Health Business Blog

I’m a health care expert who follows health reform closely, so when I’m confused about something I know most people are. When Massachusetts passed the universal coverage law in 2006 I didn’t understand exactly what the Connector was supposed to do. If they had called it a health insurance store or marketplace or comparison site I would have grasped the concept better. Once it’s explained it’s obvious, but why use the word “connector” in the first place?

The federal Affordable Care Act makes matters even worse. It calls these things health insurance “exchanges.” That word has the wrong connotations. When I hear the word “exchange” I think of a stock exchange. That’s not somewhere I go to buy or compare products or services to use. Others think of “exchange” as what they do when they made a purchase that was the wrong size or received a gift they didn’t like.

Even for health wonks that fully grasp the concept, the word “exchange” is confusing, because the term is also used in the context of health information exchanges, which are used to exchange clinical data. I often hear people asking about the impact of the “exchange” –without specifying “insurance exchange” or “information exchange,” and I have to ask them which they mean.

There’s a simple solution to this: let’s dump the word “exchange” and use a term that’s more understandable and appropriate. How about:

• Store
• Marketplace
• Comparison site
• Supermarket

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For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.

Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, does it?

But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work –or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.

The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in today’s CNN story:

Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage [emphasis mine] will reemerge in the United States.

“We’ve been really worried about the future workforce because we’ve got almost 900,000 nurses over the age of 50 who will probably retire this decade, and we’ll have to replace them,” [economist and nurse Peter] Buerhaus said.

I don’t buy this logic. And I stand by what I wrote almost a year ago in Nursing shortage cheerleaders: There you go again:

My issue with the workforce projections is that they don’t take into account long-term technological change, but simply assume that nurses will be used as they are today. I’ve taken  heat for writing that robots will replace a lot of nurse functions over time. People seem to be offended by that notion and have accused me of not having sufficient appreciation for the skills nurses bring.

So let me try a different tack. Think about some of the job categories where demand is being tempered by the availability of substitutes. Here are a few I have in mind that have similar levels of education to nurses:

• Flight engineers. Remember when commercial jets, like the Boeing 727 used to fly with two pilots and a flight engineer? Those planes were replaced by 737s and 757s that use two-member flight crews instead
• Junior lawyers and paralegals. Legal discovery used to take up many billable hours for large cases. Now much of it is being automated
• Actuaries. Insurance companies used to hire tons of them, but their work can be done much more efficiently with computers

I don’t know exactly how the nursing profession is going to evolve but I do notice that the advocates for training more nurses are typically those who run nursing schools rather than prospective employers of nurses, such as hospitals.

If you want to be a nurse, go for it. But if you’re choosing nursing because you think it’s a path to guaranteed employment, think again.

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I’ve been surprised at the upswell of support for increasing access to mental health services as an antidote to gun violence like we witnessed in Newton on Friday. I’m a big advocate of mental health care but just don’t see how anything we do in that arena would have prevented either of the last two mass shootings.

Accused Colorado killer James Holmes seemed to have plenty of access to mental health. According to Reuters he had been “under the care of a psychiatrist who was part of a campus threat-assessment team.” Meanwhile, Newtown shooter Adam Lanza lived in an affluent community, where a high percentage of residents have commercial health insurance that includes straightforward access to mental health services.

Access to mental health care did nothing to stop Holmes or Lanza, but access to high-powered weaponry enabled mass killings. It seems the case for reducing access to such arms is therefore a lot stronger.

Advocates of increasing access to mental health services would be wise to back away from using the Newtown tragedy as a springboard for their cause, especially when there are so many other sound reasons to  back mental health. Instead I would highlight how offering mental health services to people with depression can free up needed capacity in primary care and lower overall medical costs, and how improving mental health treatment can boost productivity and economic growth. There are also plenty of compelling arguments to make about the opportunity to improve quality of life for mentally ill patients and their families even if they are not as dramatic as preventing a massacre.

