Be the change you wish to see in the world, Gandhi has been attributed as saying. This sentiment was echoed by Lauren Singer last Friday 18th May as we brainstormed the social determinants of health and the factors that underpin healthy communities.
Each of us four participants came to the conversation with a point-of-view:
Lauren is a zero-waste advocate, sharing knowledge and hacks about how to simplify life to reduce personal, physical, and financial friction, and simply ask, “what makes you happy?” on a daily basis – then live that authentic life.
Garth, a board-certified physician in internal medicine and cardiologist by training, is a long-time researcher on health equity and disparities that compromise public and personal health.
Pedro’s life work as a sociologist has been in education’s role for enriching peoples’ lives, and how schools are influenced by social and economic conditions as well as by demographic trends in local, regional and global contexts.
My own lens as a health economist informs my view that health is shaped where we live, work, play, pray, learn, and shop – in our communities. We each have the opportunity to make health — but too often our ZIP code and neighborhood prevents us from doing so relative to the quality of schools, access to healthy food, air and environmental quality, and limits on our ability to “walk with our feet” and find healthy opportunities each day.
Some of the key points were covered were that:
Education, from the earliest age, is key to lifelong health and well-being.
Adverse childhood events (ACEs) can stay with people their whole life long, compromising their ability to learn, get a job, work productively, and self-care for health and healthy relationships.
Life expectancy can significantly vary in a matter or a few neighborhood blocks, meaning “the difference between living like it’s 2017 or 1917,” Garth recently wrote in U.S. News.
The research of Christakis and Fowler in their book, Connected, demonstrates that our own behaviors, every single day of our lives, inspire other people in our social circle/network. This then inspires folks in their networks, and so on. That is the viral nature of social networks, so that our own healthy behaviors can initiate a virtuous cycle of health for ourselves, our families, our friends, our work colleagues, and our communities. This is truly being and living out the change for good, for our own health and the health of our communities.
The Healthiest Communities study analyzed a wide range of factors influencing health. I learned that in my region of Chester County, PA, we have many health factor blessings: relatively high life expectancy compared with other U.S. areas and a lower smoking rate. But my home county is also the richest and poorest in the state of Pennsylvania. I sit on board of our town’s free clinic so am aware of our local health challenges based on our own clinic’s patient demographics and my detailed review of our local hospitals’ community assessment reports.
However, the Aetna Foundation study revealed some light-bulb moments that are under the radar in the typical community health assessments: the racial disparity in education in our county is double the national rate, local food sites are less prevalent (which is ironic as we are a heavily agricultural county), we have greater airborne cancer risks, and while the area is relatively walkable, people undergo long commutes.
To hear all of the conversation and ask questions about your own community and healthy lifestyle, please tune into the Facebook Live session tomorrow 19th May at 1 pm Eastern time here.
Health Populi’s Hot Points: I was so moved by the Episcopal Church Bishop Michael Curry’s remarks at the wedding of Prince Harry and Meghan Markle this weekend. Here are some snippets from the sermon that resonated with me, especially in the context of social determinants of health and our Healthiest Communities discussion just hours before (Reverend Curry’s words are in italics, and I’ve bold-faced my separations):
Quoting Dr. Martin Luther King:
“We must discover the power of love,
the redemptive power of love.
And when we discover that, we will be able to make of this old world
a new world. Love is the only way.”
There’s power in love. Don’t underestimate it. Don’t even over-sentimentalize it. There’s power, power in love. If you don’t believe me, think about a time when you first fell in love. The whole world seemed to center around you, and your beloved. Oh there’s power, power in love. Not just in its romantic forms, but any form, any shape, of love. There’s a certain sense, in which when you are loved, and you know it, when someone cares for you and you know it, when you love and you show it, it actually feels right. There’s something right about it. And there’s a reason for it.
There’s power in love.
There’s power in love to help and heal when nothing else can.
There’s power in love to lift up and liberate when nothing else will.
There’s power in love to show us the way to live
Then on the power of love:
I’m talking about some power.
Power to change the world.
And if you don’t believe me, well, there were some old slaves in America’s Antebellum South, who explained the dynamic power of love and why it has the power to transform. They explained it this way – they sang a spiritual, even in the midst of their captivity. It’s one that says:
“There is a balm in Gilead”
A healing balm, something that can make things right –
“There is a balm in Gilead
To make the wounded whole
There is a balm in Gilead
To heal the sin-sick soul.”
And finally, channeling John Lennon from his anthem, Imagine…
Think, and imagine.
Well, think and imagine a world where love is the way.
Imagine our homes and families when love is the way.
Imagine neighborhoods and communities when love is the way.
Imagine our governments and nations when love is the way.
Imagine business and commerce when love is the way.
Imagine this tired old world when love is the way.
