April 26th, 2008 by Dr. Val Jones in Expert Interviews
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In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.
Dr. Val: What role could consumer-directed healthcare initiatives play in helping to reduce healthcare costs associated with chronic disease? Is the government doing enough to support this movement?
Dr. Carmona: I think the consumer-driven initiatives struggle for a number of reasons, and the most important one is that we’re a health illiterate nation. Studies show that about one third of our population doesn’t understand the connection between their lifestyle and their health outcomes. Consumer-driven initiatives are predicated on the assumption that the consumer can understand the issue and take appropriate action to change behavior.
Are we doing enough? No. The government could pour all of its budget into patient education, but if the people don’t receive a message that they can understand and act upon, we’re wasting our time. The real challenge for consumer-directed initiatives is to deliver health literate, culturally competent messages that resonate with diverse populations. If I sent a bunch of posters to certain communities with a picture of the Surgeon General saying, “eat less and exercise more” would that change behaviors in that community? No. What we need to do is partner with community leaders, whether it be a priest or a rabbi or a grandmother or a block neighborhood captain – someone who has credibility in that community and work with them and spend the time necessary to change the culture.
The American public wants the best of everything, they want it yesterday, and they don’t want to pay for it. That pretty much characterizes the problem that we have. We see health as a right, we want somebody to give us a card, and if we want to smoke, that’s our right too. There’s this attitude that if we want to drink excessively, that’s our right, and if we want to ride a motorcycle without a helmet, that’s our right (“you can’t tell us what to do”). However, when I crash my motorcycle and I have a head injury and I’m disabled for life, I also expect society to pay for that.
We have to do a better job of improving health literacy so that American people of all socio-economic strata can understand the consequences of the choices that are deleterious to their health and help them to adopt appropriate behaviors that optimize health and wellness. Health literacy is the currency of success for everything we need to do to improve the health, safety, and security of our nation. It’s part of what we include in every project we do at Canyon Ranch Institute, with all our partners.
Dr. Val: And how do we get the message across to them, then?
Dr. Carmona: Boy, people have written books on that one. I’ve been plagued by this question, Val, ever since I came into the office of Surgeon General. I remember one day sitting down with my staff and taking a look at the previous Surgeon General reports. I thought they made pretty good book ends and looked nice in my office, but I wanted to know what we used them for. One staff member said, “Well sir, these have been developed to define the base of knowledge on a given topic and it helps our peers decide what needs to be done. It has a long bibliography and it’s based on science.”
But then other staff told me, “Really these are written for the public, so they’ll understand the information.”
And I thought to myself “I don’t know that any of the ‘public’ that I grew up with could read this.”
So I started a program to help communicate health messages to the American public. The goal was to develop resonant messages that would result in maximal behavior change over time. My advisors told me that the messages had to be written at a sixth grade level. So what we did with every Surgeon General’s Report and every Surgeon General’s Call to Action and other publication – we published the “Peoples’ Piece” to go along with it. It was full of pictures and written like a comic book to facilitate parent-child dialog about health. We also wrote them with cultural sensitivities in mind. The science behind our recommendations doesn’t change, but you have to send out thousands of messages to resonate with people from different cultures and languages – who are all Americans – in order to change their behaviors. So that’s what makes this so difficult.
Dr. Val: How do you get the ‘Peoples’ Piece’ to the people? Do you use the Internet or new media approaches?
Dr. Carmona: Unfortunately it’s often the case that the people who need the information the most don’t have Internet access. But the Internet can be incredibly powerful. For example, Dr. Francis Collins (the head of the human genome project at NIH) helped me with the U.S. Surgeon General’s Family History Initiative. We put our heads together to help people understand the significance of family health history.
We put it on the Internet and also distributed it to libraries, post offices, community centers, and schools. It helped people to create a family health tree to use as a talking point with their doctors. They could remind their doctors that, for example, their aunt and grandmother had breast cancer and then ask if they should be monitored more closely. Or they could discuss the fact that their uncles and cousins all had heart attacks before age 50. This tool helped people to begin identifying their risks based on a good family history – which busy docs don’t pay enough attention to anymore. When you know your history, genomics becomes valuable. If we can characterize disease, then we can search for potential genetic loci to help explain what’s going on and take a preventive approach to modifying the person’s environment to mitigate risk.
This concept is extraordinarily hard to communicate, but the Family History Initiative helped to make it accessible to people. We released the project at Thanksgiving time – when we knew that families would be together and could discuss their health histories, and it was a resounding success. Within a week or two we had hundreds and thousands of hits, with people asking for more information.
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The Surgeon General series: see what else Dr. Carmona has to say about…
Cost Savings Associated with Preventive Health
Obesity is America’s #1 Health Concern
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 25th, 2008 by Dr. Val Jones in Expert Interviews
5 Comments »
In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.
Dr. Val: Obesity rates continue to rise each year. Does obesity lie at the core of the chronic disease crisis and if so, what can America do to reverse this trend?
