Saturday, May 4, 2013

If this was a pill, you’d do anything to get it - Washington Post

When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It's not his graph, he's quick to say. Coburn is not the sort to take credit for other's work. But it's a graph that explains why he's doing what he's doing. It's a graph he particularly wishes the folks who run Medicare would see, because if they did, then there's no way they'd be threatening to shut down his program.

The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it's below 100. When's the last time you heard of an American dying from diarrhea?

"For all the millennia before this in human history," Coburn says, "it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn't have 85-year-olds with chronic diseases."

With chronic illnesses like diabetes and heart disease you don't get better, or at least not quickly. They don't require cures so much as management. Their existence is often proof of medicine's successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today's medical system: Its successes have changed the problems, but the health-care system hasn't kept up.

Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. "This is the Willie Sutton rule," he says. "If 80 percent of the spending is going to patients with five or more conditions, that's where our health-care system needs to go."

Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they're healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.

Most care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. That model has mostly been a failure. And while many health systems send a nurse regularly in the weeks or months after a serious hospitalization, few send one regularly to even seemingly healthy patients. This a radical redefinition of the health-care system's role in the lives of the elderly. It redefines being old and chronically ill as a condition requiring professional medical management.

Health Quality Partners' results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.

Others in the profession have taken notice. "It's like they've discovered the fountain of youth in Doylestown, Pa.," marvels Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.

Now Medicare is thinking of shutting it off.

Lucrative potential

The origin of Doylestown's fountain of youth is not particularly mysterious or mythic. It can be found on Page 93 of the 1997 Balanced Budget Act. Under "Subchapter D — Other Projects," there are two pages of dull legislative language authorizing Medicare "to conduct demonstration projects for the purpose of evaluating methods, such as case management and other models of coordinated care, that (A) improve the quality of items and services provided to target individuals; and (B) reduce expenditures."

In the health-care world, however, these yawn-inducing paragraphs sounded like the beginning of a revolution — or, perhaps, a gold rush.

The project was remarkable in two ways. First, it used the gold standard of experimental design: Randomized-controlled trials. Each of the 15 programs — of which HQP was one — would see some seniors enrolled in the program and some left out. The assignment would be random, and the groups similar — that would let the researchers be certain that whatever differences they saw between the groups were attributable to the care they received rather than, say, the company's success at signing up healthier seniors. "We did it that way so nobody would ever question the validity of the findings," says Randall Brown, a senior fellow at Mathematica Policy Research, the outside evaluator Medicare hired to judge the programs.

The second unusual feature was that the secretary of Health and Human Services had the authority to scale it up. Typically, Congress keeps tight hold of the reins on these kinds of experiments. But not this time. As long as the programs were increasing quality without increasing costs, the secretary could "continue the existing demonstration," "expand the number of demonstration projects," or even "issue regulations to implement, on a permanent basis, the components of the demonstration project that are beneficial to the Medicare program." It was, for an experiment of this type, an extraordinary, and extraordinarily rare, amount of authority.

That made it potentially very, very lucrative. A midsize care-management company that proved itself in this demo could, theoretically, get the green light to provide services to every chronically ill Medicare patient. Everyone understood the implications immediately: There were billions of dollars on the table. And there were plenty of for-profit companies who were certain they'd be able to get them.

"I was at conferences when this was all getting underway," Brenner says. "These huge vendors from these really big companies had gotten into this. I remember all these really well-dressed people strutting on the stage. They thought they were going to get access to the gold mine of health care. I remember seeing them speak and thinking, 'I can't be this dumb.' I couldn't understand how their models would work. I've never seen a telephone call change behavior."

Their models — and their telephone calls — didn't work. Program after program either failed to help patients, save money or both. "You'll see some disease management programs out there led by MBAs or people who used to be doctors and are now businessmen," Brown says. "They're totally different kettles of fish. They tend to be telephonic, and the telephone centers might be in California or Missouri. They don't work. We've shown it time and time again."

But Health Quality Partners, with its emphasis on continuous nurse-to-patient contact, did work. Of the 15 programs, four improved patient outcomes without increasing costs. Only HQP improved patient outcomes while cutting costs. So Medicare extended it again and again — now it's the only program still running under the demo. But Medicare has notified Coburn that it intends to end HQP's funding in June.