When love is the way, unselfish, sacrificial, redemptive.
When love is the way, then no child would go to bed hungry in this world ever again.
When love is the way, we will let justice roll down like a mighty stream and righteousness like an ever-flowing brook.
When love is the way, poverty would become history.
When love is the way, the earth will be a sanctuary.
When love is the way, we will lay down our swords and shields down by the riverside
to study war no more.
My brothers and sisters, that’s a new heaven, a new earth, a new world.
A new human family.
So the great and good Reverend Curry was delineating the social determinants of health to inspire all of us.
Or succinctly put by Tim Sanders, #LoveIsTheKillerApp.
American saw the greatest number of deaths from suicide and alcohol- and drug-induced fatalities was recorded in 2016. That statistic of nearly 142,000 equates to deaths from stroke and exceed the number of deaths among Americans who died in all U.S. wars since 1950, according to Pain in the Nation Update from the Well Being Trust and Trust for America’s Health.
The line graph soberly illustrates the growing tragic public health epidemic of mortality due to preventable causes, those deaths of despair as Anne Case and Sir Angus Deaton have observed in their research into this uniquely all-American phenomenon.
While this is a national challenge, there are regional differences underneath these numbers. The Northeast and Midwestern U.S. states had the biggest increases in alcohol, drug and suicide deaths between 2015 and 2016, and in six states and Washington DC the death rates grew by over 20% — particularly in the Mid-Atlantic region.
The report’s forecast calculates that on the current growth path, deaths from alcohol, drugs and suicide could reach 2 million in 2025 based on a worst-case scenario.
Deaths due to synthetic opioids like fentanyl (100 times more potent than morphine) and carfentanil (10,000 times more potent than morphine) doubled from 2015 to 2016, surpassing mortality due to heroin and prescription opioids. For context, carfentanil is used as a large animal tranquilizer for example in elephants.
Deaths due to the use of synthetic opioids were most common in the Northeast region of the U.S. (11.5 deaths per 100,000), and in people between 18 and 54 years of age (about 10.5 deaths per 100,000). While the overall deaths-per-100,000 people due to synthetic opioids was 6 per 100,000 in 2016, deaths in the White male population exceed those of women and people of color. Nonetheless, deaths across all demographic groups are increasing due to these “despair” causes. The second chart details the demographic differences in synthetic opioid deaths by gender (far and away male-dominated), race and ethnicity (Whites more than people of color, although significant growth among the Black population), people ages 18 to 54, and the Northeast as the virtual capital of opioid deaths, followed by the Midwest.
The impact of these deaths of despair is that U.S. life expectancy fell, again, in 2016. While the country has done a great job at addressing and preventing deaths due to heart disease and cancer, this trend of alcohol, drug and suicide mortality has reversed the positive gains made in the nation…indeed, a Nation in Pain.
The Trust for America’s Health is a non-profit, non-partisan organization focused on public health and healthy communities. The Well Being Trust is a non-profit organization devoted to peoples’ social, spiritual, and mental wellness.
Health Populi’s Hot Points: How to deal with this think-the-unthinkable public and personal health reality?
The Trust detailed a National Resilience Strategy in 2017 with elements of:
Improving pain management and treatment
Stemming the opioid crisis with a comprehensive approach integrating responsible prescribing and provider education, public education about safe disposal of unused drugs and proper use, anti-trafficking to stop the flow of these substances, and expanding use of rescue drugs and sterile syringes
Addressing the impact of opioids on children, targeting multi-generations, services for children and families including grandparents, and expanding support for the foster-care system
Expanding and modernizing mental health services and treatment in U.S. healthcare
Lowering excessive alcohol use especially among minors
Preventing suicides via school and Veterans programs
Prioritizing prevention and resilient communities
Rebooting school prevention and mental health programs.
That’s a heavy lift, and one that would require a re-boot, indeed, of how the U.S. allocates dollars and resources from healthcare to health, wellness, prevention, and social services.
Regular readers of Health Populi will tire of my continued reminder that the U.S. allocates an inverse proportion of spending to healthcare versus social care, but in the case of deaths of despair, it’s so obvious a mindset/paradigm to raise. This changing resource allocation is a central tenet of health economics – how to allocate resources in a resource-scarce environment. Will there be political will at the national level in America, and in the healthcare system, to face the underlying causes of the deaths of despair? We will need to hold many truths in our collective hearts, souls, and minds, and work on many parallel tracks, to effectively deal with this American epidemic.
One-third of Americans are following a specific eating pattern, including intermittent fasting, paleo gluten-free, low-carb, Mediterranean diet, and Whole 30, among dozens of other food-styles in vogue in 2018.
