Dan Prince

A lot of my reading lately is taking me back to the theme of how the healthcare system needs to move out of hospitals, doctors’ offices and insurance company headquarters and into the community if it’s going to make a real dent in society’s biggest health problems.

The problem of obesity is a good example. We reported in our Living in Denial white paper a few months ago on Americans’ strong sense that the country is in the grips of an obesity crisis – and their adamant denial that their own personal obesity is contributing to it.

A recent National Public Radio (NPR) series on obesity included a piece about new research on how our hormones fight us when we try to lose weight.

It reported some emerging insights into why losing weight slows metabolism – which makes it hard to keep losing, and very hard to keep the weight from creeping back on.

NPR’s Patti Neighmond wrote, “For example, if you weigh 230 pounds and lose 30 pounds, you cannot eat as much as an individual who has always weighed 200 pounds. You basically have a ‘caloric handicap.’ And depending on how much weight people lose, they may face a 300-, 400- or even 500-calorie a day handicap, meaning you have to consume that many fewer calories a day in order to maintain your weight loss.”

One of the interesting links in the NPR piece was to a study by the American Journal of Clinical Nutrition of 784 people (629 women and 155 men) who had succeeded in losing weight and keeping it off. These folks were, years after losing weight, still eating less than other people who had never had to lose. In particular, they were eating less fat.

The other secret to their success was exercise. The group exercised in a variety of ways, but the researchers calculated their average caloric burn and said it was the equivalent of walking 28 miles a week – four miles or about an hour a day.

I mentioned these statistics to a friend of mine who is a weight loss success. She found them interesting because they matched her experience, but she had always thought she was unusually cursed – especially by the way she still has to curb her caloric intake – 10 years after losing the weight.

Just how hard it is to lose weight and keep it off is not a news flash, but I don’t think it’s something our society and our healthcare system have fully internalized. Obesity is tied to the most dangerous chronic conditions and a root cause of much of the cost of American healthcare.

If healthcare reform and the ACO movement succeeded in its mission to shift more of the healthcare system’s focus to wellness and prevention, doctors and hospitals would have a new motivation to look beyond the acute conditions that bring people into their facilities, to help them work on making better day-to-day choices as to how they eat, drink, sleep, move – live.

Taking better health out to the community

Taking better health to the streets was the theme of another piece in the NPR obesity series: ‘Secret to a Long, Healthy Life: Bike to the Store.’

Physician Jonathan Patz and a team of researchers at the University of Wisconsin-Madison studied the health impact of making short trips by bike rather than car. They gathered up data sets for 11 Midwestern cities on obesity, automobile pollution and pollution’s health effects. They estimated that, in those 11 cities, with 31 million people, 1,100 deaths influenced by overweight and pollution (heart attack, strokes, asthma) could be avoided every year, and $7 billion a year in healthcare costs could be saved.

I found particularly thought-provoking a short comment by Dr. Patz at the end of the piece. He’s a dedicated bike commuter in Madison, and he can do that because Madison is a bike friendly city with 87 miles of bike lanes, 116 miles of bike routes and features like ‘bike boxes’ on the streets – painted rectangles at intersections where bikes can move in front of cars, to protect bikers from drivers making right turns.

Dr. Jonathan Patz. Photo by Jean Patz.

Dr. Patz commented that when he lived in Baltimore, a city not set up for biking, he didn’t bike-commute. “I tried it about three times, and realized this could be very hazardous to my health.”

If he still lived in Baltimore, Dr. Patz might not be the picture of health he appears in the NPR blog.

One of the thrusts behind the government push for Accountable Care Organizations is the desire to make healthcare professionals and hospitals broadly responsible for the health of their community – not just treating its illnesses, keeping it healthy.

I think a healthcare professional like Dr. Patz, looking beyond the clinical setting, at where patients live day to day, sets a positive example for the healthcare system and suggests some of the ways that healthcare could be truly “accountable” to its community.

What do you think? Comment on this post or send me a message at dan.prince@catalysthcr.com.