Dr. Carmona: Obesity is absolutely at the core of the chronic disease crisis. When we look at the relationship of obesity to other diseases that plague society today (such as asthma, cancer, cardiovascular disease, and diabetes) obesity increases the incidence of each of them, and can even accelerate some of them. Losing weight is not about trying to emulate models in fashion magazines, it’s about being healthy.
If we could only address one major public health issue as a nation, I would focus on the obesity crisis. Weight loss could have the greatest impact in decreasing the chronic disease burden in America.
Dr. Val: So what can we do about obesity?
Dr. Carmona: That question is simple on the surface but incredibly complex when you begin to analyze it carefully. First of all we have to identify the variables that contribute to this problem, because it’s a multi-factorial issue. The socio-economic determinants of heath are inextricable from the health status of individuals and communities. That means that if you’re poor and have less education, you’re going to experience health disparities. You can’t afford to buy healthy food, you don’t live in a neighborhood where you can walk at night and get exercise, and so on. So understanding all the determinants of health to address obesity is important.
Let me describe just one significant variable contributing to the obesity epidemic: the sedentary lifestyles of children. Thirty years ago it was commonly believed that physical education in school was not important, because kids played during all the hours that they are out of school. Parents reasoned: ‘Why should I pay a teacher to have my kids play ball at recess? I’d rather have her teach them math and science.’ So there was a sweeping trend to discontinue physical education at school. Now, however, kids spend too much time on playstations rather than on play grounds – or they watch over 4 hours of TV a day. They’re sedentary at school and at home.
Other variables that influence obesity rates in kids include the accessibility to fast food, the increased rate of single parenthood, and the change in cultural traditions around meal time. For wealthier families, easy access to large volumes of food of every possible kind can create an environment where people overeat.
The solution to the obesity crisis is not “one-size fits all.” The approach to obesity must be tailored to the cultural and socio-economic sensitivities of the sub-population that you’re trying to reach.
Ultimately we need to change behavior – walk a little more, eat a little less, buy some healthy foods. But targeted interventions must be culturally sensitive and socio-economically relevant. For example, the government is funding programs to make healthy foods more accessible to underserved areas, and physical activity programs are being reinstated in schools. But the effects of these programs are not going to be seen for many years because it takes time for the culture to catch up. Also, the approach must be comprehensive. If we were able to get all of our children enrolled in a daily game of baseball (to increase their physical activity), that would not solve the problem of fast food and video games.
There needs to be a community approach, so that no matter where the child turns they’re getting positive reinforcement of healthy behaviors. That’s part of what I’m doing with the national non-profit health organization that I’m president of now – Canyon Ranch Institute.
***
The Surgeon General series: see what else Dr. Carmona has to say about…
Cost Savings Associated with Preventive Health
Consumer Directed Healthcare and Health Literacy
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 24th, 2008 by Dr. Val Jones in Expert Interviews
2 Comments »
Here it is… the long anticipated interview about chronic disease with Dr. Richard Carmona, 17th Surgeon General of the United States. I asked him 5 key questions and will split the Q&A into 5 posts. Enjoy!
Dr. Val: What do you say to those who argue that disease prevention is critical for quality of life, but does not ultimately reduce costs?
Dr. Carmona: The real value of prevention is best captured by some of the simpler interventions that have little or no cost to implement, such as smoking cessation. The returns on these prevention strategies are huge, and the only “cost” is in educating people to change their behaviors. Another great example is childhood vaccination – it costs pennies per child but protects them from polio and other deadly diseases.
In the recent past there have been a number of editorials where learned individuals have cited examples such as the cost of treating hyperlipidemia in the population at large. For every heart attack that lipid-lowering drugs prevent, it costs hundreds of thousands of dollars to provide the drugs to the population with high cholesterol. I guess if you’re the one with the heart attack it is worth it. But not withstanding that issue, I think the argument is a misapplication of the concept of prevention.
If you look at prevention in the appropriate light, you can make the business case for it. Health itself and quality of life are priceless things. We need to provide the right drug for the right person at the right time. But better yet, lifestyle interventions like physical activity and healthy eating behaviors can eliminate the need for many medications.
The real issue here is how to attain optimal health and wellness through appropriately vetted prevention strategies that will reduce the cost of care while improving the quality and quantity of life. That is the challenge we have before us and I’m working to answer as chairperson of the Partnership to Fight Chronic Disease.
***
The Surgeon General series: see what else Dr. Carmona has to say about…
Obesity is America’s #1 Health Concern
Consumer Directed Healthcare and Health Literacy
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 23rd, 2008 by Dr. Val Jones in Medblogger Shout Outs
5 Comments »
My radiologist friend in India pointed out an interesting blog post of his (via Twitter*) today. See if you can pick your jaw up off the floor on this one:
A basic MDCT scanner (6 or 8 detector rows) costs about 2 to 2.5 crore rupees here in India (INR 20 to 25 million = US $ 500,000 to 630,000). I learnt from a source in the industry that the cost of the scanner is about 40% subsidized for the Indian market (compared to its cost in the North American & European markets). So the same basic multislice CT scanner would cost about $ 900,000 in the US.
