Health Business Blog

When I saw the MedPage Today headline, “Study: Docs in dark about complementary therapies” I assumed it meant that doctors didn’t understand these therapies. But the story described patients withholding information about what they were doing from their physicians. That’s not exactly a new or surprising finding.

The study advises physicians to ask about what else patients are taking or doing, which is probably a good idea. But I’d like to see more attention paid to how physicians react when they hear about other therapies and the extent to which they are willing or able to engage with the large percentage of patients that seek relief or cure outside the medical setting at the same time they are working with their doctors.

Some of these therapies are herbs or other substances that may interact with prescribed drugs. Doctors definitely need to know about that and deal with it. Other approaches, such as massage, meditation and reflexology may be helpful for some patients –and it may or may not matter if the physician is involved.

The best physicians take a personalized, holistic approach to their patients, and do so in ways that do not conflict with the evidence based mantra.  One physician I know has a medicine man (who’s also his patient) perform a ceremony blessing the statin he prescribes to another member of the same tribe. I’m willing to bet his patients are more adherent as a result of this approach.

I’m not a major proponent of alternative and complementary medicine, but I do find it revealing to see how physicians relate to other approaches, especially for diseases they can’t cure. Do they insist that other approaches are invalid and consider them an affront? Do they balance a healthy skepticism with open mindedness to the idea that they don’t know everything? Do they vary their approach depending on the individual patients and their situations?

Share

Yesterday’s Boston Globe article (Hospital charges bring a backlash) was spot on. Reporter Liz Kowalczyk nailed the topic:

• Hospitals are adding facility fees in the hundreds of dollars for many visits to hospital-owned physician practices, even when those practices are nowhere near the hospital
• Facility fees are becoming more common as hospitals purchase formerly independent physician practices and tack on the fees
• Patients are pushing back. One reason is that more of them have high deductible plans that force the patient to bear more of the cost
• Insurance companies are aware of the issue but have generally been allowing the fees

Share

The recent study of the benefits of the Mediterranean diet and olive oil got huge buzz. I heard about it everywhere –even from my mother. Whenever something so definitive is released it makes sense to be skeptical. And no one’s been quicker to critique the findings than proponents of low fat diets, whose reputations and livelihoods are threatened if this study achieves lasting influence.

The following guest post was written by Pritikin Research Director and UCLA professor, James Barnard, PhD.

—-

We’ll start by talking about what’s good about the newly published study (1) that garnered headlines like “Mediterranean Diet Shown To Ward Off Heart Attack and Stroke.”

The study affirmed the benefits of a healthy diet even for people already taking medications for high cholesterol, blood pressure, or diabetes.

The takeaway:  Drugs have benefits.  Drugs plus diet have even more benefits.

And there’s no question that a Mediterranean-style diet (fruits, vegetables, legumes, fish, whole grain, nuts, olive oil, wine) is healthier than a typically American diet, full of fast food and other artery-cloggers like cheese, butter, red meat, processed meats, refined flour, sugar, and salt.

Now to the problems (and there are many) with this study.  We’ll focus on three major ones.

• The study followed 7,447 people with heart disease risks who were randomly assigned to either Mediterranean-style diets or a low-fat diet, but the low-fat diet was not low in fat.  Not even close. The people in the “low-fat” group started out with a diet that was 39% fat.  They decreased fat intake to 37%.

So, the authors weren’t really comparing a Mediterranean diet to a low-fat diet.  It’s much more accurate to say they were comparing a Mediterranean diet with a fatty American-style diet.  And sure enough, a lot of the foods the so-called “low-fat” group was eating were heart-damaging foods like red meat, commercially baked goods full of refined flour and fat, and sugary sodas.

• Some argued that the people in the “low-fat” group were unsuccessful in reducing their fat intake because a low-fat diet is too difficult to maintain, but it could also be argued that the scientists conducting this study never really gave the “low-fat” diet group a chance.