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Health insurance in Massachusetts is more expensive than anywhere else in the country and yet the state is able to afford universal coverage. How can that be? An important part of the explanation is that the state values education, and a well educated population yields a highly skilled labor force with high incomes. Those high incomes can support health insurance coverage.

While the US as a whole is a laggard in education –scoring 25th among 34 countries in math, for example– Massachusetts students are world class. In science, Massachusetts is right up there with Singapore, and it does well in math, too where our students rank right below Japan and above Russia. This bodes well for future Massachusetts performance in technology and science fields, which are likely to be major drivers of the economy in the next generation (unless finance takes over everything). There’s no international comparison that I’m aware of for creativity, but I’m willing to bet Massachusetts would come out well there, too.

Achieving meaningful health care reform and universal coverage require more than just passing health care laws. Enlightened policy in multiple fields –especially education– is a critical enabler.

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A New England Journal of Medicine Perspective (Candy at the Cash Register — A Risk Factor for Obesity and Chronic Disease) argues that, “the prominent placement of foods associated with chronic diseases should be treated as a risk factor for those diseases. And in light of the public health implications, steps should be taken to mitigate that risk.”

In other words, the authors would like to see the concept of New York City’s ban on large, sugary drinks taken a step further: restricting where within a store potentially harmful products are placed. A decade or two ago the tobacco industry unsuccessfully tried to defend itself from smoking bans by claiming that this line of reasoning would lead us down the path toward restricting unhealthy foods, like cheeseburgers.

At the time I thought the tobacco campaign was disingenuous and the fears were ridiculous. Second hand cigarette smoke was annoying and dangerous to bystanders, whereas people who eat unhealthy food mainly harm themselves. It seemed implausible to me that we would actually get to food bans. Looking back, I can see that Philip Morris et al. were actually on to something. I’ve even gotten to the point where I can see the logic of rules that restrict the sale of soda in schools, for example.

But that’s as far as I think we should go. While it’s undoubtedly true, as the authors argue, that “food choices are often automatic and made without full conscious awareness,” I don’t agree that this provides sufficient cause to take regulatory action. Instead it would be better to educate people about how their choices may not be as autonomous as they think. Once they understand that, marketing and placement of products may still be effective, but I’m more confident leaving choices in the hands of the consumer.

This education about marketing should be extended further, and I’d particularly like to see physicians have a better understanding of how they are affected by industry marketing and how patients are influenced by drug company ads.

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The New York Times advertising column (In a Forthright Campaign, More Unmentionables Mentioned) highlights a new campaign by Purdue Pharma’s Senokot laxative that asks, “Does your prescription medication give you the burden of constipation?” As the headline suggests, the Times’ focus is on the relaxing of taboos in advertising, but I think they’ve missed a more significant point.

Sure, advertisers used to avoid mentioning bodily functions, only hinting discreetly at them when promoting tampons, toilet paper and the like. But after many years of ads for Viagra and its “ED” competitors, and the mainstreaming of pornography and rap, is it really a shock that a company uses the term constipation?

The bigger story is that the market is now ready for a more grownup conversation about drug side effects. “Minor” side effects such as constipation are a widespread consequence of drug therapy, yet they can have a serious impact on patients’ quality of life. Often doctors don’t realize how serious such side effects can be, and patients are either embarrassed to bring up the topic or worried their doctor won’t take them seriously. But it turns out patients will discuss the topic with other patients on sites such as PatientsLikeMe.

Drug ads are required to mention side effects, but the information is generally conveyed in a compliance-oriented style that does not contribute to consumer understanding. I wouldn’t expect anything more from the drug ads, but there is an opening for products such as laxatives that can provide relief.

As a final point it should be noted that Purdue Products has plenty of experience with this side effect. The company’s cash cow, oxycontin is a leading cause of the very constipation that Senokot is designed to relieve!

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The Health Business Blog is taking a break and re-running some posts from 2008. If you’d like to comment, please do so on the original post.