It’s mainstream now that Americans are shopping food for health, with eyes focused on heart health, weight, energy, diabetes, and brain health, according to the 2018 Food & Health Survey from IFIC, the International Food Industry Council Foundation.
But underneath these healthy eating intentions are concerns about the cost of nutritious foods, IFIC reports. And this aspect of home health economics can sub-optimize peoples’ health.
Consider the first graph on consumers’ interests in the health benefits accruing from food and nutrients. Cardiovascular health ranks at the top among one-fifth of people, followed closely by using food with the goal of weight loss and maintaining a healthy weight.
Weight loss, energy, and disease prevention are on a plurality of peoples’ minds when adopting a specific eating pattern like paleo or the DASH diet.
Consumers say the number one food factor is sugar, followed by carbohydrates which are increasingly blamed. 3 in four people are limiting or avoiding sugars in their diet, using tactics like drinking more water than soda or juices and no
longer adding table sugar to beverages.
With these good intentions, most people could not connect a food to a health goal. Only one-third of consumers could name a food they would seek for a top
health issue. Among those who could connect these dots, they named protein, vegetables, fruits, and oils.
While taste ranks the top purchase driver for food shopping, price and health tie for second-place.
That price issue is central to consumers’ perceptions about their ability to afford healthy food. One-half of Americans have purchased less healthy food than they would otherwise do because they don’t have enough money to buy healthier food options. Nearly 1 in 2 people have also delayed grocery shopping due to other expenses in their household like utility bills and rent, or purchased less food overall because they didn’t have enough money in their budget.
As a direct result of medical or prescription expenses, one-third of Americans delayed buying food or purchased less food, the survey found. Look carefully at this chart on food insecurity.
To mitigate cost challenges for food buying, more than half of Americans use coupons, and nearly half purchase more products on sale. 40% of Americans have cut back on eating out in restaurants, and have shifting purchasing generic or store brands versus brand named products.
More women than men are taking on these cost-cutting strategies to manage food expenses.
IFIC surveyed 1,009 American online adults ages 18 to 80 in March 2018.
Health Populi’s Hot Points: With consumers focusing their food consumption in the context of their health, it’s important to note that most consumers trust clinical professionals first as sources for what foods to eat or avoid. Registered dietitians and nutritionists, personal healthcare professionals, wellness coaches and reading scientific studies rank at the top as trusted sources of healthy food information. This chart on the relationship between trust and reliance illustrates this issue, with the upper right quadrant of high trust coupled with reliance as a source capturing the evidence-based, clinical value in the eyes of healthy-minded consumers.
This is an opportunity for the legacy healthcare system, hospitals and physicians, to address the food-as-medicine gap that consumers (patients) want and need. IFIC found that 54% of consumers get information from their healthcare professionals, and when doing so, 78% of those consumers made a change like eliminating certain types of foods from their diets or increasing consumption of vegetables.
Clinicians can leverage their trust-factor with patients and in local communities to counsel patients on the food-health opportunity, and work with organizations in their towns to connect people to grocery stores and Big Box retailers as well as food pantries that go that last mile for convenient consumer touch-points.
Be aware that primary care providers are already switched-on to this idea. The first employee-hat that primary care doctors would bring on staff if they had resources to do so wouldn’t be another doctor or nurse — that person would be a dietitian or nutritionist, based on a recent PwC survey on re-imagining primary care, Building the Primary Care Dream Team. That individual would be hired ahead of a mental health professional — recognizing that perhaps the obesity epidemic is top-of-mind for clinicians, coupled with behavioral health, as the bar graph suggests.
Innovative healthcare providers are already on this opportunity, like Geisinger who is working both the precision medicine/genomics technology angle as well as the social determinants of health approach to nutrition through the organizations Fresh Food Farmacy.
In October 2018, IFIC will publish a supplement to this report focusing on people enrolled in Medicaid, partnering with the Root Cause Coalition. I look forward to this research, which will be an important contribution to our understanding the cost-health trade-offs people make in daily life which can sub-optimize our individual and community health and wellness.
Disparities in Americans’ health vary among people living in each of the 50 states. These differences in health status generally fall into two regions: north and south, found in the Commonwealth Fund’s 2018 Scorecard on State Health System Performance.
The map shows this stark geography-is-health-destiny reality: the worse-than-average states, the Fund found, run from Nevada southeast to Arizona, through New Mexico and Texas all the way to Atlantic Ocean and the Carolinas, then north west all the way up through the industrial Midwest states through Michigan to the north. Wyoming is the only non-contiguous state in the worse-performing U.S. state map.
Health citizens living in states in New England, and then those west of Michigan and north of Missouri and Kansas, demonstrate better-than-average health outcomes.
The top-line of this national health scorecard is that “deaths of despair” are surging, due to suicide, alcohol, opioids, and other drugs whose use has grown by 50% since 2005 to 2016. Premature deaths are rising, reversing ten years of improvement throughout America.