During the first half of the study, the people assigned to the Mediterranean diet received intensive education in eating well, including regular visits with registered dietitians.  The people in the “low-fat” group got one visit.  That’s it.  It was the equivalent of a doctor’s visit in which the doctor hands you a pamphlet with what to eat, and what not to eat, and essentially says, “Good luck.”

Moreover, the “low-fat” diet that the scientists designed excluded an important food proven to protect against heart disease, a food that is a part of many low-fat plans, including the Pritikin Program – omega 3-rich fatty fish.  The subjects in the study were discouraged from eating fatty fish like salmon.

And ironically, this “low-fat” diet devised by the scientists had no limits on some foods known to increase heart disease risk, like soft drinks.

• The scientists summarized that the Mediterranean diet “reduced the incidence of major cardiovascular events” compared to a low-fat diet, and media articles led with announcements like “30% of heart attacks, strokes, and deaths from heart disease were prevented.”

But in the study itself, the scientists reported no significant reductions in heart attacks or cardiovascular-related deaths among the Mediterranean dieters. They wrote, “Only the comparison of stroke risk reached statistical significance.”

So how did they jump from stroke reductions to all reductions in cardiovascular risk?  Well, it’s easy when you know how to play with numbers.  They pooled all the data on heart attacks, strokes, and deaths, and the numbers on strokes were high enough so that the average of the three looked good.

Bottom Line:  It appears that the scientists were doing everything they could to make the Mediterranean diet the winner.  Why?  We don’t know for sure, but consider this:

The olive oil, nut, and wine/alcohol industries were very involved in this study.   Two olive oil companies supplied all the olive oil.  Two nut companies supplied all the nuts.  The lead author, Dr. Ramon Estruch, has served on the board and received lecture fees from wine groups like the Research Foundation on Wine and Nutrition and the European Foundation for Alcohol Research.

The other authors of the study have deep ties with other olive oil, nut, and wine groups such as the California Walnut Commission, the International Nut and Dried Fruit Council, the Mediterranean Diet Foundation, and an wine/alcohol public relations group in Spain called Cerveceros de España.

Yes, it could be argued that these scientists had a vested interest in making the Mediterranean diet look as good as it possibly could.  By contrast, there was no financial interest in making the “low-fat” diet look good.

What would have been a far better study is one in which a Mediterranean diet was compared with a truly healthy low-fat plan like Pritikin.

Pritikin includes all the excellent elements of a Mediterranean diet (fruits, vegetables, whole grains, legumes, fish) as well as the ability to shed excess weight (something the subjects in the Mediterranean study did not achieve) because on Pritikin calorie-dense foods like oil and nuts are kept to a minimum.

So strong are the data affirming the heart-healthy benefits of the Pritikin Program that Medicare is now covering it for people with a history of cardiovascular disease.

In summary, the Pritikin Program combines daily exercise with an eating plan that emphasizes:

• Hearty consumption of fruits, vegetables, whole grains, and legumes like beans
• Moderate intake of fat-free dairy products and lean animal protein like fish, skinless poultry, and bison
• Little or no intake of added sugars, saturated fats, trans fat, and sodium (no more than 1,500 mg of sodium a day).

Is this a low-fat diet?  Yes.  Average intake is about 10 to 15% fat.

But more importantly, it’s an extremely healthy diet, proven in more than 100 studies over the past three decades to dramatically reduce virtually every modifiable risk factor for cardiovascular disease, including LDL bad cholesterol, trigylcerides, blood glucose, insulin, hypertension, inflammatory markers like C-reactive protein, and excess weight/obesity.

A study comparing this type of healthy, low-fat diet with the Mediterranean diet would have been a study that deserved headlines.  Not the study that was published this week.

Share

This is a transcript of my recent podcast interview with Anne Weiss of the Robert Wood Johnson Foundation.

David E. Williams: This is David Williams, author of the Health Business Blog.

I’m speaking today with Anne Weiss. She is Quality/Equality Health Care Team Director and Senior Program Officer at the Robert Wood Johnson Foundation.