I’ve posted before about the marketing of infant formula through hospitals and about the practice of sending formula samples to expectant mothers.

Today I glanced through Nurture (Volume 08-1), a promotional magazine from Enfamil baby formula’s maker, Mead Johnson Nutritionals. The publication includes clearly marked advertisements for Enfamil products along with some articles on nursing and other typical new-mom questions, like whether babies can recognize colors and how to involve dads and grandparents in their care.

The formula companies go to some lengths these days to be seen as supportive of breast feeding. The first two-thirds of the relatively long article on returning to work focus on buying a breast pump, stockpiling milk at home and pumping at work. Only in the last third does the discussion turn to baby formula. That should satisfy most critics.
But the most interesting marketing pitches for formula are subtle ones, contained in pieces that are ostensibly medical or parenting advice. Here are two examples:

Q&A:

[Question] My 3-month-old is eating like a champ. Is she ready for solids?

[Answer] Not quite. The American Academy of Pediatrics recommends waiting until your baby is 4 to 6 months before introducing solids. Before then, she won’t have enough control over her tongue and mouth muscles to swallow food, and it may increase her risk of developing allergies. But there’s no need to wait beyond 6 months either, even if you’re worried about allergies…

Subtle marketing message: As baby grows and starts drinking more and more, you may be worried about whether you are producing enough breast milk. Don’t give solid food, but definitely supplement with formula!

Here’s another example:

Make Room for Daddy

Want to get in on a little secret about the daddy-baby bond? Well, you can start by putting Dad on diaper duty. (We though you’d like that!)… The more Dad is involved in day-to-day caregiving tasks, the stronger the bond will be… So have Dad take the night-feeding shift, stroll with baby in a carrier, or just enjoy playtime…

Subtle marketing message: Tired moms definitely deserve a break on the night shift. Of course Mom could pump extra breast milk during the day or just before bedtime, and let Dad give it to Baby, but who has the energy? Just let Dad mix up the formula and feed it to Baby. After Dad does that job a few times the nightly formula routine will become well-established. And while he’s at it can’t Dad just take along a bottle of formula with him for that “stroll with baby in a carrier,” too?

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The Health Business Blog is taking a break this week, and re-running some posts from August 2008. If you’d like to comment, please do so on the original post.

The distribution of prescription pharmaceuticals is beginning to take on some of the characteristics of online videos and music. Traditionally, access to prescriptions works as follows:

1. Patient has a problem
2. Patients sees his/her physician
3. Physician diagnoses problem and writes prescription
4. Patient takes prescription to traditional pharmacy or PBM-owned mail order company
5. Pharmacy fills prescription with a drug manufactured by an FDA-regulated brand name or generic pharmaceutical company
6. Patient takes medication
7. If patient needs more medication after initial prescription and refills are exhausted, patient requests renewal from physician and repeats steps 4 to 7

But steps 2 through 7 are breaking down. Instead of seeing their physicians, increasing numbers of patients are either going directly online to order from pharmacies or are borrowing pills from friends and family who’ve received prescriptions. According to MedPage Today (Adults Commonly Share Prescription Drugs with Friends and Family) almost 30 percent of adults reported sharing prescription medications with others. Younger people are the most likely to share.

Meanwhile, shady web-based pharmacies that don’t require prescriptions and often sell counterfeit drugs are becoming increasingly sophisticated and impressive. MarketMonitor estimates that about 1000 shady pharmacy sites generate an average of 100,000 hits per day each and that such pharmacies spend about $25 million per year on search advertising. An acquaintance who works in the pharmaceutical security business told me that these pharmacies aren’t what they used to be. In fact they are adopting marketing and customer service best practices that are used by legitimate vendors. Rather than going for a quick score, the web-based companies are looking for repeat business and word-of-mouth referrals by providing products that work, offering easy-to-navigate websites and low prices.