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Dan Prince

National Public Radio has been running a series on obesity. I have found the segments on the radio and the related articles in their blog very interesting, particularly in light of the findings we reported in our Living in Denial white paper a few months ago.

In the NPR piece “Workplaces Feel the Impact of Obesity,” author Jennifer Ludden writes that obesity costs U.S. employers $73 billion a year. And that doesn’t cover everything. Ludden said companies are having to use pickup trucks as company ‘cars’ to accommodate plus-size drivers. They are having to replace toilets when wall-mounted ones collapse. They are having to spend big money on big office chairs. A spokesman from chair manufacturer ErgoGenesis told Ludden that sales of their ‘bariatric’ chair, for workers up to 600 pounds, are brisk.

A custom chair ErgoGenesis made for a customer too big for its <600 lb 'bariatric' office chair. The custom chair cost $1,800. The regular bariatric chair costs $1,300.

Pete Gaffney of ErgoGenesis is quoted as saying that the intended users of these chairs are sometimes offended by them. “I’ll kid around with the ladies sometimes,” he says. “They’ll say, ‘Well, that’s too big for me! It’s too wide!’ I’ll say ‘Look, when you go home everybody likes to get into a nice pair of comfortable jeans. Just consider the few extra inches as a nice comfortable pair of jeans. You’ll thank me.’ ”

They do thank him, Ludden writes.

The large ladies who look at the chair and say “That’s too big for me!” reminded me of many of the respondents in our “Fitter or Fatter” study, the substance of our Living in Denial white paper. We did an online survey of 1,500 adult Americans. With all the media and public health attention that has been paid to the obesity epidemic, we wanted to see if it was having any effect. Were people trying to get in shape? Did they think they already were?

We didn’t recruit for the study based on weight, but it turned out our respondents mirrored the general population. Based on BMI measurements, 60% of our respondents were overweight or obese.

Many of them seem to have just as faulty a self-concept as the ladies who think they’re too small for the ErgoGenesis bariatric chair.

Among the overweight or obese respondents to our survey, 11% said they were in “excellent” health; 61% said their health was “good.” Yet excess weight contributes to almost every malady that plagues us as a nation, from diabetes to heart disease. And our respondents, at least on some level, know that. When asked what America’s number one health issue is, 60% of them said, “Obesity.” (The health issue that came in number two in the voting, “Cancer,” was cited by just 16% of respondents.)

Who is going to break the news to these people, that they are part of the obesity epidemic? Employers avoid the issue. Family members do, too. And too often, so do doctors.

“A physician’s behavior is the strongest predictor of how they will counsel patients around preventive health behaviors,” according to Harvard Medical School professor Dr. David Eisenberg, quoted in a blog called Obesity Discussion. The post cited a 2003 study that found doctors who watch their own weight are more likely to advise and encourage their patients to lose weight. It cuts the other way, too. A heavy doctor was quoted as saying she felt like a hypocrite if she counseled patients to lose weight when she had her own weight problems.

I found a vintage 2004 statistic (from a study published in the Annals of Epidemiology) that 44% of male physicians were overweight and 6% were obese. (No stats were available for female physicians.) If doctors are trending like the rest of us, I would guess that half of them are overweight by now. That would suggest that very few of us with weight problems are likely to get straight talk from the professional we would trust most on the matter – our physician.

The conclusion would seem to be, ‘Doctor, heal thyself’ – so you can give the rest of us the help we need to get our weight under control.

What do you think we should be doing about obesity? Comment on this post or send me an email at dan.prince@catalysthcr.com.

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Dan Prince

Health literacy is a problem that confronts nurses, doctors and hospital staff every day. It’s going to be an even bigger problem for healthcare professionals when millions of currently uninsured Americans flood into the system in 2014.

But the organizations that may feel the most pain when the floodgates open are the health plans. I’ve been reading about how they are preparing for the change, and I’m concerned that insurers may be focusing too narrowly – and cutting a few too many corners.

What is “health literacy?”

The US Department of Health and Human Services defines health literacy as “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” People with low health literacy are less likely to know what healthy behaviors are and to adopt them.

