this is an excerpt.Read More
(Originally published at EisenhowersLastSmoke.com on 8/8/2013)
I digress from health care for a moment. I need to address the topic of guns. Actually, guns in America probably explain much of the difference in life expectancy between Americans and Australians because so many Americans die young due to gun violence, accidents, and suicides, whereas few Australians do. So actually, it is a health issue.
From nearly the start of my travels in Australia, people have been asking me to explain guns in America. They literally cannot understand why, particularly after the school shooting in Newtown, we would not pass “common sense” gun legislation.
To put guns (or lack thereof) in Australia into context, even the wife of the head of Eisenhower Fellowships Australia, a self-proclaimed staunch conservative, was pretty animated about a recent Australian policy shift to allow guns in national parks. She was concerned about what might happen if people were hunting and accidentally shot other visitors. No pun intended, but she was pretty up in arms.
I had many conversations with Australians that went something like this:
“How do you explain guns?” –Any Australian
“Um…I really can’t and wouldn’t try.” –Me
“Did people actually think arming teachers was a good idea?” –Any Australian
“Uh…I think so. But most of us didn’t.” –Me
“We actually thought it was a farce when people suggested that America needs MORE guns after the school shooting (Newtown). We literally thought it was a joke. It took us a while to realize that was a serious position.” –Any Australian
“I know. I think people were serious about that. But the vast majority of Americans supported some kind of legislation. If ever there was a time when we could have passed something, it should have been after 20 children died. The fact that we couldn’t pass anything is simply a failure of leadership in my opinion. We just lack leadership courage.” –Me (May as well just own this national embarrassment. I could see no other way to explain it.)
Carol Bennett, CEO of Consumers Health Forum of Australia said it well. “We look at guns in the U.S. and we think, ‘That’s ridiculous.’ We just don’t understand how the rights of one lobby is allowed to impact the lives of so many people.”
I heard the word “ridiculous” on almost every occasion where the topic of guns arose.
In the context of consumer empowerment in health care, I had asked Carol what she would do in the U.S. She said she’d start with a question, which I think applies perfectly to guns, too. Her question: “You have to decide, what kind of society do you want to have?”
Yes. I reckon we do.
(Originally published at EisenhowersLastSmoke.com on 8/7/2013)
My last stop in Melbourne before I had gone to the airport for Canberra had been at Cabrini Hospital, where Dr. Simon Woods shared a quote from a British actor whose name I didn’t capture. The quote went roughly like this: “Australia is the most civilized place in the world. In all other nations, they allow politicians to roam amidst the population. In Australia, they quarantine them all in one place. It’s like a free range zoo for politicians.” (I learned here that disdain for elected officials, even in a place that generally accepts government intervention, is universal.)
At the airport, which I spent about 6 hours in just to travel 1 (faulty radio, waiting for part, etc), I met a resident of Canberra who called it "the most boring city in the world" which I think is a common saying, not just his opinion. He also told me that Canberra itself represents Australian pragmatism. When Sydney and Melbourne squabbled about which would be the capital city, they decided instead to split the difference and create a capital roughly in between.
I had travelled to the capital because there's no way around that some of the people you want to meet need to be in the capital. For example, I met with the people who oversee operations of Medicare, the government insurance program. The division I met is responsible for the service centers (remember all Australian health care is retail), billing, data analysis, utilization management, and ultimately, the results of the program. They do not set policy, but they have to make the policy work.
They outlined the history of Medicare as more than just a safety net, as many people see it today, but an actual universal coverage system. Though Medicare began with no real sense of limitations on services, there had always been small gaps between what many general practitioners charged and the portion that Medicare picked up. Those gaps are growing – in some cases dramatically – causing some to wonder, “What has happened to our universal system.” Like virtually every other nation, Australia is recognizing they can’t, or won’t be able to continue to afford their health care system at current growth rates. And people are feeling it.
The upside of the increasing consumer cost sharing is some amount of market power for consumers. Consumers can choose not to go to a GP who charges above and beyond what Medicare covers. They can also negotiate are protected by their ability to vote with their feet (sounds like a market to me). My host here described consumer empowerment in terms her father, who, upon hearing of what he felt to be an outrageous price of a procedure, argued, “Fred down the road charged my golf buddy less, so maybe I’ll go see Fred instead.” And wouldn’t you know, he got a reduced fee.