The social determinants of health — income and good jobs, using tobacco, and having health insurance — bolster good health.
Ultimately, the Fund asserts, where you live matters. If you’re in Hawaii, Massachusetts, Minnesota, Vermont and Utah, you will probably be healthier than if you live in the lowest-ranked states of West Virginia, Florida, Louisiana, Oklahoma, and Mississippi.
Health Populi’s Hot Points: The second graphic includes two sets of eight maps of the United States, one showing trends of uninsured Americans by state, and the lower group proportion of people who avoided healthcare due to costs. Light blue to blue is a good thing; the grey area is negative for level of uninsured population and greater self-rationing health care services due to costs.
The top row illustrates that the ACA covered a lot of people with health insurances between 2012 and 2016. The lower row shows that the level of self-rationing due to costs fell across the entire northern section of America, leaving at least 15% of people living in the deeper south to continue to ration in 2016 as they did in 2012.
“Insurance coverage is a necessary but not sufficient condition” to improve health outcomes in America, the Fund asserts in its report summary. Integrating social care, addressing social determinants, and expanding quality and accessible mental health services to reach people who need them will help to bring more “blue” to the map of the United States.
To get to more blue, there are several performance indicators that must improve that would yield quantifiable benefits to the nation’s public health and individuals’ personal health. If all states achieved the top rates of performance…
14 million fewer adults would skip care due to cost
837,000 more young children would receive all recommended vaccines
1 million fewer Medicare enrollees would receive a high-risk prescription drug
5.7 fewer emergency room visits for non-emergency care could be treated with primary care
89,000 fewer people would die before 75 years of age from treatable diseases.
In 1981, I read the book The Nine Nations of North America by Joel Garreau. The author mapped a new concept for America and part of Canada thirteen years before NAFTA was agreed. The map, shown here, grouped states into nine distinctive cultural and economic regions: New England (or New Britain), covering both the quintessential states along with eastern Canada; The Foundry, the industrial heartland of North America, including the Great Lakes region and the manufacturing northeastern states; Dixie, generally the secessionist Confederate states of America but excluding western Texas, and the southern tip of Florida; the Breadbasket, including the Great Plains states, and some of the Prairie provinces of Canada; the Islands, a federation of the Caribbean and also Greater Miami and the Keys; Mexamerica, a melange of Tex-Mex culture including northern Mexico, much of the southern US and New Mexico, part of California, and Texas; Ecotopia, Northwest U.S., including Alaska and British Columbia; Quebec including, well, Quebec; and, the Empty Quarter, the sparsely populated part of North America.
I thought about this important book when considering the Commonwealth Fund’s study and the two-America’s map. Healthcare and health outcomes have morphed the nine nations generally into two, a country of health have’s and have not’s blurring since 1981. Income-related health disparities continue to separate American health citizens, as do the presence of food deserts in a community, poor air quality, lack of transportation infrastructure, and in the contemporary era of social determinants through the THINK-Health/Health Populi lens, lack of access to broadband connectivity, especially in rural areas.
The ability to access broadband via a smartphone, increasingly common platform among lower income folks who have cut the cord to landline phones, means people can look for jobs and access information. For health, that access enables health citizens to sign up for health insurance, receive text messages for medication reminders, and access telehealth visits for healthcare and mental health counseling and support.
Congress will re-visit net neutrality in the coming weeks, which would be one way to address the connectivity-disparity for social determinants of health. Advancing mental health for all and reducing obstacles and taboos will also help improve the healthcare scorecard across states. Finally, balancing social care investments vis-a-vis capital-intensive healthcare spending is important to get to the heart of what’s wrong with U.S. healthcare.
This is what happened to pharma stock prices on Friday after President Trump and Secretary of Health and Human Services Alex Azar outlined their new policies focusing on prescription drug prices.
The graph is the Nasdaq U.S. Smart Pharmaceuticals Index (NQSSPH) from May 11, 2018, the date when POTUS and Secretary Azar made their announcement.
What this upward driving curve indicates, from the start of stock trading in the morning until the ring of the closing bell, is that the pharma industry players, both manufacturers and PBMs, were quite delighted with what they heard.
The blueprint for restructuring the prescription drug industry, is called “American Patients First,” addressing four challenges:
High list prices for drugs
Seniors and government programs over-paying for drugs
High and rising out-of-pocket costs for health consumers
Foreign governments’ “free-riding” Americans’ investment in innovation.