The Foundation recently released a report called The Revolving Door: A Report on US Hospital Readmissions, which uses data from the Dartmouth Atlas Project to show that many Medicare patients are readmitted to the hospital after being discharged. The report also includes results from interviews with patients and providers to provide insights into how to reduce avoidable readmissions.

Anne, thanks for joining me today.

Anne Weiss: Thanks for having me.

Williams: Anne, consistent with other Dartmouth Atlas Reports I’ve seen, there’s a lot of emphasis in this one on regional variation. So, my question to you is how significant is this regional variation for readmissions and to what extent do the outliers actually represent best and worst practices that should be emulated or avoided?

Weiss: We do see pretty significant variation in the rates of readmission for Medicare patients who go home after identical surgeries or identical medical problems. There are very different experiences around the country. This is 2010 data and we saw readmission rates for surgical patients ranging from 18% in the Bronx to 8% in Bend, Oregon. For medical readmission, again, 18% in the Bronx down to 11% in Ogden, Utah.

So it’s significant variation. This study is not designed to tell us about the practice patterns in these areas. We looked strictly at admissions and post-acute care. We do know that there are a lot of different reasons behind this kind of variation. You could see differences in the underlying health status of the patients. You can see differences in the quality of hospital care including discharge planning. You can see best and worst practices in care coordination. And this is really important; you can see a lot of differences in the availability of primary care locally and the availability of hospital beds.

We know that the Dartmouth Atlas has already demonstrated that the local supply of hospital beds drives practice patterns. So other things equal, I think we can assume that when there are more hospital beds, patients are more likely to be admitted and readmitted to the hospital.

So, the short answer is we don’t learn a lot about what the best and worst practices are from looking at the Dartmouth data. But it does tells us it’s a local problem; and our emphasis is on helping people at the local level look at their market circumstances and talk about solutions that will work for them.

Williams: It looks from the report that there’s been only limited progress on reducing readmissions, even though readmissions are something that people have at least been looking at for awhile. And it also seems like some of the efforts that looked promising initially have not proven to be sustainable. I realize it’s 2010 data, so maybe things have changed from there. I’m wondering whether there are examples of programs or approaches that had been shown to work well over extended periods of time.

Weiss: When we released the report, we featured a couple of models that do seem to have been picked up widely enough that I think it gives us hope that they can sustain their progress.

One is the Care Transitions Intervention, widely associated with Eric Coleman, a physician at the University of Colorado. It’s a four-week program with a transition coach who helps patients with complex conditions manage their medications and helps them know what to do when their condition gets worse. This has been picked up by about 750 organizations, including 34 who are a part of a major Medicare initiative, the Care Transitions Program. I have not seen specific data, and obviously, it hasn’t been years since this is in place. but the degree to which it has been picked up is pretty promising.

The other program that we featured is the Transitional Care Model developed by Mary Naylor (a nurse at the University of Pennsylvania) along with her colleagues. They provide very comprehensive training in the hospital and then follow up at home for chronically ill high-risk older patients. They use transitional care nurses. They have the skills of a nurse and the care manager and also a patient advocate. I know they’ve had a lot of very promising conversations with health plans and others. So again, I think that’s a sign that they are poised for the kind of sustainability you’re asking about.

I do want to make one other point about some of the programs that we’ve seen developed in communities that are involved in the Foundation’s signature initiative, Aligning Forces For Quality. This is the Robert Wood Johnson Foundation’s major effort to improve quality and reduce cost in 16 targeted markets around the country. And we’ve seen initiatives in places like Cleveland, Memphis, Maine and Oregon that haven’t been in place for a long time. We don’t have data that say that they’re sustainable, but the fact that they’re embedded in a larger community effort where there’s a great deal of transparency is promising. In many of these communities, there is a publicly available report online that compares hospital readmission rates.

They’re in communities that are working on payment reform, unbundled payments. They’re in communities that are working hard to build quality improvement infrastructure and to engage patients and families in demanding better care. I think that offers a lot of potential to sustain a good care transitions effort, although I can’t say today that we know that all these efforts will sustain themselves.