This isn’t quite the same as what’s happened in the field of digital music and video, but there are similarities:

• The intellectual property violators (e.g., Napster, YouTube, shady pharmacies) have made it easier and more convenient for consumers to get what they want –either for free or cheaply
• Traditional players have had a hard time reacting (e.g., the big music companies, the big pharma companies). In music this has led to a major loss in sales and it’s also meant that the record labels have been willing to sell online. The emergence of DRM-free music downloads is due to the existence of free –though illegitimate– alternatives. It’s also allowed iTunes to gain leverage over the record companies

There are some important differences, though:

• Unlike digitial music files, counterfeit pharmaceuticals aren’t exact copies of the originals –and it’s much harder to tell the difference
• The existence of insurance and general acceptance of the doctor’s role in prescribing means there’s less demand for free, presciptionless drugs
• Pharmaceuticals are physical products, so it is possible to secure the supply chain

Still I wonder whether some of the shady websites will end up going legit (like Napster) and whether pharma companies will be forced to react (e.g., by pushing for OTC clearance of lifestyle drugs that are still on-patent or by bundling services in with their products).

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I’m no big Mitt Romney fan, but I’m warming to him a bit after his Israel stopover, despite the so-called gaffes. Since this is the Health Business Blog, I’ll focus on Romney’s praise of aspects of the Israeli health care system. A front page Boston Globe article basically ridicules Romney for complimenting the Israeli system, considering there is a serious socialistic element to it that is at odds with Romney’s free-market philosophy. The Globe gives multiple critics the chance to point out that Romney is praising a system that offers universal coverage and has plenty of central government involvement, which is the opposite of what he espouses for the US.

Let’s give Romney the benefit of the doubt and assume he isn’t totally ignorant. Let’s assume he knows that Israel doesn’t have a completely free-market approach to health care. Let’s even imagine that Romney perceives universal health care and the high concentration of physicians as consistent with the “cultural” or (heaven forfend!) Jewish  character of the State of Israel.

I give Romney credit for calling out the advantages Israeli society enjoys as a result of spending only 8 percent of GDP on health care compared to 16 percent or more in the US, while attaining life expectancies that are three or four years higher. He’s brave to admit –if only implicitly– that different approaches work best in different places. It’s really not so inconsistent with the view he’s espousing about health care in the US –that what’s right for Massachusetts is not automatically right for the country as a whole. The emphasis on judging policies by their results rather than their ideological underpinnings is  a good one, and would represent a nice change for Washington, DC. And it has the advantage of seeming to be what Mitt actually believes.

Keep this kind of thinking and speaking up when you get home, Mr. Romney and you may find yourself closing in on the White House.

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If you ever feel like being pessimistic about public health, at least consider the case of cigarette smoking. As a kid growing up in the 1970s I hated the smell of smoke. But my mother told me to get used to it, since the important decisions were made in the smoke-filled rooms (remember that term?) and I wouldn’t want to get left out. But things did change, if gradually, to the point where smoking became uncommon in airplanes, then restaurants and eventually even bars.

It’s funny how after getting used to smoke-free environments it’s really offensive when you’re back in the olden days. I remember flying first class from London to Boston on American Airlines in 1995. There were three rows of first, and the third row was the smoking section. Smoking had been dumped on domestic flights but most international flights still had arrangements like this. I wrote to the airline and told them I was switching to Delta, which had gone no-smoking systemwide.

I never thought they’d get rid of smoking in Europe, especially Italy. In 2002 I spent some time in Rome where I was amazed to meet chain-smoking cardiologists stinking up the office. But even there they’ve changed.

The South has been the most smoking-friendly part of the US, but that’s changing, too. Atlanta is the latest to ban smoking in public parks. Laws like this are being enacted at the state level, but have gotten the most traction at the local level, even in tobacco country.

Overall I’m feeling good that people have become concerned enough about public health to intervene. In another 50 years we might treat firearm proliferation with as much concern as secondhand smoke is getting today.

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