We have a basic four-slice MDCT scanner in our hospital. A patient would be charged Rs. 3500 ($ 90, yes ninety dollars) for a plain CT scan or Rs. 4500 ($ 115) for a contrast CT scan of the whole abdomen. Ours is a small city. The charges are likely to be as high as Rs. 8000 or Rs. 9000 ($ 200 to 230) in the bigger metros like Chennai, Mumbai or Delhi.
Compare that price to a patient in the US who was charged $6,500 for an abdominal CT scan.
(Usual cost is ~$2000, but still!)
*If you’d like to follow me on twitter.com, my user name is drval. Check it out for quick updates and daily eyebrow raises.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 23rd, 2008 by Dr. Val Jones in Expert Interviews, News
5 Comments »
Imagine that you were diagnosed with cancer, and were told that you had one of two treatment options: 1) you could receive a one time dose of a medicine that will go directly to the tumor cells and kill them only, having very few noticeable side effects or 2) you could undergo months of exposure to toxic chemicals that will kill the tumor cells and many other healthy cells as well, resulting in hair loss, bowel damage, nausea, and vomiting. Which would you choose?
Unfortunately, choice number one may no longer be an option for lymphoma patients due to government funding cutbacks, and the development of such treatments for other cancers is in jeopardy as well.
Radioimmunotherapy (RIT) is a relatively new approach to cancer treatment, new enough that the government is having difficulty categorizing it correctly. (RIT involves targeting cancer cells with special antibodies that carry tiny, lethal radiation doses to individual cells.) In fact, drugs like Bexxar and Zevalin have been misclassified by CMS as “supplies” rather than medications, and so the reimbursement allowed doesn’t come close to covering the cost of the therapy. Although there are many new targeted therapies under development, investors are worried that the drugs will never be used in patient care because the country’s number one payer (Medicare) is unwilling to cover their costs. Other health insurers often follow the government’s lead when it comes to treatment coverage policies. If no one will pay for the cost of the drug, then ultimately no one can afford to make it available.
Similar funding problems are beginning to limit access to diagnostic nuclear imaging modalities like PET scans, PET CT, cardiac SPECT scans, and bone scans. Reimbursement levels that do not cover the cost of the imaging drugs means that facilities cannot afford to offer these diagnostic technologies to patients, and centers are slowly reducing the number of tests they offer. Nuclear imaging studies are often critical in diagnosing heart problems, infections, and early detection of cancer. Senator Arlen Specter had his cancer recurrence diagnosed at the very earliest stages thanks to PET scanning technology. Early treatment offers him the best possible prognosis, but he is in a dwindling group of people who have access to this imaging modality.
I spoke with Dr. Peter Conti, professor of radiology at the University of Southern California, and former president of the Society of Nuclear Medicine, from Spain this week – as he is attending the 6th International Workshop for Nuclear Oncology, a lymphoma conference where the crisis in reimbursement for targeted cancer therapies is being discussed, along with exciting advances in treating patients with lymphoma. The two different RIT drugs (Bexxar and Zevalin) for non-Hodgkin’s lymphoma are in jeopardy of not being available to Medicare patients due to proposed cuts in reimbursement. Recent plans to cut payment for these drugs have been halted by a temporary moratorium from Senator Kennedy. Here’s what Dr. Conti had to say:
“Let’s face it, lymphoma is not as high profile as other cancers such as breast, colon, or prostate. However, we’ve found a fantastic treatment option for it, and there are implications for the more common cancers, but that treatment option is being denied to lymphoma patients because facilities cannot cover the costs of offering it. I’d like the entire cancer community to rise up in support of lymphoma patients so that Congress will tell Medicare to fix the funding problem. If this doesn’t happen, it’s only a matter of time until novel RIT treatments are no longer an option and we’ll be stuck in the dark ages of non-specific chemotherapy and radiation treatments that harm the good cells with the bad. Personalized, targeted therapy is the future – and we’re missing the opportunity to further develop these novel therapies due to budget cuts.”
I reached out to the current president of the Society of Nuclear Medicine, Dr. Alexander J. McEwan, for comment:
“Molecular imaging offers critical tools for the early detection, diagnosis and treatment of many life-threatening diseases, including cancer. SNM recommends that CMS establishes appropriate reimbursement for all forms of nuclear and molecular imaging and radioisotope therapies at levels that allow optimum access and improved outcomes for all patients.”
Denial of RIT to lymphoma patients may be the first sign of a new trend limiting the development of high tech therapeutic innovations. Will America’s research engine run out of gas before we figure out how to treat cancer without side effects? Should we buy one more tank to get us over the crest of the targeted therapy hill? This is a judgment call that affects all of us at a time of great need and limited resources. What’s your take?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
