directed health care” to reframe health care as just another commodity, the reform debate has focused the nation on its uniqueness, and on the moral imperative of providing some baseline of care to all. By vigorously blocking so many other modes of achieving better work conditions, entities like the Chamber of Commerce and Club for Growth have, ironically, shifted progressives’ focus to conservatives’ bete noir, the health care system. I predict that, if other guarantees of humane working and living conditions decline, we will see ever more “medicalization” as a way of upping the urgency of demands made by an increasingly pressed middle class.

Cut money to the EPA, and the US’s toxic waterways grow, increasing the flow of carcinogens to the populace. Put workers in insecure and demoralizing environments, and don’t be surprised if there’s an upsurge in demand for anti-anxiety drugs. Decimate funds for roads and public transit, and turn a blind eye to dangerous driving, and watch the ER’s fill with accident victims. The closer we come to a “minimal state,” the more we’ll see the resulting externalities increase demand for health care. The mechanic in the old oil filter commercial speaks for the public at large: “Pay me now, or pay me later.” When we defer maintenance of the social determinants of health, we shouldn’t be surprised when demand for doctors and hospitals rises.

Soda & Diabetes, How Much Does That Can of Soda Really Cost? Part II

Diabetes. In a brief but interesting interview on NPR’s Marketplace, Kaiser Permanente CEO George Halvorson had this to say:

HALVORSEN: …. Right now, when you look at diabetes, 32 percent of the cost of Medicare is diabetes. It’s the number one cost of blindness, it’s the number one cause of amputations, it’s the number one cause of kidney failures. And when you look at the care delivery patterns in America, we only get care right for diabetics 8 percent of the time. If we got care right for diabetics 80 percent of the time, we’d cut the number of kidney failures in half.

A few days ago we began to ask, “How Much Does that Can of Soda Really Cost?” We considered cost in terms of external or social cost (not price for the actual can of soda, but that which results incidental to the primary transaction and may be borne by other than the buyer or seller), and noted that a recent study shows that obesity plays a prominent role in health care expenditures, and that many believe that soda and other sugary soft drinks play a prominent role in obesity. We noted that the Wall St. Journal reported that

Overall obesity-related health spending reaches $147 billion, double what it was nearly a decade ago, says the study published Monday by the journal Health Affairs.

Obesity-related conditions now account for 9.1% of all medical spending, up from 6.5% in 1998, the study concluded.

Obesity is a key factor in Type 2 diabetes. And  32% of Medicare costs are attributable to diabetes. It is no stretch to say that if we have a Medicare cost problem in this country (we do), what we really have is a diabetes problem (and, considering Halvorsen’s “we only get it right 8% of the time” figure, a diabetes treatment problem as well).

But first things first. 32% is a mere scooch (yes, that’s the technical term) away from ONE THIRD. That’s an enormous number. If one were to relate this portion of Medicare expense to houesehold expenditures, it occupies a place similar to a mortgage– but an expensive mortgage in a house that no one wants to live in.

In addition, according to the American Diabetes Association (ADA)

The total annual economic cost of diabetes in 2007 was estimated to be $174 billion.  Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for excess general medical costs. Indirect costs resulting from increased absenteeism, reduced productivity, disease-related unemployment disability, and loss of productive capacity due to early mortality totaled $58 billion.  This is an increase of $42 billion since 2002. This 32% increase means the dollar amount has risen over $8 billion more each year.

Importantly, the ADA believes those numbers may be understated:

The actual national burden of diabetes likely exceeds the $174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by non-paid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetes-attributed costs for health care expenditures categories not studied. Read more

Employees, Fearing Increased Cost-Sharing and Loss of Benefits, Utilize Current Employer-Based Health Plans More

The Kaiser Family Foundation reports that a recent survey reveals that employees are utilizing employer-based health plans more in fear that their plans will increase cost-sharing or dissolve altogether.

KFF reports:

U.S. workers are making more use of their employer-sponsored health insurance benefits because of concerns that employers could cut benefits or increase costs during the economic recession, according to a survey released Friday by the International Foundation of Employee Benefit Plans, the Milwaukee Journal Sentinel‘s “Dollars & Sense” blog reports. IFEBP surveyed its members between March 30 and April 6 and found that one-third reported an increase in their workers filling prescription medications or undergoing costly medical procedures before their insurance runs out, the study found. Sally Natchek, senior director of research for IFEBP, said, “Plan participants are feeling anxious about the possibility of increased cost-sharing and a reduction in benefits due to the financial crisis.”