The blueprint lists about 50 line items for “now” (immediate action) and “later” (to be considered). The 50 ways to reform prescription drug pricing include:
Increasing competition via promoting innovation and competition and developing proposals to drop Medicaid and ACA programs from raising drug prices in the private market
Better negotiation through experimenting with value-based purchasing in federal programs and “working across the Administration” to assess the problem of free-riding among other countries
Incentives for lowering list prices for medicines, such as FDA requiring that drug companies include list prices in ads and bringing more transparency to Medicare drug pricing and generic competition, and
Lowering out-of-pocket costs for consumers, like prohibiting Part D contracts from preventing pharmacists’ telling patients they could pay lower OOP costs by not using insurance.
“The stock prices of Express Scripts and CVS, two leading PBMs, also went up, indicating the industry and investors don’t anticipate a major shake-up,” Axios commented. The Wall Street Journal’s judgement was that, “Trump’s Plan to Cut Drug Prices Leaves Industry Relieved.”
Ronny Gal, pharma industry analyst at Sanford Bernstein & Co., is quoted in the WSJ as saying, “They’ve confirmed this administration was and will remain very pro-pharma.”
These prescriptions for lower pharma costs contrast with what most U.S. health consumers/voters want to see, shown in the second graph. Most consumers across party lines believe the Federal government should be allowed to negotiate lower prices for people on Medicare — namely, Part D outpatient prescription drug costs. Based on several years’ worth of polling data, people would want this “sooner” versus “later.”
The “blueprint” for putting American Patients First doesn’t explicitly promote such negotiation in the immediate term, among the 50 policy prescriptions.
Most of these majority-agreed drug cost-policies aren’t part of the fast-track ideas in the blueprint. Many are included in the “future opportunities” list of several dozen “maybe’s.”
Health Populi’s Hot Points: The vast majority of Americans, cross party identification, believe prescription drug costs are “unreasonable,” the Kaiser Family Foundation Health Tracking Poll found in April 2017.
This sentiment continues into 2018, with the advent of EpiPen price spikes, and the growing price curve for specialty drug spending. American Patients First rightly calls out increasingly specialty drug costs, shown in the third graph, versus lower traditional drug spending as more medicines move into generics.
Out-of-pocket spending on prescription drug costs have become a retail-facing household issues for American consumers. For patients facing complex conditions where new-new therapies are coming on to market, a new form of toxicity — financial toxicity — is becoming a more common side effect. As the Trump Administration faces strategic options to help Americans continue to deal with a fairly flat wage profile, facing high-cost specialty drugs and first-dollar costs for high-deductible health plans, people will continue to look to the Federal government for empathy and financial support. Healthcare will be among the top 2018 mid-term election issues, and prescription drug costs rank top-of-mind to healthcare voters.
“If it isn’t a health problem, then why are all these people dying from it?” rhetorically asked Dr. Garen Wintemute, professor of emergency medicine at UC-Davis and director of the Violence Prevention Research Program at the U.
Guns are a public health issue, according to a study from — wait for it — the American Psychiatric Association, published this week. Gun violence, including violence from mass shootings, is a public health issue, say 9 in 10 Americans. Furthermore, 8 in 10 Americans believe Congress should do more to address the issue of gun violence and mass shootings.
As for jobs, through the Health Populi/THINK-Health lens, it’s all about financial wellness in U.S. households. Note that the American Psychiatric Association study also gauged growing stress in the U.S., leading to a kind of anxiety epidemic in the nation. This dovetails with similar research conducted by the psychiatrists’ behavioral cousins, psychologists, whose national association has conducted the Stress in America study for several years discovering growing stress among U.S. health citizens.
The economy and personal finances can also compromise personal health. The researchers Anne Case and Angus Deaton pointed to deaths of despair in the past two years, noting an up-tick in mortality among Caucasian men age 45-54 reversing several decades of positive trends for lifespans in America. I covered this seminal, heartbreaking research here in Health Populi.
Financial stress is a social determinant of health, and as U.S. patients continue to evolve as health consumers, bearing more financial risks whether in employer-sponsored or individual health insurance plans, more Americans feel more health financed-stress.
Thus, my mantra of “the patient is the payor.”
Health Populi’s Hot Points: The 2018 mid-term elections in America will be strongly focused on healthcare and health costs. While not the #1 issue for every U.S. voter, both Democrat and Republican likely voters say health care costs are their top healthcare issue.
The answer: not well. One-fourth of insured Americans, about 41 million people, were defined as under-insured in late 2016, double the 2003 rate when The Fund began to poll on this question. Half of under-insured adults had problems with medical bills or debt, and 2 in 5 said they did not get needed healthcare due to cost.
So having health insurance in itself isn’t a guarantee to ensure patients’ financial health.
The rolls of the uninsured are growing in America, the latest Gallup-Sharecare Poll indicates. The U.S. uninsurance rate rose to 12.2% by the fourth quarter of 2017, up 1.3 percentage points from the year before.