Williams: What can you say about individual patients and their families or caregivers who are perhaps in a region of the country that has above average readmissions, whether they’re in the Bronx or somewhere not quite as much of an outlier? Is there anything that an individual patient can do even in places where such programs are not in existence? And is there any evidence or do you have a sense of whether there are certain patients, perhaps those with higher levels of education or income, that are in a better position to make an impact on whether they are re-admitted?

Weiss: I don’t know from this study. We don’t know a lot about the specific characteristics of the patients. However, I think with rates that are this high, it’s not a problem that’s confined to patients who have low literacy or low incomes. I think if we talk about some of the things that patients and families can do, which I’ll mention in a moment, it suggests that these are things that can be done in a variety of socio-economic circumstances. So I don’t think it’s wholly dependent on family income or education level, although that helps.

The single most important thing we tell people to do is to ask questions, not to be afraid to bother the doctors and nurses and pharmacists, to keep asking until you understand the answer, and when you do get an answer to say it back, to repeat the answer to make sure you’ve understood it.

The second major area is to leave the hospital with a detailed written plan that covers two things — medications and appointments. So, a written list of medications with instructions about when and how to take them and a written list of follow-up appointments. The appointments are very important. If people have trouble making appointments or they don’t have a doctor, a family doctor, or the right specialist to go to, you can ask the hospital for help. And for both of these things, the medications and the appointment, I think it’s really important to involve a family member or a friend to make sure that they understand what could be done and they can help with things like transportation and making sure that you keep those appointments.

The last thing we tell people to do is to know what to do if you don’t feel well. Know the danger signs and know what you’re supposed to do if your symptoms got worse. I think it’s obvious that these things are more challenging for people who have low literacy or low health literacy. But I think all of them are things that any patient and family can try to become more engaged in.

I also want to mention that we have a great many tip sheets and other resources for patients at the website we set up for this initiative, which is called CareAboutYourCare.org. There’s a lot of information there that is really helpful for people from a very broad range of backgrounds and circumstances.

Williams: For a patient or a caregiver who is not currently contemplating a hospital visit, are there things that can be done perhaps structurally, and not just behaviorally, to try to make it less likely that a readmission would be needed? So for example, does it matter if a patient picks a primary care physician who practices as part of an integrated delivery network? Is there a difference in readmissions if the primary care practice uses hospitalists? Does it matter what type of health plan is used?

Weiss: Intuitively, it does seem that being part of an integrated system, your doctor being able to see you in the hospital, that those things should make a difference, but I have not seen data on this.

I will say that we conducted extensive interviews with patients and providers as part of the study and we did hear that the use of hospitalists can lead to more fragmented care, because the doctor isn’t always glued in to what happened in the hospital. That doesn’t mean that hospitalists are bad but it may mean that an intervention has to have an explicit step of getting the information back to the primary care doctor. And watching my parents in the health care system, I can’t think of how many times somebody threw a clipboard on their feet in the ambulance, and that was the extent of the information transfer.

Again, I haven’t seen information that compares the experience as patients in an integrated system or not. That does seem appealing, although we hope anyone who follows the weekly story about the safety implications of electronic health records can tell you that even in a completely integrated system, people miss pieces of information that were answered in one clinical setting and are relevant in another. So I don’t think you can let your guard down just because you’re in an integrated system. But you’re right, it’s promising.

And I know you said you wanted structural answers and not behavioral ones, but in my heart, I don’t think at this point in our health care system that there is a substitute for people understanding their conditions, understanding the behaviors that put them at risk, getting information that was proven to work, talking to the doctors, participating in making informed choices. And I don’t think we have the health care structure in the market yet that allows us to stop behaving that way as patient and consumers.

Williams: Fair enough.

So this sounds to me, Anne, like a problem that’s big, complex, perhaps even intractable. But the bright side of that might be some opportunities for entrepreneurs who are looking at ways to address elements of this readmission challenge. Any thoughts that you have for folks that are contemplating businesses in this area about where they might want to point their compass?