Medicare's official explanation is carefully bureaucratic. "The authority that CMS had to conduct this specific demonstration, which predated the health care law, did not allow us to make the program permanent and limited our ability to expand it further," says Emma Sandoe, a spokeswoman for the Centers on Medicare and Medicaid Services. "As we design new models and demonstrations, we are integrating lessons from this experience into those designs."

Every expert I spoke to — as well as a plain reading of the law — disagrees. If they wanted to make HQP permanent, or scale it up in a big way, Medicare has the power to do so. Then there's this: "Thanks to the health care law, we can now test new, innovative models for delivering health care and expanding models that show promise," Sandoe continues. "With this new authority, we can take best practices to scale and provide more incentives to deliver high-quality health care at lower costs."

Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP's lessons. It's not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP.

To Health Quality Partners and its defenders, Medicare's decision is ludicrous. "We're spending tens of billions of dollars now on Medicare innovation where Medicare already discovered something amazing and now they're forgetting what they discovered?" Brenner says. "It's an amazing government moment."

But to Medicare, it's not so much forgetting as being realistic. After all, HQP worked, but most of the programs in the demonstration didn't. It notes that HQP is a relatively small program that only ever treated a couple of thousand people. For a program the size of Medicare, working to scale up a small operation like HQP seems less likely to deliver a big return than working to change the payment structure that governs the entire system.

This drives Coburn crazy. "People always ask if what we do is scalable. Well, define scalable. It's less difficult than open-heart surgery, which is one of the most common surgeries in the country, and it's more difficult than giving a vaccine. There's this amazing double standard in medicine. For the kind of thing we do, if it's more difficult than making a phone call once in awhile, then it's not scalable. But you provide enough economic incentives and all of a sudden every hospital has an open-heart surgery program."

Brenner puts it more vividly. "There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you'd say, 'Of course I want that.' But then you'd say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you'd say, no, you just have to have a nurse come visit her every week."

Making the house call

Here's what I thought would happen when I went with Patty Graefe, a Health Quality Partners' nurse, on her daily rounds: I thought I would see a highly skilled medical professional showing off her success stories. I thought I would meet seniors who were overwhelmed by their illnesses a few years back, but since signing up for the program, were now carefully protecting their health. Nothing else, I figured, could possibly justify the numbers HQP seemed to be producing.

Instead, I met Paul and Betty Bradfield.

Getting to the Bradfield's house is harrowing. You drive over a stone bridge that looks neither wide enough nor structurally sound enough to support a car. You nose up a curving road that has been cut into a steep hill. You walk past a giant pile of wood into the sort of old, rickety farmhouse that quickens the step of kids on Halloween. It's a place I might be scared to live. It's a place I'm definitely scared to find Paul and Betty living.

Paul, at 83, suffers from serious heart failure and mild cognitive impairment. A year ago, he climbed a ladder to change a birdfeeder at 10 o'clock at night. He fell, breaking his neck. Betty, at 80, is legally blind and has diabetes.

The Bradfields are warm hosts, and clearly glad to see Patty. But their situation isn't good. "I messed up on my medication this week," Paul says, shortly after we walk in the door. He's not sure how. It's possible he took a double dose. Or it's possible that he skipped a dose. And he's already thrown away the evidence. "I'm not worried about the mess-up," Graefe says kindly. "I just need to figure out if you took a double dose." She makes a note to call Paul's doctor.

Graefe has been a nurse for 28 years. She has worked in cardiac wards and with patients in rehab. She has been in hospitals, in call centers, and now on home visits. "This is the best nursing I've ever done in my life," she says. "And that's because it's really all about nursing."

As a hospital nurse, Graefe worried she wasn't able to build the trust she needed with her patients. "I dealt with a lot of heart failure," she says. "A patient would come in, filled with fluid. You'd ask them whether they were taking their medicine. Or if they were eating right. The patient gets almost defensive because we always assume they're doing something wrong. I found that the hospital setting wasn't the best place for these conversations."

I asked a half-dozen seniors what difference Health Quality Partners made in their lives. Every one of them began the same way: They could ask their nurse questions, they said with evident relief. They could get help understanding and navigating their doctor's orders. They didn't feel like they were being a burden if they needed to ask one more thing, or have their medications explained to them again.