2017 reversed advancements in health insurance coverage increases since the advent of the Affordable Care Act, and for the first time since 2014 no states’ uninsured rates fell.
The 17 states with declines in insurance rates were Arizona, Colorado, Florida, Hawaii, Illinois, Indiana, Iowa, Missouri, New Mexico, New York, North Carolina, South Carolina, Texas, Utah, Washington, West Virginia, Wisconsin, and Wyoming.
Among these, the greatest losses of health insurance were for people living in West Virginia with the greatest drop of 4.2%, New Mexico falling 3.8%, and Hawaii and Iowa declining 3.3%.
Texas wins the award for the greatest percent of uninsured people at 22.1%. For ten years in the Gallup research, Texas has reigned the state with the highest level of the uninsured.
Massachusetts gets the nod for lowest level of uninsured at 4.0% (thank you, Romneycare, which was a model for the Affordable Care Act).
This research is part of the ongoing Gallup-Sharecare Well-Being Index surveys conducted every day, tracking questions for U.S. adults 18 and over.
Health Populi’s Hot Points: It’s insightful and correct that Gallup posts this survey on the uninsured under the tab, “Well-Being.”
That’s because being health-insured is a social determinant of health. As Dr. Vivek Murthy pointed out in his talk at the PwC 180 Health Forum earlier this week, there are six categories of #SDOH:
Economic stability, including housing, financial wellness and debt
Neighborhood and physical environment, such as housing safety, walkability, utilities
Education, arguably the big kahuna here, covering literacy and early childhood education which has proved to strongly correlate to health
Food security, increasingly recognized as central to health
Community and social factors, especially social connections, and
Healthcare system factors, such as health insurance coverage.
So having health insurance in America is a social determine for individuals’ health like access to healthy food, clean water (THINK: Flint), and living in safe housing.
This week, the Commonwealth Fund points out Americans’ falling confidence in their ability to pay for healthcare. One-third of people with individual health insurance coverage told the Fund their healthcare has become harder to afford over the past 12 months. This bar chart shows that 50% of working-age adults would not have sufficient funds to pay an unexpected $1,000 medical bill within 30 days.
President Trump campaigned on this issue and was quoted in his TIME magazine “Person of the Year” profile saying, “we have to…create new bidding procedures for the drug industry, because they’re getting away with murder, pharma. Pharma has a lot of lobbies, a lot of lobbyists, a lot of power. And there’s very little bidding on drugs.”
Remember that prescription drug spending continues to hover around one-tenth of overall U.S. National Health Expenditures. A move to re-align prescription drug prices will be welcomed across the political spectrum as Big Pharma continues to take the bulk of the blame for rising healthcare costs. But actually, “it’s the prices, stupid” across the entire healthcare system that plague, ultimately, the patient-as-payor including but not limited to insurance premium costs, hospital and physician bills, and to be sure, prescription drugs.
As a final reminder, most Americans are looking for the Federal government to ensure that every U.S. health citizen is covered by health insurance. I’m just the messenger – this was the Gallup-Sharecare research findings from December 2017. Just sayin’.
Two weeks in a row, The Economist, the news magazine headquartered in London, included two special reports stapled into the middle of the magazines. Universal health care was covered in a section on 28 April 2018, and coverage on financial inclusion was bundled into the 5th May edition.
While The Economist’s editors may not have intended for these two reports to reinforce each other, my lens on health and healthcare immediately, and appreciatively, connected the dots between healthcare coverage and financial wellness.
The Economist, not known for left-leaning political tendencies whatsoever, lays its bias down on the cover of the section here: universal healthcare is “an affordable necessity.” In making its case for universal healthcare (UHC), the writers acknowledge that the argument for UHC is clear, but difficult to reach.
The U.S. is a special case, an outlier, the report calls out. In the “Land of the free-for-all” discussion, the section notes that, “American made a good start” toward the end of the Civil War, noting that Abraham Lincoln announced there would be services, “to care for him who shall have borne the battle, and for his widow and his orphan.” At the time, this was one of the world’s biggest public-sector financed health plan. Over time, America’s approach to health care provision fragmented by plan sponsor, whether U.S. government (which offers several flavors of plans through the VA, Tricare for active military, Medicare for aging people and Medicaid for people with low-incomes) or private sector employers, unions, and other insurance-conveners.
Millions of Americans who are “insured” are now considered “under-insured,” defined by the Commonwealth Fund as people who pay an insurance premium who also spend over 10% of household income on covering health care co-payments and coinsurance percentages, and meeting deductible limits. For poorer citizens, that under-insured definition falls to spending 5% of household income on healthcare payments.
“America has a version of a problem seen the world over: voluntary insurance cannot ensure that everybody gets coverage,” the editors observe.
Affordability remains elusive in U.S. healthcare.
