Month: February 2016

Behavior change and patient empowerment

(The following is a response to an event co-hosted by NEJM Catalyst and LDI CHIBE on “Patient Engagement: Behavioral Strategies for Better Health.” It has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

As a medical student going into primary care, I value health behavior change not only as a disease prevention strategy, but as a way of empowering patients. In many areas of our health care system, we ask our patients to be passive recipients of care: to take their pills obligingly, get their colonoscopies on the appointed date, and to consent to the surgeries we recommend. In health behaviors such as diet and exercise, patients are instead active promoters of their own wellbeing.

This altered power balance in which the patient has control and the provider has only influence can make health care practitioners who are used to being in charge feel deeply uncomfortable. However, with a third of all premature deaths in America attributable to health behaviors, there is tremendous opportunity here to better our nation’s health by partnering with patients to promote more healthy behaviors.

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A Brief Intervention for Behavior Change

This essay is based on a talk I gave to medical students and faculty at the Perelman School of Medicine at the University of Pennsylvania on how physicians can help patients achieve behavior change.

Developing instincts

heart_attackThis image is enough for most of you in the audience to start building your differential diagnosis. When this older gentleman shows up in your emergency department sweating profusely and complaining of chest pain, you’re going to instinctively reach for an aspirin and an EKG.

Much of our medical training is focused on these kinds of situations where procedural memory helps us act quickly and effectively. This is important because when we’re in a time limited and stressful situation, it can be difficult to think clearly and so we need to develop good instincts.

Yet let me turn the clock back twenty years, well before his coronary arteries are overrun with plaque. What happens when this same patient shows up to your outpatient practice and during a routine exam you find out that he smokes a pack of cigarettes a day?

You’ve got 5 minutes until you see your next patient. Once again, you’re time limited and stressed. What do you do? Are you still ready to act?

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Why do we pay more to treat illness than prevent it?

(The following has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

David Asch, Mark Pauly, and Ralph Muller have a great piece in this month’s New England Journal of Medicine on how we as a society think about preventive versus cancer care. They observe that whenever preventive care strategies are studied, there is an obsessive concern with the return on investment of these strategies and that this same scrutiny is not applied to cancer care.

The entire article is well worth reading, but in summary their argument is that this difference occurs because:

  1. Cancer care is more profitable for healthcare providers than preventive care.
  2. There are more well-defined and evidence-based strategies for cancer treatment than for preventive care.
  3. Seeking reward for treating illness is a much stronger motivator than avoiding penalty for failing to prevent illness.

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Rationing through self-triage, my patient perspective

As I fell off the curb, my first thought was about my deductible.

Earlier in the year, I had tried to save a little money and chose a high deductible plan. This meant that I would have to pay the full cost of any doctor visit (including my primary care provider) until I had spent down my $6500 deductible. With an emergency department visit costing hundreds of dollars, I worried that my clumsiness had effectively wiped out whatever premium savings I had achieved with this choice.

In choosing a high-deductible plan, I had gambled that I could get through a year without illness and in the process fallen victim to my own optimism bias. As my ankle rolled inward and I heard an extremely unsetting *snap*, I felt very stupid about it.

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Alan Pean and the use of excessive force

When Alan Pean, a patient St. Joseph’s Medical Center, was assaulted and nearly killed by off-duty police officers, it highlighted the need for better police training to de-escalate tense situations without the use of deadly force. More broadly, it highlighted the need for broad reforms to reduce the use of excessive force. Campaign Zero has a list of specific policies that can accomplish this goal.

DeRay Mckesson, a ‪#‎BlackLivesMatter‬ activist and Baltimore mayoral candidate, brought these policy proposals to President Obama this week during a inter-generational meeting of civil rights leaders. Obama promised to look into implementation of these policies, a promise I hope he keeps and one that I hope both the Sanders and Clinton campaigns support.

If we are to have a culture that celebrates the sanctity of life and promotes justice, reducing the rate and racial disparity of excessive force is essential.