Physicians are brusque, and harried, and they talk quickly and confidently, and chronically ill seniors often leave with complicated instructions and a hazy understanding of how to follow them. "In a doctor's office, a lot of people, especially older people, feel pressure to get out because they know the doctor is busy and they're a bit intimidated," says Bill Allen, a friendly 78-year-old who is also a patient of Graefe's. "Because she's here in our home, you can feel more free to ask her anything. It's great."

As a nurse, Graefe's style is practical and nonjudgmental. It seems obvious that chronically ill seniors should take their medicine. But Graefe doesn't see the situation as quite so black-and-white. "You have to find out why a patient isn't taking their medicine," she says. "In the case of heart failure, the water pill has a lot of side effects. Imagine losing control of your bladder. Not being able to go out because you always need a bathroom. We're talking about adults here."

This is, to me, the surprise of accompanying Graefe on her rounds. Despite the years-long relationships, she's not turned her patients into highly effective self-
caregivers. Everyone we see admits to missing their medicine or making bad diet decisions or slacking on exercise routines. Graefe just laboriously pushes them to make slightly better decisions on the margins. The Bradfields, for instance, are, after years of cajoling, finally readying themselves to enter assisted living — something that might not have happened at all without Graefe's nudging.

Because she has been to patients' homes so many times before, she can see when something has changed and things are about to go very wrong. And she's got the personal relationship to intervene. Allen, who suffers from lung problems but hates to take medicine, recalls a bad cold he had a few weeks ago. "Because of Patty's insistence, I ended up using the — what do you call it? — the nebulizer. I probably wouldn't have done it without her. And I probably would have ended up with pneumonia again. I'm sure that's what got me through." It also saved Medicare money, and perhaps saved Allen's life.

We think of the hospital as a place people go to get better. At Health Quality Partners, the view is that a hospital is a place where seniors get worse. "Being in the hospital for three days or five days sets them back to a point where they'll never regain what they were," says Sherry Marcantonio, chief program architect of HQP. "That's where the scales tip. That's where people end up needing a nursing home." Keeping seniors out of the hospital, which is a core focus of its program, cuts costs and saves lives, but it also preserves quality of life — a measure often ignored in these discussions. There's a good argument to be made that if a program like HQP cost slightly more than traditional Medicare but cut hospitalizations by a third, it would still be worth it. The point of health care, after all, is to keep people healthy. But HQP saves money — and lots of it.

If there is a secret to the success of Health Quality Partners at preventing hospitalizations, it's this: No one else is checking in with the Bradfields or the Allens every week. Medical technology — from pills to devices to surgical procedures — is so advanced and so competitive that making further gains requires enormous investment and rarely brings high returns. But the exciting field of knocking-on-the-Bradfield's-farmhouse-door is almost totally empty. Medicine has been so focused on what doctors can do in the hospital that it has barely even begun to figure out what can be done in the home. But the home is where elderly patients spend most of their time. It's where they take their medicine and eat their meals, and it's where they fall into funks and trip over the corner of the carpet. It's where a trained medical professional can see a bad turn before it turns into a catastrophe. Medicine, however, has been reluctant to intrude into homes.

For the most part, the medical system treats the old very much like it treats the young. It cares for them when they're sick and ignores them when they're well. Coburn's basic insight is a discomfiting one. He doesn't really believe in "better," at least not for elderly, chronically ill patients. He wants someone going over frequently to see if they're depressed, if their color is good, if they understand their medications, if there's anything they need. This isn't medicine so much as it's supervision.

At another time, these functions would have been filled by the family, who would be right in the other room, and who would know if their mother looked different than she had a few weeks ago. But few of today's elderly live with their children. Many don't even live in the same state, or they don't have any contact with their children, or they don't have children.

A recent study in the Proceedings of the National Academy of Sciences found that after adjusting for demographic factors and underlying health, social isolation increased the likelihood of death among the elderly by a stunning 26 percent. "People with few social contacts may not have people around them who can give them advice, recommend that they go to a doctor with symptoms, ensure that they maintain healthy lifestyles, or perhaps they don't have anyone around when they experience acute symptoms," says Andrew Steptoe, the lead author on the study.