Weiss: A couple of things. I think the study does tell us that this is a local problem. And one thing we heard very strongly during all the public events was that you don’t pick something up in one market and just turn the key and it works in another market. Reinvention — what was it that somebody said — replication is reinvention. So, I think it’s important for entrepreneurs to think about that local market customization. That’s one point.

I think there is room for entrepreneurship across the continuum, whether it’s home care, whether it’s alternatives to the emergency department in the middle of the night, whether it’s new mobile technology. We heard from a patient who had a PDA that allowed him to answer five questions about his breathing condition every day; his nearest kin could monitor his status from afar and see how he was doing. So you could see all kind of mobile apps that could do that.

I think we have a payment system right now in this country where there’s a lot of financial rewards to a lot of people from the admissions. So for an entrepreneurial solution to work, it’s going to have to pay better or differently from readmission. The Medicare policy for readmission will start to rebalance that equation, but I think that’s a challenge.

The last thing I want to say is probably a little provocative to say to your readers. But I will say it anyway. I’ve been interviewed frequently about things like the company that provides care coordination to large employer groups. “If you get cancer, our company will come in and manage all your appointments and help you keep track of all the billing and everything.” And to me, that’s a symptom of what’s wrong with our health care system. And people will hold it out like, “Isn’t this great that we’re helping patients.” And I think that is true. I do think that a lot of the entrepreneurial opportunities have a lot of potential for improved care. But the problem we’re seeing here is a bad problem and my hope would be that we have a health care system that is patient centered enough that we don’t always need entrepreneurship to cure the ills that shouldn’t exist in the first place.

So I have mixed feelings about it but I do think that there are a lot of opportunities in the short run to make things better for patients and family.

Williams: I see on the motto of Children’s Hospital things like, “Until there’s no more childhood illness.” I think the children’s hospitals are busy trying to put themselves out of business. But they have no real fear of that happening in the near term. This may be something similar.

Weiss: Right, I mean it’s sort of like the argument we often have on primary prevention. And yes, we definitely can prevent a lot of chronic illness, but most cases of cancer are not preventable. We don’t know enough about them to prevent them. It’s a lot of things, so we still have a lot of room to make our health care system perform better and meet people’s needs. Some of the best opportunities right now, I think, are coming from innovative entrepreneurs.

So, in the short run, I think there is room for that. I just think it’s important for us to also keep track of the overall impact of the system on patients.

Williams: I’ve been speaking today with Anne Weiss from the Robert Wood Johnson Foundation. We’ve been talking about a new report on hospital readmissions and about RWJ’s Care About Your Care Initiative.

Anne, thank you so much.

Weiss: Thanks for having me.

Share

A new study purports to demonstrate that primary care physician offices in Ontario discriminate against the poor by being less likely to offer them appointments. I saw an article about the study in the LA Times (Canada’s universal healthcare may not be so universal after all) and was a bit puzzled. Here’s what is said:

The researchers posed in each call as one of four types: a wealthy banker in good health, a wealthy banker with diabetes and back problems, a welfare recipient in good health, or a welfare recipient with diabetes and back problems.

Overall, the callers were 50% more likely to be offered an appointment when they posed as bankers than when they posed as welfare recipients.

‘Staff at physicians’ offices may hold negative attitudes toward this group, especially toward people receiving social assistance,’ the authors wrote. ‘Physicians have been shown to perceive patients with low socioeconomic status more negatively in terms of their personalities, abilities, behavioral tendencies and role demands.’”

Certainly the results sound bad and are consistent with the general notion that rich people get away with things while the poor get the shaft. But do Canadian primary care offices routinely try to assess the socioeconomic status of patients? It seemed odd to me.

So I read the original study (which is not linked to in the article) and my assessment is that the methodology is biased. Researchers were given scripts to use when calling the doctor’s office and were told to read them neutrally. Even if we assume they were able to be neutral (which I doubt) the language is biased in a way that throws the results and conclusions into question.