Keep that in mind as we turn to the second special report on financial inclusion, which the World Bank defines as peoples’ access to useful and affordable financial products and services that meet their needs, including transactions, payments, savings, credit and insurance, all delivered in a responsible and sustainable way. Financial inclusion is recognized as an engine for economic development that helps grow the GDP, improve individual and social well-being, and build small business.
When it comes to financial inclusion, don’t let the map here fool you: while the US looks to be well-banked compared with financial citizens in other parts of the world, 109 million Americans fall below U.S. banks’ definition of “prime” customers, and 53 mm people are “credit invisibles” without sufficient financial history to build a FICO score. The Economist explains:
“In America the Centre for the New Middle Class, the think-tank arm of Elevate, a Texas-based onlin7e lender specialising in the “nonprime” market (not immediately creditworthy), estimates that 109m Americans are nonprime and a further 53m are “credit invisibles”, without enough of a financial history to be assigned a credit score. A survey by the Federal Reserve last year found that 44% of Americans would struggle to meet an unexpected expense of $400 without selling something or borrowing.”
Digital technology is not only useful for scaling healthcare service and health literacy/education access — the mobile phone is also a platform for medical banking and personal health financial management. Back to The Economist‘s financial inclusion report:
“Digital technology provides data through the apps that users download on their phones. Lenders say they can learn a lot from how, and how often, their customers use their app. Oakam, for example, offers an in-app game in which customers climb a “ladder” of client categories to earn a higher status and discounts. For people at the bottom of the credit pile, it is an apt metaphor.”
Now, connect the dots, at just the top-line: The Federal Reserve survey cited by The Economist found that 44% of Americans would “struggle” to meet an unexpected expense of $400 without selling something or taking out a loan.
Note the average costs for various health care services in the U.S.:
An emergency room visit = $580 to $700, according to Blue Cross & Blue Shield of Massachusetts
A root canal at the dentist = $762 to $1,111, according to FAIR Health
A prescription for EpiPen at retail = $630 for the branded version and $320 for generic, according to GoodRx.
I’ve been a regular reader of The Economist since leaving college, and it’s been essential content for me. These special sections make the case for The Economist being must-reading for lifelong learners who care about the world and its peoples.
Health Populi’s Hot Points: The titles of the two special reports could be reversed: “An affordable necessity” could correspond to financial inclusion, and “exclusive access” to the reality of healthcare in America.
A common demographic underlies the covers of these sections: that the have-not’s living in developing nations — health citizens and financial citizens, both, at once — lack access to healthcare and banks.
As I pointed out with the “unbanked” map, which indicates that U.S. has a lower proportion of unbanked individuals than the developing world — what lies underneath is a much less sanguine story, which relates to both personal financial and individuals’ access to affordable healthcare.
These realities are intimately inter-related in the U.S.: addressing one without the other misses the point that the social determinants of health underlie Americans’ health and financial wellness.
Expect “new combinations” of industry actors and technologies to reorganize and re-imagine healthcare, with an eye on both price and investments in customer experience (CX), PwC envisions in their latest report on The New Health Economy in the Age of Disruption.
In this vision, healthcare will be a more flexible marketplace underpinned by data, platforms, and workers. Yes, it’s challenging to get from here-to-there, but PwC explains just how this can happen.
Four archetypes, models, of healthcare deals have begun to emerge in the marketplace, illustrated by the Big Deals and announcements reshaping the industry in the past couple of years:
Vertical integrators, represented by the CVS/Aetna combination (still in FTC review), and Cigna’s acquisition of ExpressScripts, the PBM.
Employer activists, which the Amazon + Berkshire Hathaway + JPMorgan Chase alliance embodies.
Technology invaders, illustrated by Apple’s healthcare efforts in electronic health records and the company’s portfolio of “Kits,” Lyft and Uber’s entries into healthcare transportation, and Google’s growing portfolio of healthcare projects.
Health retailers, such as Walmart’s ongoing growth in health and beauty aisles, clinical care, and potential merge with Humana; grocery stores co-located with pharmacies and clinics; and, re-use of shopping malls as health malls.
What’s driving these transformational alliances is the unsustainable economics of healthcare, especially in the U.S.: a cost-increasing workflow instead of a value-oriented ecosystem. So the vertical integrators look to increase efficiencies in the production of care; the employers seek more value-for-money and ROI on benefit spending through scale; the technology invaders disrupt old modes of production and value-chain disruption; and, the retailers serve up care, services and products in lower-cost, more convenient and consumer-enchanting environments.
It won’t come easy, as Ringo knew, but will require speaking in three languages, Jeff Arnold, Sharecare’s Chairman and CEO, advises in the report: those languages are healthcare, technology (e.g., analytics and artificial intelligence), and media which provides both content and platforms for conversations and support.