We've been conditioned by "Grey's Anatomy" and hospital rooms to believe that saving lives is a complicated, heroic business. And it is — after people get very sick. But keeping them from getting very sick doesn't necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they're doing. The problem is, it's hard to make money off it.

The uneven legacy

If you go into the hospital for heart surgery and you end up getting a central-line infection, you'd hope that the hospital would be penalized for it. The opposite, in fact, is true. According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients.

This, too, is a legacy of a health system built for acute care. Hospitals make money when they do more to patients. They lose money when their beds are empty. Put simply, Health Quality Partners makes hospitals lose money. "There's no doubt that it's a hit to the bottom line," says Rich Reif, the former CEO of Doylestown Hospital, which worked with HQP.

Reif's answer for why he worked with a group that cost him money is simple: His hospital was unusual. In 1895, 14 women came together to form Doylestown's "Village Improvement Association," which was dedicated to "the health and beauty" of the community. The association actually owned Doylestown Hospital, and its mission was the hospital's mission. "I did get some heat from my senior management team," Reif says. "When you're doing annual budgets you see reduction in revenue. But I could always come back and say, 'Wasn't that our responsibility?' "

But not all hospitals are run by the local Village Improvement Association. Many seek to turn a profit. That makes models like Health Quality Partners something of a threat. "If we scaled what Ken is doing," Brenner says, "you would probably shut down a third of the hospitals in the country. It's a disruptive innovation. It just guts the current business model."

This is where Medicare's focus on changing that payment model could help programs like HQP. It's pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient. If they spent less, they could keep the difference. In theory, this should push them to partner with tested organizations like HQP that have a proven ability to help them spend less. But many experts are skeptical that ACOs will be the game changer Medicare hopes.

"I don't have a lot of confidence in the ACOs working out," Mathematica's Brown says. "None of the ACOs you talk to are willing to say which hospital they'll close. And the only way to save big money in a system is to reduce hospitalizations. That means you need fewer hospital beds. You can't make money off of an empty hospital. So until they're talking about closing some local hospitals to realize the gains from reducing hospitalization, they're not going to be saving much money."

Robert Berenson, a Medicare expert at the Urban Institute, is also skeptical. "To understand ACOs, you have to go back to the physician group practice demo. That was the basis for the ACOs. It was the model adopted into law in the Affordable Care Act. It was these 10 multispecialty groups, and the idea was we'll pay you fee-for-service and if your total spending comes in under the control group's costs, you get to share the savings. Everybody thought it was a great success, but when the results came in, it didn't save any money at all. The one exception was a plan called Marshfield, perhaps because it wasn't based in a hospital and so could keep people out of hospitals."

This is a tough truth of the health-care system: It's got a lot of incumbents, and a lot of fixed costs, and reforming the way care is delivered will mean creating a lot of losers. "This is about power and money," Brenner says. "The largest group in the top one percent of income in America are physicians."

The chronic-care focused system that Coburn is pioneering is more about nurses than doctors, more about home visits than hospitals, and more about human interaction than high-tech intervention. A system based on managing chronic care is a truly different system from the one we have today. Health Quality Partners was lucky to find a hospital that wanted to work with it. But many hospitals wouldn't want to work with a program dedicated to sharply reducing their revenue stream. And without cooperation from the hospital and a patient's doctors, the HQP model would fail.

The only payer with the size and the incentives to push something like HQP is Medicare. "For them to say it's not their responsibility to scale a program like this is ridiculous," Brenner says. "They send market signals all the time. One day it's an experimental oncology procedure and the next day everyone is using biologicals. That's because of them and what they pay. They're the ones who scale this stuff. It feels to me like they're scared to pull a lever on a very clear market signal. But if they said here's Ken Coburn's model, here's the code for it, here's how much we'll pay for it, and, by the way, we'll overpay for it, because we think it's important, the marketplace would drive that."

They could stop far short of that, of course. They could begin another demonstration project that took the lessons of HQP and used them to seed 15 more programs. There is, after all, a flip-side to the skepticism over whether the program can scale. It's possible Coburn's model, which has been run on a shoestring budget, could, with real resources, be improved. Coburn is quick to agree. "I really think we're just at base camp. There are so many contributors to health the system isn't addressing right now. As proud as I am of what we're doing, I think we're just scratching the surface of this stuff."