Alan Pean sought refuge

Alan Pean, a college student with bipolar disorder, recognized in the midst of a manic episode with terrifying delusions that he needed help. Driving to the first emergency room he could find, he sought refuge in our medical system.

As he lost track of reality and a frightening paranoia set in, he became agitated. At another hospital, personnel trained in de-escalation might have helped re-orient him to his surroundings and calm the situation. A doctor may have given him Haldol to calm his storming mind and help him sleep until the morning when a trained psychiatrist could have tended more thoroughly to his suffering.

Unfortunately, he ended up in the wrong hospital that day. He ended up at a hospital patrolled by armed off-duty police officers with no training in de-escalation and insufficient experience helping patients having psychiatric crises. Rather than help Alan, they shot him the chest, rupturing his lung. The bullet passed within millimeters of his aorta, millimeters of his life.

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Subsidizing U.S. healthcare

In this month’s issue of the American Journal of Public Health, Drs. Steffie Woolhandler and David Himmelstein of Harvard Medical School describe the extent to which our healthcare costs are already largely subsidized by the government.

In fact, between the tax subsidies for employer-sponsored insurance, Medicare, Medicaid, and insurance for public employees, the government already pays for 65% of all U.S. health expenditures, amounting to $6,560 per person in 2015. For less than this countries like Canada are able to offer universal coverage without the extremely expensive premiums and deductibles we are saddled with in the United States.

Woolhandler and Himmelstein argue that the excess we pay is essentially a handout to healthcare industries. When so many Americans are struggling with stagnant wages, is it wise for us to be doling out cash to these companies?

Read their op-ed here: “Single-payer health plan wouldn’t cost U.S. more”

An insurer’s perspective on healthcare costs

Jonathan Blum of CareFirst BlueCross BlueShield gave a great talk on delivery system transformation at the Leonard Davis Institute today. As someone that has worked for the Center for Medicare and Medicaid Services (CMS) on cost-control initiatives and now does similar work for a commercial insurer, he had a unique perspective on optimal strategies for curbing the rise in healthcare spending.

Unsurprisingly, he pointed out that brand name medications are a major driver of rising costs for health insurers (and thus a major driver of rising premiums). For both personal and legal reasons, insurers have a hard time saying no when physicians and patients push for expensive treatments.

Drug companies know this and so they have a extremely strong negotiating position when choosing a price for their therapy. They rightly predict that individual consumers, pressured by glossy advertisements, will demand their expensive medications; insurers will be unable to say no for an extended period of time; and when these costs push up premiums for everyone, this consequence will be so dissociated from its cause that it will lose emotional salience to the general public.

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Monitoring outcome-switching in medical journals

Outcome-switching (changing the what outcome you measure after an experiment has started) can invalidate statistical methods leading to false positives and problems with trial replication. Yet, most scientific journals have not reliably reported when this has been happened.

Compare-Trials.org tracks outcome-switching with public registries and then encourages journals to issue corrections, yet some major journals such asAnnals of Internal Medicine have resisted this form of transparency. Scientifically valid results require scientifically valid methods, and it is concerning when major medical journals are not holding themselves to modern standards of scientific rigor.

“Make Journals Report Clinical Trials Properly”

Early results from Mexico’s sugar tax

Mexico has one of the highest rates of soda consumption, overweight, and diabetes in the world. The average Mexican adult drinks 163 liters of soda. 72% of adult Mexicans are overweight, and 15% have diabetes.

In the fall of 2013, the Mexican federal government passed a 10% tax on sugar-sweetened drinks. The following year, purchases of these beverages decreased an average of 6% relative to the counter-factual (controlled for seasonal and pre-existing trends), indicating that this tax was an effective deterrent. Evaluating the public health benefits of this tax will require more time, but this is a promising early result.

While hard evidence for dietary interventions is difficult to gather, much of what we know already argues for a compelling public interest in curbing the consumption of refined sugar similar to the public interest in decreasing smoking or excessive alcohol consumption.

A tax on refined sugar with proceeds going to consumer-level fresh produce subsidies would be a great way for us to invest in a healthier future for ourselves.

“Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study”