In testimony Susan Pisano of AHIP (America’s Health Insurance Plans) presented in July 2011 at the Institute of Medicine’s Health Literacy Roundtable Meeting, she said 9 in 10 Americans have “difficulty using health information to make informed decisions about their health, profoundly affecting their health and access to care.” And profoundly impacting their interactions with the companies processing payments for their care.

Health plans’ efforts to raise health literacy

Ms. Pisano’s testimony was about AHIP’s efforts to assist health plans in addressing and improving health insurance literacy.

Health insurers see more and more clearly the writing on the wall for their companies. AHIP conducts health plan surveys every two years on disparities in health, and one of the topics covered is health literacy. Their 2008 study showed 69% of plans had introduced some components of a health literacy program. Two years later, in 2010, this was up to 83%.

A big focus of AHIP’s effort is to assure that the reading level of materials is low enough and the language is plain enough. A little aside here, I have to mention as the head of a healthcare research company: Pisano said consumer testing of materials was an important priority, but that many companies were skipping it, instead testing materials on their own employees who seem similar to the target audience. As a research company, we can, of course, point out all kinds of flaws with this approach, starting with the fact that employees who work in almost any part of a health insurance company are likely to be more health and health insurance literate because of where they work. But the biggest threat to the reliability of this kind of research is the fact that these employees already have health insurance benefits and have dealt with the system as customers. They really can’t stand in for people who haven’t.

Health literacy is about more than reading

Another concern Ms. Pisano’s testimony raised for me was the almost exclusive focus on “materials.” A 2004 study by Dean Schillinger, Andrew Bindman, Frances Wang et al. on “Functional Health Literacy and the Quality of Physician-Patient Communication Among Diabetes Patients” showed that health literacy isn’t just a “reading” issue. It profoundly affects how well people understand verbal explanations and follow instructions they get in face to face or phone encounters.

Schillinger et al. were thinking about doctors’ and nurses’ encounters with patients in offices, clinics and hospitals, but health literacy colors people’s experience of every part of the healthcare system. The implications are very clear for health insurers.

Health plans need to be preparing front-line service people to ascertain the level of the customer’s health literacy and adjust their vocabulary, their pace, their tone and possibly the language they’re speaking in – to fit the need.

As millions of people open their first EOBs ever in 2014, the phone banks will be lighting up. Health plans who step up to the health literacy challenge now will be the winners – or at least the survivors.

Seize the opportunity

There’s an opportunity here as well as a threat. I hope that health insurers, along with the rest of the healthcare system, will see the opportunities in the 2014 challenge. In addition to bracing themselves for millions of customers with even less health literacy than their current customers, they should be doing what they can to increase Americans’ health literacy across the board.

What do you think? How is your company getting ready to deal with customers who have little to no experience with the healthcare system? And let me know what your company is doing to increase customers’ health literacy. Comment on this post or send me an email at dan.prince@catalysthcr.com.

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Dan Prince

Pauline Chen, MD, wrote in the New York Times about the reaction she got when she described ACOs to friends who didn’t work in healthcare.

“I concluded to my friends, A.C.O.’s will be able to stem spiraling costs, increase efficiency and improve quality. Clinicians and hospitals will have a financial motive not to do more procedures and incur more visits but to keep patients healthy and out of the hospital.

“I took a deep breath then looked around. One friend had stood up and was excusing herself to go to the bathroom. The other was looking into her bag, rummaging around for her cellphone.

“’Thanks for the explanation, Pauline,’” she said. She pulled her phone out and quickly glanced at its screen. “I hate to break it to you,” she continued, ‘but whatever that care plan is called, it still sounds like an H.M.O. to me.’”

Accountable Care Organizations seem to be a good idea. Their aim is to reduce cost, enhance healthcare quality and improve the patient experience. But ACOs are a fuzzy concept to most consumers, and if, like Patricia Chen’s friends, consumers confuse them with HMOs, the ACO concept may be DOA when it gets to market.