It wouldn't cost Medicare very much to find out. Quests for the fountain of youth have been launched from far flimsier maps.

Friday, May 3, 2013

Comedian Tig Notaro Shared Her Personal Tragedy With The World And Made Us Laugh - Business Insider

The comedian Tig Notaro did something truly revolutionary in August 2012.
She'd just been diagnosed with cancer in both breasts, and she stepped onto a stage in Los Angeles where she'd originally planned to tell jokes. The jokes didn't come, though.

Instead, Notaro talked about her cancer and the string of tragedies she'd experienced in the span of just four months. This is not the typical formula for an evening comedy show.

"With humor, the equation is tragedy plus time equals comedy," Notaro said that night. "I am just at tragedy right now."

Notaro — an androgynous 41-year-old with deadpan humor — continued to go over the truly crappy things that were still troubling her during a set that has since become legendary. The cancer diagnosis. The sudden death of her mother. A breakup. To top it all off, Notaro got a life-threatening intestinal disease that left her frighteningly thin.

"The condition I had in the hospital is called C diff. And so I just refer to it as the C diff diet. You just sit there and watch the pounds melt away. Don't like exercising? Who does, girlfriend? This diet does all the work for you. Just clear all the bacteria from your intestines and let the C diff whittle way at your waistline," she said that night.

A week after she got out of the hospital, her mother died.

"I know, it's hilarious. Then I went through a break up, right in the middle of it all. It's tough times. You can't stick around for that. Got to get out before the cancer comes," she added.

The audience was rapt. People looked on sympathetically, but they also laughed. At one point, she suggested telling goofy jokes instead of talking about her cancer, to which one man shouted, "This is f---ing amazing."

Notaro's dry take on her cancer that night was indeed funny. It was also incredibly raw and one of the most emotionally honest performances in recent memory. (You can listen to the entire thing here.)

"It's OK. It's going to be OK. It might not be OK. But I'm just saying, it's OK. You're going to be OK. I don't know what's going on with me," she said.

She didn't plan on going on stage to talk about her tragedy. The first part of her performance — "Good evening. Hello. I have cancer." — popped into her head in the shower an hour and a half before the performance, Notaro told Business Insider.

Once she got on stage, she says, she was consumed with thoughts of dying.

"I was just so scared that my life was about to slip away. When I went on stage I didn't have all the information yet," she told us. "It [The cancer] was bilateral. It was invasive. I just didn't know a lot. It was standup but it was also just me being on my knees in a way."

It turns out Notaro will probably be fine. She had a double mastectomy, and there's only a 7% chance that her cancer will come back.

But her few moments on her knees before a live audience have touched a lot of people. She gets letters every single day from people with cancer, and from people who are dying of other diseases. People tell her she's helped them get through their own impossibly rough times.

"This one guy he was in his early 30s and he had pancreatic cancer he said he felt like it [her set] gave him courage, like he could do this," Notaro said. "And it was terminal cancer."

If it's difficult to imagine how somebody who's dying can get courage from a comedy set, consider these observations on Notaro's set from the comic Louis C.K.

"Tig took us to a scary place and made us laugh there," he writes. "She proved that everything is funny. And has to be."

By taking everybody to that scary place, Notaro showed us that we can stare tragedy in the face and laugh despite our terror. Notaro admits the cancer has changed her. She's more honest than ever, and she doesn't stay angry at people. But one thing won't change.

"I love silliness," she says. "That will never go away."

Thursday, May 2, 2013

Molecules in the brain trigger ageing : Nature News & Comment

The area of the brain that controls growth, reproduction and metabolism also kick-starts ageing, according to a study published today inNature1. The finding could lead to new treatments for age-related illnesses, helping people to live longer.

Dongsheng Cai, a physiologist at Albert Einstein College of Medicine in New York, and his colleagues tracked the activity of NF-κB — a molecule that controls DNA transcription and is involved in inflammation and the body's response to stress — in the brains of mice. They found that the molecule becomes more active in the brain area called the hypothalamus as a mouse grows older.