The International Foundation reports that:

[W]hile few plan sponsors (3.6%) are cutting or considering cutting health care benefits altogether, many are ramping up their cost-sharing approaches.  Thirty-five percent of plan sponsors are increasing employee deductibles, coinsurance or copays due to the financial crisis.  Nearly the same proportion are also increasing employee premiums.  Other cost-sharing actions that plan sponsors are taking include adding consumer-driven health plans as an option (12.8%), replacing a current plan with a consumer-driven plan (9.6%) and instituting spousal charges (10.8%).

The Foundation report confirms that more employers are using consumer-directed health plans in an attempt to rein in the cost of health benefits.

Perhaps the silver lining of this survey, though, is that there was also found to be “a heightened focus on wellness programs.  Eighteen percent of the respondents have introduced or are considering introducing wellness initiatives due to the economy (Foundation).” In a recent post, we noted that Kaiser had reported that

Eighty percent of large U.S. companies this year are offering chronic disease management programs for workers in an effort to reduce health care costs, up from 51% last year, according to a new survey by Hewitt Associates, the Houston Chronicle reports.

At the confluence of unfavorable economic conditions, rising health care and insurance costs and an administration which has vowed reform, these burgeoning trends may be only the forward guard in changes to employer-based plans. Driven by economic concerns, there seems to have been generated among employers an understanding that one way of avoiding the high costs associated with acute and/or catastrophic health care, is simply to help employees to avoid becoming sick (it may be only a matter of time before employers begin handing out “an apple a day.”) Unfortunately, with increasing frequency employers also seem to be learning that another means of avoiding the costs of  health care is to simply discontinue,  decrease, or “shift” the costs of health benefits. The numbers seem to suggest that employees have read the writing on the wall, and are visiting their doctors while they still can.

Free Healthcare for the Newly Uninsured?

In a move that has garnered both praise and criticism, Walgreens is offering free health care at its in-store Take Care clinics to patients (and their uninsured children and spouses) who have lost their jobs.  This program, called the Take Care Clinic Take Care Recovery Plan, is designed to assist current and future patients who lose their jobs and health coverage on or after March 31, 2009.

Free services do not include full spectrum preventive care, but do include routine screening and treatment for respiratory illnesses, seasonal allergies, urinary tract infections, etc.  Quest Diagnostics has teamed up with Walgreens to provide free laboratory testing services associated with the care of qualified patients.   A significant item not covered by the program is the cost of any prescription necessary to complete treatment for any of these conditions.

Walgreens warns that “[t]he Take Care Recovery Plan is in no way intended as a substitute to COBRA health benefits or any other insurance” and advises patients to carefully consider all forms of coverage that may be available to them given the limitations of care available for free through a Take Care Clinic.

While many may view the program as an advertising stunt, it is hard not to take solace in the fact that families who might otherwise have to resort to a hospital emergency room, and potentially face an exhorbitantly high bill, may now take refuge in a local clinic.

As the economy continues to sour and the unemployment rate reaches levels not seen in more than a quarter-century (8.5%), the impact on access to healthcare and our economy could prove to be unprecedented.  One study indicates that for every 1% increase in unemployment, Medicaid and SCHIP enrollment would increase “by 1 million (600,000 children and 400,000 non-elderly adults) and cause the number of uninsured to grow by 1.1 million.” And as we noted in a post at the beginning of this year, there are those (including Jane Sarasohn Kahn of The Health Care Blog) who believe that even that dire metric will prove to be  somewhat understated for present conditions.

I am certain that Walgreens is concerned with its bottom-line in this effort: calling it an “experiment,” restricting the hours that non-paying patients can seek care, and noting that every patient who visits a clinic talks to about 8 other people about the experience.  Most people, I am certain, are aware that the move is a mere band-aid on a wound that is hemorrhaging.  But for the families the program helps, these points are probably irrelevant.  What is relevant is the fact that a company is using its own resources to provide free health care to a growing population who need it.

Universal Health Insurance for America’s Children – Can It Happen?

It is no secret that America’s health care infrastructure leaves much to be desired.  It spends more on health care than any other country in the world, but is far from achieving the best results.  The extreme cost of care has contributed to increased rates of the un- and underinsured — climbing from 41.2 and 15.6 million in 2003 to  49.6 and 25.2 million, respectively, in 2007.

Most observers agree that the American health care system is badly broken–if it ever was intact–as evidenced by the large number of Americans without health insurance, the high and rising costs of health care, and the relatively poor health outcomes achieved for the money spent.

What might be lesser known is the degree to which lack of health coverage affects children.  In their article, Universal Health Insurance for Children, published in the Journal of Health Care for the Poor and Underserved, Hughes et al. note that despite programs designed to enhance children’s access to coverage like State Children’s Health Insurance Program (SCHIP), about 8.1 million children were a part of the uninsured population in 2007.  Confusion about eligibility is often cited as a reason many children — over 80% of low income uninsured children – who are eligible for coverage do not have it.

