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A Surgeon General’s Opinion: Consumer Directed Healthcare And Health Literacy

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.

Dr. Val Talks to iHealthBeat about Consumer Driven Healthcare

January 26th, 2008 by Dr. Val Jones in Health Policy, Opinion
3 Comments »

As patients increasingly turn to the Internet for health care information and online tools to manage their health, many companies, both new and old, are stepping up to meet the consumer demand.

It is still too early to tell which companies will be successful and how the Internet-savvy health care consumer will transform the patient-physician relationship, but the trend has captured the interest of many health care insiders.

Val Jones, senior medical director of Revolution Health and author of a blog called “Dr. Val and the Voice of Reason,” spoke to iHealthBeat about the online health care market, physician concerns about patients relying on the Internet and the role of medical blogs.

…

A recent Harris Interactive survey found that the percentage of U.S. adults who looked for health care information online increased from 72% in 2005 to 84% in 2007. Why do you think more and more consumers are turning to the Internet for health information?

I think it’s partially because more and more consumers are turning to the Internet for information, period. Online information is incredibly convenient, served up lightning fast and has revolutionized how we research everything from buying toasters to finding a doctor. Of course, health is much more serious and complicated than purchasing products, so consumers should be very wary of the source of their health information.

Do you see a generational divide in the people using Revolution Health?

We primarily appeal to everyone between the ages of 20 and 60, though women conduct more health searches than men. The only age gaps are related to the medical subjects being researched. Clearly, not too many 20-somethings are reading about menopause, and not too many 50-year-olds are reading about college stress. Otherwise, all of our community tools and groups are fair game for people of any age. We have 60-year-olds blogging and enjoying discussion groups, and 20-year-olds posting forum questions too. It’s wonderful to see the generations interacting online and learning from one another.

New York orthopedist Scott Haig in November wrote an essay in Time Magazine complaining about patients who research their symptoms, illnesses and doctors online before seeking treatment. What are the downsides to patients searching for health care information online?

I think Dr. Haig’s essay has been somewhat misinterpreted because he was focusing on a specific patient with a serious disorder. My favorite quote from Dr. Haig’s article is that “the role of the expert is to know what to ignore.” I think the major downside for patients searching for health information online is that it can be difficult to figure out what’s contextually relevant to them. Aside from that, the next major downside is that there are snake-oil salesmen out there preying on the frustrations that we all have about our broken health care system and promising “miracle cures” and fueling mistrust in doctors.

What can be done to ease concerns from physicians, like Haig, about consumers relying on the Internet for health information?

Educated patients are a pleasure to work with, but misinformed patients require lots of extra help. The hours we spend every week dispelling urban legends and Internet-fueled medical myths is really mind-boggling. Physicians are naturally protective of their patients and don’t want them to be duped or misled.

From Google to Microsoft, companies are beginning to recognize an opportunity in the online health care market. Is there enough room for all of these companies? What will make successful ventures stand out from the rest of the pack?

There’s as much room as consumer demand will fuel. However, only the largest and most innovative companies will ultimately survive long term. While we’re all waiting for the government to create standards for health information and the creation of interoperability rules, successful companies will meet the needs of today’s consumer. Small but practical tools and innovations will keep the companies solvent while we work toward the holy grail of a common health information platform for all the stakeholders.

Medical blogs seem to have taken off in recent years. Who do you think the intended audience is?

Actually, while there are an estimated 70 million blogs out there, only a few hundred doctors are blogging. That’s a huge discrepancy, and I don’t think we’re even at the beginning of the wave of medical blogging that will inevitably occur as doctors enter the Web 2.0 world. The first pioneers of the medical blogosphere are writing mostly for their peers, though patients find their blogs very engaging and read them as well. Very few medical bloggers write specifically for consumers.

What are your predictions for the online health care market in 2008 and beyond?

With decreasing access and increasing patient loads, I think we’re going to see the consumer-driven health care movement take center stage. Patients are going to need to “do it themselves” a lot of the time (meaning manage their own health information, teach themselves about disease management and make financial plans to take care of their own needs if the government cannot afford to do so).

Another trend I have my eye on is the retainer medicine movement. As primary care physicians continue to be squeezed out of existence by decreasing Medicare reimbursements, they are beginning to join an “off-the-grid” group of providers who simply do not accept insurance.

As more PCPs create retainer practices, I think IT solutions will really take off. Online tools that simplify their practices and speed up their patient communication will be welcomed and encouraged.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Why Doctors Are Better Than Google

November 9th, 2007 by Dr. Val Jones in Opinion
5 Comments »

“One major responsibility of an expert is to know what to ignore.”

— Scott Haig, MD

Health information is more plentiful and accessible to patients than ever before. As a physician I am thrilled that people are empowered with knowledge to take control of their health, but I am also sincerely worried about the “misses:” misinformation, misconceptions, misdiagnoses and mistakes.