Further tests suggested that NF-κB activity helps to determine when mice display signs of ageing. Animals lived longer than normal when they were injected with a substance that inhibited the activity of NF-κB in immune cells called microglia in the hypothalamus. Mice that received a substance to stimulate the activity of NF-κB died earlier.

"We have provided scientific evidence for the concept that systemic ageing is influenced by a particular tissue in the body," says Cai.

Health and well-being

The researchers examined the health and mental abilities of the mice six months after the initial experiment. Animals injected with the NF-κB inhibitor performed better than controls on tasks designed to test their cognition and movement. They also showed less age-related decline in muscle strength, skin thickness, bone mass and tail-tendon integrity. The mice in which NF-κB was activated experienced more age-related decline. The results were similar in males and females.

Most previous studies have simply observed how long mice live after treatment, says Richard Miller, a pathologist at the University of Michigan in Ann Arbor. "Looking at different aspects of age-specific functions is a very good idea," he says. "It makes a much stronger case that the whole ageing process has in some way been decelerated."

Treating middle-aged mice to suppress the production of IKK-β, an enzyme that activates NF-κB, in microglia in the hypothalamus also reduced age-related cognitive and physical declines. Suppressing IKK-β in all areas of the brain increased median lifespan by 23% and maximum lifespan by 20%.

The researchers report that NF-κB counteracts the effects of a hormone called gonadotropin-releasing hormone (GnRH), reducing brain-cell growth and shutting down the mice's reproductive systems. Injecting mice with GnRH slowed down ageing and triggered the growth of new brain cells. That suggests that inflammation and stress are an evolutionary signal to the body to stop reproducing, which triggers the start of the ageing process. 

The findings are "a major breakthrough in ageing research", says David Sinclair, a molecular biologist at Harvard Medical School in Boston, Massachusetts.

He says that a key finding is that blocking the effects of NF-κB produced anti-ageing effects even when it was done in middle age. "If we're going to translate this research into medicines that can help people, clearly we cannot start very early in life."

The research "is certainly worth a lot of additional attention", says Miller. He thinks that Cai's study will stimulate research into treatments for slowing down age-related illnesses that are linked to inflammation, such as arthritis, diabetes and Alzheimer's disease. 