Children’s health insurance status helps predict whether they receive needed health care and provides a critical means for identifying and addressing their health problems early in life… Children  who experience unmet health problems are more likely to miss school, to incur high costs for medical care, and to have parents miss work due to caring for an ill child.

Consequences of non-coverage of children start with compromised access to health care and turn into compromises to the American economy.

Lack of insurance coverage for children not only has an immediate impact on those whose access to care is limited, but it also has social implications in terms of potential public health threats due to untreated communicable diseases, higher health care costs for end-stage treatment, and consequences for the economy in terms of productivity and high insurance costs to businesses.

It has been well documented that providing health insurance coverage is cheaper than paying for the consequences associated with the alternative, but America has been resistant to providing universal coverage.  Providing coverage specifically for children, on the other hand, has been met with less resistance.

The social and individual benefit of extending preventive care and health insurance to children, however, is somewhat less contentious [than providing insurance to adults], largely because children are viewed more sympathetically than adults by health care leaders and the American public.

Hughes et al. argue for immediate universal coverage for children, rather than waiting for universal coverage for the country as a whole and note that it would have to occur at the federal, as opposed to state and local, levels.  They make two recommendations for achieving this goal.

One option is to create a Medicare-like federal program under which all children are automatically enrolled in a comprehensive insurance program, regardless of income. By and large, Medicare works well for seniors and is a reasonable model for children. Another option involves modifying Medicaid, SCHIP, and other categorical programs to create a uniform insurance program for low-income and undocumented children that eliminates the confusion and complexity associated with multiple programs. Both options would require sufficient minimization of paperwork and reimbursement to providers to ensure that coverage translates into genuine access to care.

Hughes et al. point out that most Americans support universal coverage, especially for children, despite the added tax burden it may cause.  This is probably a sentiment reflecting the reality of the extreme cost and gross inefficiency of the American health care system.  As children constitute a categorically vulnerable population which affords them the sympathy of the country, it makes sense to begin the road to universal health care in this country with them.  The vast majority of taxpayers are willing to foot the bill and we have an administration ripened to bring about such a change.  If ever there was the time to begin the process of providing universal health insurance to children in America, it would be now.

Surprise, Surprise: Older Americans are Sicker than their European Counterparts

In this international study, we found that US adults of all wealth levels reported worse health than did Europeans at comparable wealth levels.  Poor Americans were at particularly worse health compared with their English or other European counterparts, but even well-off Americans reported health comparable to substantially poorer Europeans.  Differences in behavioral risk factors accounted for only a fraction of these disparities.

As behavioral factors were insufficient to account for this disparity, Avendano et al. distinguish between national health care systems.

Features of the US health care system may contribute to the worse health of Americans compared with Europeans.  In particular, most European countries have a stronger primary care orientation than does the United States.  Previous evidence suggests that a strong primary care system is associated with better health outcomes, partly because it entails a stronger focus on primary prevention, a more equitable distribution of resources, and a higher efficacy of the health system.

Investing less at the primary care stage where prevention is key, necessarily means that there is a greater focus on disease maintenance or amelioration after its onset.  Which is to say that Americans, for the most part, are not afforded significant medical attention until they are sick.

In addition to having a stronger focus on primary care than the United States, European countries have greater protections for their poor.  European countries offer virtually universal health care coverage, so even the poor have relatively unfettered access to necessary care.  The United States on the other hand, has an uninsured population totaling 41 million (or over 45 million by some estimates).

The fact that health disparities in England still persists despite access to care,

suggests that mechanisms outside the health care system may also be involved.  Wealth enhances access to material resources such as housing, and is a source of immediate consumption in periods of economic strain. Wealth may also increase sense of control over life and other psychosocial resources that can enhance health.

This study gives further credence to the notion that America has at least something to learn from the European health care system.  Universal health care is one component, but focusing more keenly on primary care and easing the social burdens of the poor are another.  Racial health disparities is also an issue that has to be addressed in the United States, but this study restricted its study population to non-Hispanic Whites in order to determine what factors beyond those attributable to race are at issue in the United States’ lag behind its European peers.  Given the fact that racial health disparities are prevalent in the United States, it would not strain reason to conclude that the gap between Americans and Europeans would be exacerbated if racial minorities were included.  The correlation between economic status, residential segregation and well being may help explain why this is the case.

The United States health care system clearly demonstrates that dollars spent is no indication of the quality or efficacy of health care actually received.  Moving into a more cost-effective health care  paradigm that provides access to comprehensive care at a stage where it can impact long-term health is essential.  The Avendano study offers proof of this.