Australia’s Medicare is also meeting consumers naturally evolving behaviors. For example, patients have had the option to submit claims right in the doctors’ office for almost a decade, and as of last year, the government eliminated cash payments and now offers direct deposit and electronic funds transfers. They’re even working on a system where people can snap a photo of their bills or other documents about which they have questions, upload them, and get help over the phone.
The Medicare retail centers are also evolving with the times. The government has realized it’s inefficient to have different retail arms side by side, run independently from one another all with taxpayer money. Moreover, fewer people are visiting Medicare branches in person since they can do more transactions online. So the new Centerlink sites combine a range of government services. However, Centrelink has a primary focus on lower-income residents who qualify for assistance programs, whereas Medicare had been a broadly middle class program; there is some concern that middle class people won’t seek services in a Centrelink branch. It’ll be interesting to see how Australian stated values of egalitarianism play out in this arena.
After Medicare, I met the CEO of Consumers Health Forum (CHF), Carol Bennett. Consumers Health Forum is known as a “peak body” for Australian health care consumer advocacy. I knew about CHF from my research and it was the reason I had booked time in Canberra. I couldn’t think of a more fitting person to meet given my focus area.
I found Carol to be more than up for the task of representing consumers in the Australian health care policy world. She is clearly media savvy and strategic about how to get issues on the public policy radar screen. Among CHF’s top issues is the rising out-of-pocket costs hitting consumers, particularly vulnerable ones, and on the huge variability in doctors’ fees (sounds familiar). Of course consumers have no idea why prices vary, and Carol argues that for price signals to work, there should be some rationale for the differences. Thus, you could argue that Australia in fact has a market failure in this regard. “We should have access to comparison data to make informed decisions.” (If I knew Carol better I’d say, ‘Amen Sister!’). CHF is also about to start a body of work on informed financial consent, wrapping financial disclosures and consent into the existing clinical informed consent framework. Pretty genius. Hopefully it’ll work.
Carol had really interesting views on the need for more pay-for-performance and less fee-for-service in the Australian system. While this is the conventional wisdom in the U.S., I found it rather a rare view. One reason for less blind faith in incentive-based payments is that it would require a broader adoption of a medical home model, which would in turn require residents to sign up with a single provider and apparently, Australians don’t like to be locked in. Perhaps it’s a residual effect of arriving in Australia as convicts.
One of my favorite parts of my meeting with Carol was her explanation of how Australia fits sort of in between the U.S. and the U.K. (I had heard shades of this before and being in the country, it feels intuitive though I wouldn’t have been able to articulate it on my own). Australians are worried about turning into America, paying way too much for lower-quality outcomes with a sense that government should have no role. On the other extreme, the U.K. is seen as way over-regulated and providing insufficient choice to suit the Aussie independent streak.
Australians see a role for government in public health, in preventing market failures, and in protecting the public good. On the other hand, their acceptance of government programs is by no means “socialist” or particularly based on a “rights” framework. Rather, there’s a sense that “we’re taxpayers, so we’re paying for this system, and we use it when we need to.” In this way, Australians are every bit consumers in the way I have been arguing Americans need to be. They understand that they pay for their health care one way or another. They expect good information, good results, and to be part of the process. Australians expect government to operate responsibly and transparently, and to fix it if the system fails. They hold the government accountable because, after all, they are paying the bill. “We are active participants not passive recipients.” And thus, I had gotten what I came for and the capital seemed worth the long journey.
On my flight from Auckland to Brisbane later the following week, I caught the first half of “Canberra Confidential,” a show done by my fellow Eisenhower Fellow Annabel Crabb (@annabelcrabb) who I’d gotten to meet in Sydney. Her show was a sort of satirical expose looking for clues into the scandalous history of this very boring capital city. Though I didn’t catch the conclusion, and though I am every bit the Annabel Crabb fan (as was everyone I met), I am not sure I’m convinced that the place itself is at all interesting. But for me, Medicare, Consumers Health Forum, and several others that I met sure were.