When the Doctor Is Overweight -

Dr. George Fielding, a pioneer of weight loss surgery in Australia, remembers how patients treated him in the late 1990s, when his weight reached 330 pounds on his six-foot frame. He would meet new patients, dressed in Armani suits and feeling on top of the world, and then be abruptly upended.
"They'd say, 'Mate! You're sitting there telling me I need it? You need to have your surgery!' "
Despite being an internationally recognized expert on lap band and gastric bypass surgeries, Dr. Fielding knew that his appearance was dissuading some patients from using his services. And years of yo-yo dieting and extreme exercise hadn't helped him keep the weight off.
"People would come for consultations and say they would do it, and then they didn't come back," said Dr. Fielding, who now works at New York University's Langone Medical Center. "I knew they were probably thinking, 'Wow, he's fat! Is he any good?' "
So Dr. Fielding wasn't at all surprised by the results of a recent study in the International Journal of Obesity showing that patients secretly — or not so secretly — look with disdain on doctors who are overweight or obese. Just as overweight people are stigmatized in an array of professional and personal settings, overweight doctors are seen as less credible than "normal weight" doctors, and patients are less likely to follow their medical advice, the study found.
The study's stinging conclusions resonated, too, with Dr. Deep Ramachandran, a pulmonary critical care and sleep doctor at Genesys Regional Medical Center in Grand Blanc, Mich. After administering tests exploring his patients' breathing irregularities, he often has to tell them a blunt truth: they need to lose weight.
That can be a particularly tough message for this messenger to deliver. Dr. Ramachandran, 42, says he has a body mass index of 38 and should lose at least 60 pounds.
"It's easy for doctors to assume that once we put on the white coat, patients will listen to what we say," he said. "But this study says the white coat doesn't protect you. You have to own your problems and communicate with patients in ways they can understand."
So he often tells patients that he, too, struggles with weight loss and knows how hard it is.
"How do we deliver a message that may be seen as hypocritical? I don't know the answer," Dr. Ramachandran said. "But doctors are human beings first and scientists second. We are subject to the same maladies as the rest of society. It's an incredibly difficult problem, and a challenge."
The bias against overweight people is so socially accepted, said Dr. Rebecca M. Puhl, the lead author of the study and the director of research and weight stigma initiatives at Yale University's Rudd Center for Food Policy and Obesity, that "despite all the doctor's training and expertise, it can jeopardize the doctor's ability to have a conversation about health care with the patient."
Patients seem to hold doctors to a stricter standard: "If you're a health professional, people think you shouldn't be struggling with weight," said Dr. Puhl, who is a clinical psychologist and has conducted extensive research into weight stigma.
For the study, the Yale researchers randomly assigned 358 participants — about 57 percent female and 70 percent Caucasian, with an average age of 37 — to complete one of three online surveys about a hypothetical doctor, responding to questions like whether they would choose the doctor as a provider, follow the doctor's advice about exercise and losing weight, or consider the doctor credible and trustworthy. The only difference among the versions — indeed, the only identifying characteristic about the gender-neutral doctor — was whether the doctor was "normal weight," "overweight" or "obese."
The researchers also included a widely used "fat phobia" list of 14 pairs of adjectives that ranks the respondent's perceptions on a scale. Typical pairs include "lazy/industrious," "good self-control/no self-control" and "attractive/unattractive."
Those who answered the surveys about doctors described as overweight or obese were significantly more likely to change providers than those with doctors described as being of normal weight, regardless of the weight of the patient. The higher respondents' fat phobia scores, the more likely they were to place their trust in a physician of "normal weight."
Dr. Fielding, the Australian bariatric surgeon, knows firsthand the change in attitudes that can occur in patients and colleagues when they deal with doctors of different weights. Since having lap band surgery 13 years ago, at age 43, he has maintained his weight at 210 pounds, following a regimen of regular, moderate exercise and 800 calories a day. "I was treated completely differently by patients and doctors," he said. "They weren't distracted by the fact that I was fat."
He acknowledged that the respect now automatically conferred on him sometimes ignited an ancient flicker of resentment. "I'm the same guy, still George," he said.
Dr. Puhl suggests that medical professionals have a front-line position to change the bias against people who are overweight and should make sure that patients understand the many factors that contribute to excess weight, including genetics, food chemistry and the biology of satiety.
"Then shift the conversation from weight loss to health behaviors that patients can improve, regardless of body weight," she said. "I've met enough people who are thin and unhealthy because of drinking or smoking, or are overweight by the B.M.I. but are very healthy. And that is true for doctors as well as patients."

Wednesday, May 1, 2013

Will Obamacare work? A new study out of Oregon challenges shows universal health care’s limits - Ray Fisman - Slate Magazine