This report precedes the PwC 180? Health Forum, held at the Lansdowne Resort on 7-8 May 2018. I will be part of a segment called “Click for Better Health,” brainstorming digital health opportunities and consumer engagement with Jeff and Dr. Joshua Riff, CEO of Onduo.
Health Populi’s Hot Points: Speaking in tongues will require collaboration across the three dimensions that Jeff identified — healthcare expertise, technology savvy, and media chops. So it’s perfect that Onduo is one of our “three J’s” (represented by ‘J’osh Riff on our “Click for Better Health” session).
Onduo is focused on helping people with diabetes better manage daily living, from food choices and glucose testing to accessing care through coaches. For healthcare and technology “language,” Onduo is backed by Sanofi (the pharma company) and Verily Life Sciences (Google/Alphabet). For media and platforming, the company has developed a virtual care clinic and also collaborates with advocacy organizations in the diabetes community.
In the PwC archetype typology, Onduo is a hybrid of technology invader combined with vertical integrator.
This is where I land on the LEGO analogy. Aside from the fact that, in full transparency, my household and I are confirmed LEGOmaniacs, the New Health Economy requires health industry stakeholders to think design-fully, strategically, and comfortable with many moving parts.
Thus it’s intriguing that LEGO has a division that markets bundles of bricks to organizations who want to use them in developing teams and ideas: LEGO SERIOUS PLAY.
“The LEGO SERIOUS PLAY materials and methodology are effective when there is more than one possible right answer, and when the organization wants to harness all available knowledge in the team in order not only to find the best possible solution but also to get the strongest possible commitment,” the program’s portal explains.
What’s especially instructive for the New Healthcare Economy is this note from LEGO, which says SERIOUS PLAY is useful when, “the subject is complex and multifaceted and there is a need to grasp the bigger picture, find connections and explore options and potential solutions.”
This is sound advice for healthcare stakeholders looking to be relevant and resilient for the long-term. Remember that “LEGO” the brand name grew out of the Danish phrase, “leg godt” which translated as, “play well.”
PwC sees a new putting-together in healthcare: “Now emerging in place of this siloed industry is a modular ecosystem that operates similarly to industries such as retail, technology and hospitality. This ecosystem, in which consumers can choose care according to their wants, needs and wallets, is far more accessible to newer players, which can tackle discrete parts of the system without having to control, own or understand the whole. This ecosystem is more dynamic, responsive to consumers and fertile for innovation—in other words, an ecosystem ripe for novel deals.”
What if you went to visit a Vermeer still life with fruit, vegetables, and flowers, and the only image you saw in the famous painting was the flower and an urn?
That’s exactly what happened to museum-goers visiting Amsterdam’s Rijksmuseum. These art patrons witnessed a museum guard literally pulling an apple out of a painting, to leave a barren portrait of an urn and little else. Roll over, Anthony Oberman, the artist of “Still Life with Fruit in a Terracotta Dish,” one of the paintings featured in this stunt. Watch the video now to delight in the medium and the message…
Taste a Dutch Masterjuice! - YouTube
Philips has been on this healthy food kick for a while. When I attended South-by-Southwest in 2015, that was the company’s initial bold foray into digital health, beginning to divest assets and businesses that did not relate to health and healthcare. In the streets in front of the Austin Convention Center, right by the food trucks selling amazing tacos and slow BBQ pulled pork, Philips was making and distributing healthy smoothies made in its juicers in trucks parked there on the street. Here’s my write-up of health, everywhere, at #SXSW2015, including the Philips story.
The rationale for the video ad campaign was that, as Europeans don’t eat enough fruit and veg every day, “they also tend to ignore fruit and vegetables in still life paintings. Yet you miss them when they are not there,” a write-up in Advertising Age explains.
Health Populi’s Hot Points: Health is where we live, work, play, pray, learn and view art. I love this concept Philips’ ad agency adopted in so many ways. First, the company’s home base in the Netherlands is the site of one of the world’s great art palaces, the Rijksmuseum, home to Rembrandt’s and Vermeer’s and Van Gogh’s.
Second, Philips has doubled-down in health, and so the “discover fruits and veg for better health” message is spot-on, also softening up the company’s image in electronics and hard-edged tech.
Finally — it’s fun! We can inspire health behavior change through humor embedded with simple, motivation health messages.
File this in your best-in-class healthcare marketing case studies. Congrats to Ogilvy for an inspired health message combined with art and humor.
And enjoy this portrait of Dr. Gachet by Van Gogh, which is housed in the Rijksmuseum. Dr. Gachet was Van Gogh’s beloved doctor and friend, further bolstering the message of social networks, loving friends, creative outlets and access to medical care for health and wellbeing.