ACOs are provider organizations – primary care physician groups at the core, with specialist physicians, nurse practitioners, physicians’ assistants and potentially a host of auxiliaries, allied with their local hospitals – formed to “support the care needs of a defined population of patients.”

But the American public doesn’t respond very well to programs that divide it arbitrarily into “defined populations.” In their research published in the New England Journal of Medicine, Anna D. Sinaiko, Ph.D., and Meredith B. Rosenthal, Ph.D., write that “in many ACO-like models . . . patients who receive the majority of their care from participating providers have been assigned to an ACO through ‘invisible enrollment,’ with no prospective notification and sometimes no awareness by the patients that they’re associated with an ACO.”

Fundamental to improving patient experience is giving people a sense of control over their healthcare destiny. Just as they balked at HMOs and were willing to pay more for the privilege of being covered under a Preferred Provider plan, healthcare customers will find ways to sabotage the ACO they’re assigned to if they don’t think it will really serve them.

The focus with ACOs so far has been on providers and payments. To be successful, ACOs are going to have to focus just as hard on a third p – patients.

I’d like to hear your thoughts on how those promoting ACOs and those working to build them can really meet the goal of improving patient experience. Comment here or write me at dan.prince@catalysthcr.com.

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Dan Prince

Jacksonville Medical Center in Jacksonville, AL, wanted to tell the world about its high HCAHPS rating and top ranking in its county, so it took out ads and papered billboards with blue ribbons proclaiming ‘We’re Number 1.’

The campaign flopped, and the hospital has shifted gears. It’s going to show the community what is so great about its service and what the customer experience is really like there – on video.

The story was reported a few weeks ago in HealthLeaders Media, and I added it to my fat file of articles on video and its impact on healthcare marketing. In my opinion, if you’re marketing patient care and you want to send positive messages about customer experience, video is just about the best medium there is.

It appears that many hospital marketers agree with me. The American Medical Association’s news site, amednews.com, recently ran an article entitled Online videos may offer most bang for medical marketing buck.

The article cited a 2010 study of hospital marketers who said the emerging marketing tool they considered most effective was online video.

The genome video of Vanderbilt Medical Center in Nashville, TN, is part of an impressive, well-produced series that inspires confidence in the institution. That feeling that you’re dealing with best-of-breed is part of the patient experience. If your treatment is going to be cutting edge and experimental, you want that confidence. Video can deliver.

But in most cases, healthcare customer experience is more about feeling that real humans, with good hearts as well as good skills, are going to be taking care of you at a critical time. I like the video clips on the Lawrence & Memorial (New London, CT) website, which just went up in August, for the sense they give you of what it’s really like to be inside the hospital.

Lawrence & Memorial’s videos have lower production values – and, of course, an entirely different purpose – than Vanderbilt’s genome series. But low production values can have advantages. Cost is certainly one. Another is an unvarnished believability. A marketing sheen can create a credibility gap. Good clear images, no motion blur, clean editing, good audio – all the things you pay extra for in video production – are the clues to the viewer that reality has been, for good or ill, manipulated.

Your goal will dictate the way you approach video, but if your goal is simply to communicate to patients – to customers – that being served by you will be a good experience, videos that are less polished may get better results.

Video tips

A few more things to think about as you consider video for your hospital, practice group, clinic or other healthcare facility.

1. Put the videos on your website and on YouTube or Vimeo. These sites host your video for free, and anything on YouTube has a better chance of going viral (at least a little bit!) than video on your website. Vanderbilt Medical Center has a YouTube Channel. You can, too.

2. If your facility has a Facebook page (and it should!), your videos should be there as well.

3. Put your key people in short videos. Some hospitals and physician practice groups are starting to include them in their ‘Find a Doctor’ web pages.

4. Show staff in real-life situations, being themselves. And, with permission and in strict compliance with HIPAA, show real patients, too.

5. Many smart phones come equipped with video cameras inside. You may be surprised how effective videos shot by staffers with iPhones could be for you.

6. Keep the videos short. One minute is good. Four is usually too long.

I’d love to hear how video projects have worked for you. Comment here or contact me at dan.prince@catalysthcr.com.

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