Let’s compare the wording of the two questions:

“Hi, I was just transferred to Toronto with [name of major bank], and I need a family doctor for my diabetes and back problems. Is Dr. ____ accepting new patients?”

vs.

“Hi, I’m calling ’cause my welfare worker told me that I need a family doctor for my diabetes and back problems. Is Dr. ___ accepting new patients?”

The researchers assume that the only important difference between these scripts is the information about whether the person is employed in a highly paid job or is on welfare.

I disagree. In particular, the first patient sounds like a self-motivated individual who is calling because s/he is conscientious and is making an effort to be responsible and take care of him/herself.

The second patient sounds like someone who is calling because they were told to, not because they wanted to. And why on earth does the script say “’cause” instead of because? Now imagine switching around the script so the banker is calling “’cause my wife told me I had to” and the second calls to say they needed a doctor and doesn’t make it sound like someone else told them to do so.

My guess is that the main driver of the results is that office staff are giving priority to a patient who is motivated to show up for appointments and be compliant with therapy rather than one who sounds like they’re calling just so they can tell their welfare worker that they did what they were told. If the caller hadn’t told the office of their profession or welfare status I doubt the office would have raised it. 

Share

The Robert Wood Johnson Foundation (RWJF) recently released The Revolving Door: A Report on US Hospital Readmissions. It uses data from the Dartmouth Atlas project to show that many Medicare patients are readmitted to the hospital after being discharged. The report also includes results from interviews with patients and providers to provide insights into how to reduce avoidable readmissions. It’s all part of Care About Your Care, which is designed to improve care transitions and reduce readmissions.

The report has generated a good deal of press interest, so I decided to delve a bit deeper in this interview with Anne Weiss, Quality/Equality Health Care Team Director and Senior Program Officer at RWJF.

In this podcast we discuss:

• The significance of the regional variation in readmissions, and whether the variation reflects true best and worst practices to emulate or avoid, or whether other factors are at play.
• Reasons behind the lack of recent progress in reducing readmissions.
• What influence patients and caregivers have on whether a specific patient will need to be readmitted once discharged.
• Whether patients can do anything ahead of time –like picking a certain type of primary care practice– to avoid being readmitted if they are ever hospitalized.
• Opportunities for entrepreneurs to address the readmissions challenge –in the short term and long term.

Share

David Williams interviews RWJF's Anne Weiss on hospital readmissions [ 15:53 ] Play Now | Play in Popup | Download

The Health Business Blog is on vacation this week. Here’s a rerun of a post that originally appeared a year ago.

Health plans have realized for quite some time that the widespread practice of scheduled C-sections and induced labor before the end of 39 weeks of pregnancy is an expensive proposition. Even babies born a week or two early have a significantly higher chance of being admitted to neonatal intensive care units, having difficulty breathing and experiencing bloodstream infections. Such births are surprisingly common. In 2010 about 17 percent of babies were delivered at 37-39 weeks without a medical reason.

The Leapfrog Group. March of Dimes and American College of Obstetricians and Gynecologists has taken the initiative to try to address this issue by getting the word out and having hospitals set performance. They’ve decided there’s no reason for hospitals to have more than 5 percent of births in the early delivery/no medical reason category, and have asked hospitals to report their results.

The good news is that it seems to be working. The rate dropped from 17 percent to 14 percent from 2010 to 2011, according to newly published figures.  More than 700 hundred hospitals voluntarily reported their rates to Leapfrog. It’s fascinating to scroll through and see the variability. A good number of hospitals are at or below the 5 percent target while some others are way up in the 20 to 30+ percent range. That can’t be random variation.