The great sculptor Michelangelo believed that every piece of marble was a beautiful statue just waiting for the artist to remove the parts that didn’t belong. I believe that this principle applies to health information – the utility of the information is directly proportional to the reader’s ability to ignore the parts that are irrelevant or incorrect. Google cannot remove the irrelevant, because it can’t evaluate the science behind various claims, appreciate the nuances of an individual’s life circumstances, or confirm a diagnosis. No, as powerful and wonderful as search engines are, they are mere marble. The master sculptors in health information are physicians – trained for at least a decade in the art of analyzing data, appreciating the connectedness of various symptoms and body systems, and focused on chipping away at the irrelevant to uncover personalized solutions and cures – they are the artists whose experience and insight can make the difference between life or death.

Are sculptors flawed? Sure. Are some better than others. Yes. But the bottom line is that information in the hands of a person who can apply it in an intelligent, personalized, and relevant way is our best shot at good, quality healthcare. There is an art to medicine, and the trick is to know what to ignore. Find a good sculptor and stick with him/her so that you can live your very best and avoid the “misses!”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Are Cash-Only Medical Practices The Wave Of The Future?

October 28th, 2007 by Dr. Val Jones in Health Policy, Opinion
1 Comment »

MedPage Today issued a special report on a rising trend: cash-only medical practices. I guess I’m ahead of the curve, since I’ve been seeing a cash-only primary care physician for 2 years now – and I love it.

Dr. Alan Dappen is available to his patients 24 hours a day, 7 days a week, by phone, email and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.

How much would it cost to have the luxury of a personal physician on-call for your every whim?

Would you believe only about $300/year?

What’s Dr. Dappen’s secret to success? He accepts no insurance, keeps his overhead low, offers full price transparency, has physician extenders who work with him, and charges people for his time, not for a complex menu of tests and procedures.

“I believe in doing what is necessary and not doing what is not necessary. The healthcare system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don’t care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests, and procedures. Unlike any other sector, more competition actually drives up costs.”

After building a successful traditional family medicine practice in Fairfax Virginia, Dr. Dappen felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50% of office visits were not necessary – and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance.

“The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for longstanding adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time. Cutting the middle man (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits. This also frees up my schedule so that I can spend more time with those who really do need an in-person visit.”

Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide. But for routine care, “concierge medicine” can make healthcare affordable to the middle class, and reduces costs by at least 50% while dramatically increasing convenience. For the right patient, this is a welcome relief from having to wait to be seen by in-network providers or from being billed non-preferred rates as an uninsured individual. I applaud Dr. Dappen for his efforts in healthcare reform, and look forward to a movement where costs are driven down by putting patients back in the payer seat.

Online Physician Ratings: Embrace The Inevitable

August 26th, 2007 by Dr. Val Jones in Opinion
5 Comments »

The Wall Street Journal’s Health Blog recently featured a heated
debate about the utility of online physician ratings.  On the one hand, some physicians are worried
that their reputations will be harmed by poor ratings given by a select minority
of disgruntled patients.  Some have gone
so far as to ask that their patients sign an agreement not to participate in
online physician ratings.  On the other
hand, many physicians view online ratings as a welcome form of constructive feedback
– believing that the ratings will further showcase their already good work.

I believe that physician ratings are not a perfect measure of
quality care, but they can offer a legitimate and enlightening patient
perspective on bedside manner, office efficiency, and communication skills.  Many patients have nothing more than a health
insurance company’s list of “in network professionals” from which to choose a
provider.  Online physician ratings sites
now give them a little bit more information to guide their selection process.

The potential for inappropriate or libelous postings depends
upon how carefully the ratings company reviews the comments.  Open message boards may degenerate into gripe
sessions, but closely monitored ratings like those at Revolution Health, are much less risky.  Even more valuable will
be the fusion of consumer ratings, peer reviews, hospital, and health
plan ratings of an individual physician all in one place.  This kind of rating system is not far off.

The bottom line is that online physician ratings are here to
stay – and the best way for the ratings to fairly reflect the average patient’s
experience is to have physicians encourage all their patients to rate them
online.  In that way, the rare
disgruntled patient’s review will be seen in the context of the majority of
satisfied customers.  If the majority of
comments are still cautionary, then it becomes more likely that the physician
him or herself has some work to do.

Since the American Board of Medical Specialties is now
recommending demonstration of patient satisfaction as part of the recertification
process for many specialties, online physician rating sites may actually become
a great (and cost effective) way for physicians to collect such qualitative
data.  So my advice to physicians is to
embrace physician ratings and make them work for you and for the benefit of
your future patients.  Give the audience
some credit – they won’t judge you on one outlier comment… unless perhaps that’s
the only comment they see.

Your views and dissenting opinions are welcome.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.