In 2008, the state of Oregon initiated an ambitious health care policy that allowed researchers to shed light on the effects of guaranteeing Medicaid coverage for low-income adults. The results have been closely followed in large part because insurance for the poor is a major component of the Affordable Care Act—aka Obamacare—that will soon be rolled out across the country.
study published on Wednesday in the New England Journal of Medicine reports that—at least as far as health outcomes are concerned—the Oregon Medicaid experiment hasn't lived up to the hopes of many universal care advocates. Two years after getting randomly assigned to Medicaid coverage, recipients fared no better than a control group of uninsured, low-income Oregonians in tests for hypertension, cholesterol, and diabetes treatment—all medical conditions that can be managed with proper care. The Medicaid recipients did report much lower rates of depression and—perhaps relatedly—were much less likely to be on shaky financial footing than those in the control group. But the Oregon study's findings indicate that the claim that universal health care on its own will make Americans healthier, at least in these particular dimensions, may be wishful thinking.
The Oregon Medicaid experiment was initiated in 2008, when the state opened a waiting list for a limited number of new spots in the Oregon Health Plan Standard. OHP Standard provided Medicaid insurance to poor, able-bodied adults who didn't meet the usual conditions for Medicaid. Nearly 90,000 Oregonians applied for the 10,000 slots, and the state picked the lucky Medicaid recipients by lottery. This gave researchers a group of insurance applicants who were identical in every way. If the lottery winners ended up in better health, it wouldn't be because of some pre-existing condition or circumstance: Their insurance status was quite literally the luck of the draw.
The early results from the experiment, based on surveys performed a year following initial Medicaid assignment and released in the summer of 2011, seemed promising. I described them for Slate in an article titled "Does Health Coverage Make People Healthier?" The answer then was a tentative yes: Oregon Medicaid applicants who were randomly assigned to receive insurance reported that they utilized more preventive care, felt in better health, were more stable financially, and overall just a whole lot happier than those who didn't win the insurance lottery. At the time, conservative commentators cautioned that the liberal media—of which I am a proud member—were overhyping the study's implications. The results were promising but far from conclusive; they weren't based on actual health outcomes but instead things like health care usage (trips to the doctor, use of preventive care, and so on) and self-reported health status ("Are you in poor, fair, or excellent health?") rather than actual health outcomes.
Now that the clinical results have started to come in, it's time for liberal media types like myself to eat some humble pie. Today's New England Journal article presents a set of findings showing that Medicaid had no effect on a set of conditions where you would expect proper health management to make a difference. There are effective treatment protocols for hypertension, cholesterol, and diabetes, yet insurance status had no effect on blood pressure, cholesterol levels, or glycated hemoglobin (a measure of diabetic blood sugar control).
At the same time, some of the early hopes for the OHP are borne out in the recent data: Medicaid recipients had much better mental health than their control-group counterparts. Based on clinical diagnostic criteria, the insured were about one-third less likely to be depressed than those not assigned to Medicaid. And the financial benefits of insurance also remained: Insurance proved particularly important in shielding study participants from medically induced financial catastrophe—5.5 percent of the control group reported spending more than 30 percent of their annual income on health care, as compared to just about zero for those assigned to receive Medicaid. According to Amy Finkelstein, an MIT economics professor and one of two principle investigators on the study, this is a critical observation since, "a primary purpose of health insurance is to protect individuals financially in the event of adverse health events, and our findings show that Medicaid does just that." (As in the earlier study, Medicaid also translated into more use of medical services, with coverage leading to increased doctor visits, use of medication, and compliance with recommended preventive care like mammograms and cholesterol screening.)
Overall, can the Oregon Medicaid experiment be declared a success or failure two years on? As the study's other principle investigator, Katherine Baicker of the Harvard School of Public Health, puts it, the findings are like a health insurance ink blot—people see in it whatever they need to validate their existing position on Obamacare and universal coverage for the poor more generally. Those opposed to government care point to the lack of any measurable effect on health outcomes. Insurance advocates naturally highlight the importance of Medicare in reducing stress and its value as a financial cushion. Medicare is in large part health insurance that is meant to shield those covered from the ruinous effects of a health disaster. OHP seems to have been extremely effective in eliminating such catastrophic financial outcomes. And maybe two years isn't enough time for researchers to see improvements in health, which may accrue over the longer term (though the researchers have focused on health outcomes where improvements should be seen within a two-year time frame).
At the same time, the findings should give pause to even those who are most committed to universal health insurance. We shouldn't expect the Affordable Care Act to make Americans healthier (except in terms of mental well-being). The ACA will put millions of low-income individuals across the country into Medicaid programs that look a lot like what's available in Oregon; such a rapid expansion could overwhelm health care service capacity. If anything, the results of the Oregon study might be optimistic about the results.
If you're committed to better health for the poor, though, the latest Oregon results are not a reason to give up on the cause completely. Rather, the Oregon experiment is yet another argument in favor of the increasingly common view that access to medical care is necessary but far from sufficient for good health. What's the use in prescribing statins to reduce cholesterol to patients who don't take their meds, continue to consume potato chips and soda unabated, and ignore health care providers' pleas to walk more and drive less?
But changing habits, compliance, and lifestyles is a much taller order, and viewing health care in this way can make the Affordable Care Act, despite its enormous ambitions, seem almost too timid or narrow in its focus. It requires that our conception of health care go beyond a passive delivery system of waiting for patients to come into the clinic and get out into the community to reach patients in their daily lives. At least some case studies of successful health interventions emphasize this brand of community-based systemic intervention. It may be that this approach of active outreach—whether delivered by the government directly or by medically minded social entrepreneurs—may be what's required to make America healthier.