So why are these medically unnecessary early births occurring? Childbirth Connection has a good summary:

• Women’s lack of knowledge about the risks, benefits, and appropriate use of labor induction
• Lack of shared decision making
• A perception among women, caregivers and hospital administrators that induction is convenient and cost-effective
• Frequent use of screening tests at the end of pregnancy, despite lack of evidence of improved outcomes
• A belief that the best way to manage risks in pregnancy is to deliver the baby

Share

Introducing incentives for EHR adoption as part of the stimulus law was definitely the right thing to do. There was a momentary opportunity to advance health IT with significant funding and the Obama Administration went for it. But a downside is that the systems that were ready to go were pretty weak by the standards of IT overall.

I was reminded of that in reading about how shared decision making is hampered by inadequate IT systems. According to FierceHealthIT (Busy docs, inadequate IT systems hinder shared decision-making):

IT systems used were found to be inadequate. Nearly all sites’ records lacked capabilities to flag patients as candidates for decision aids or to track patients through the process, such as whether the post-decision aid conversation had taken place. Though some sites used questionnaires to gauge patients’ values and preferences, there was no way to integrate that information into the clinical system, meaning that information had to kept separately and might not be available to the physician conducting the post-decision aid conversation.

None of the sites had an IT system that tracked whether the patient received care in accordance with his or her stated preferences. Those involved at the care sites suggested automating as much as possible the process of flagging patients to be given decision aids and handing that task over to a staff member other than the physician.

If you’ve worked with health IT systems, the situation described here will come as no surprise. But challenges like this are being addressed outside the health care system. Take Board Docs for example, which provides cloud-based document management systems specifically aimed at boards of directors. Read the list of features and you’ll see that it deals with a lot of the common challenges associated with preparing and managing board meeting materials. It’s a different set of challenges than what doctors and patients face in shared decision making, but the level of complexity and coordination is similar.

The good news is that physicians are being exposed to what really good health IT is, even if it’s not in their medical practice. They have iPads and smartphones, and use social networks in their personal life. If they serve on a board they may be exposed to Board Docs or similar services.

All that means that we can expect physicians to start demanding state-of-the-art tools in the office, and not put up with what the health IT industry has offered to date.

Share

I hate cigarette smoke and have also been sympathetic to health plans that want to exclude smokers or charge them much higher premiums. Yet a new government report reminded me of the connection between mental illness and smoking and was a reminder not to rush to judgment.

The CDC/Substance Abuse and Mental Health Services Administration (SAMHSA) report indicates that about 30 percent of all cigarettes are smoked by the mentally ill. Compared with the overall population more mentally ill people smoke and those who do smoke more per person. The mentally ill are less likely than others to quit successfully.

I wrote about this very topic in 2007, when the estimate was the the mentally ill were smoking almost half of all cigarettes. The two points I discussed then are worth raising again.

First, there must be a reason why almost every schizophrenic smokes. Probably because smoking helps them feel less crazy. It’s still probably worth encouraging some mental health patients to quit but it’s not probably not so clear cut.

Second, if the mentally ill are smoking almost half the cigarettes they’re probably also paying about half the cigarette taxes. It’s been popular in recent years to jack up the cigarette tax to pay for social programs. Is it really fair to have the mentally ill pick up a disproportionate share of the tab?

Share

In Reducing surgical complications: How to make it happen faster, I contrasted the way a hospital gets paid for rework with what happens in a manufacturing environment. In short: when a manufacturing process messes up a product the company doesn’t get paid at all, but when a hospital messes up it tends to get paid for the original flawed product and then paid agin to fix it.

I heard about an experience yesterday that makes the same point. A friend had a routine blood test in the morning at a hospital clinic. When results came back at the end of the work day there was an exceedingly high reading on the sodium level. The doctor who ordered the test called the patient to say he needed to go in to the emergency room to have it checked out, since the reading was higher than the doctor had ever seen for a patient and such a level could be life-threatening.

The patient went in, had a repeat test –which came back completely normal– and departed after paying the $150 co-pay. The attending physician in the emergency department referred to it as an iatrogenic event. No doubt the hospital will get paid in the low four figures for the visit, which wouldn’t have happened if the lab had done its job well the first time.

Share