(Originally published at EisenhowersLastSmoke.com on 7/27/2013)
Perth is commonly known as the most isolated city in the world, being 1,300 miles away from the nearest ‘large’ city (Adelaide) (though I am not sure it’s 100% true). It is the capital of Western Australia, or W.A., which covers a vast territory – it covers one third of Australia, but has just 11% of the country’s population. The state has 2.4 million residents, and of those, Perth has almost 2 million of them. I learned that five Spains fit in the Kimberly, the farthest northern region of WA.
The city itself is often referred to as “a country town.” It’s set on the Swan River and has some beautiful vistas.
But I understand that the best parts of Perth are actually in the suburbs, and there wasn’t much of a city center to speak of.
What the city lacked in café culture, it more than made up for in the vibrancy of the people I met. People were bold thinkers; they thought big. The chief nursing officer for W.A. Health explained, “We’re a bit like cowgirls. We’re so far from anything else that we aren’t stuck in the mainstream.” And they look ahead. W.A. Health is working on a reform plan that will take them to 2030. The chief nurse was contemplating what the workforce will look like in 2030. And she had some far out ideas, like what if primary care as we know it today becomes secondary care in the future, because consumers, enabled by technology, are able to care for themselves for the most basic primary services? Or what if when you turn 65, you got a certain amount of health care funding to spend however you want? So if you take good care of yourself and invest in prevention, you could have a surplus? I mean, these are not the kind of ideas I thought I might find in the world’s most remote city.
Perhaps the remoteness breeds community. I had the chance to meet the former CEO of the Royal Flying Doctor Service (http://www.flyingdoctor.org.au), who explained that the organization's founder, a Reverend, encountered lonely people as he roamed the vast land. And then he realized that people in those remote areas needed doctors. And today, if you have a heart attack in the far reaches of W.A. (or anywhere in Australia), you will get medical care.
The geography might be remote, but the mentality of the people I met was simply not. My delightful host, the Executive Director for System, Policy, and Planning of the Western Australia (WA) Health department, had only recently arrived from the U.K. That they hired her, with a perspective from across the world, reflects the efforts they take to mitigate physical isolation. Almost everyone I spoke with, if not literally everyone, referenced practices from other parts of the world. They’d lived elsewhere or visited, many on a quest specifically to find out what others do. And they all could cite research studies or emerging trends from Canada, the U.S., and/or Europe.
And they were more than willing to engage with me. A call with Julie, my in-country coordinator, revealed that she doesn’t usually fill up fellows’ programs as much as she had mine. “You just want to meet everyone,” she said. “And everyone wants to meet you.” As my Perth host, David Flanagan said, “I reckon we don’t get a lot of visitors here!”
It's too bad more people don't make it here. There's a lot to learn from the cowgirls and flying doctors.
(Originally published at EisenhowersLastSmoke.com on 7/24/2013)
I left my first meeting with the Director General of NSW Health and started walking as if I knew where I was going (which I definitely did not). It had turned into a warm and sunny day, and I strolled with purpose (which I absolutely did not have). Within minutes I came upon a Medicare office. This did not look anything like a government agency service center might in the U.S. Rather, it was akin to a retail bank branch, complete with color-coordinated signs and fixtures. It was bright and orderly. There were no lines (sorry, queues), but rather an electronic system to assign numbers to people (do bakeries still have those ‘take-a-number’ dispensers?) and thoughtfully arranged banks of comfortable seats. The seats were also color coordinated.
And once you get in there, here’s what you can do at a Medicare office:
And the signs...color coordinated
Health insurance in Australia isn’t just literally retail, but it’s also “retail” in the sense that it is overwhelmingly a direct-to-consumer business here. On my walk through The Rocks area of Sydney near my hotel that evening, I noticed all the major private insurers also had retail locations.
(And one was even selling products -- see yoga mats for sale below)
One of the large private health insurance funds told me that of the very small number of employers they serve, only 10% of those were subsidizing coverage. Most employers who subsidize health insurance for employees are those with U.S. origins or start-ups seeking to attract talent.
Retail operations are part of health insurers competitive differentiation. They provide service to help people navigate a complex product, and provide an opportunity to connect and build loyalty with consumers.
I think they're on to something. Complex product - check. Competitive market - check. Need to get closer to the consumer - check.
(Originally published at EisenhowersLastSmoke.com on 7/15/2013)
Before I left on my trip, I knew intellectually that Australia is far from Boston. But it was only after about 1,000 hours on planes that took me from Boston to LA, and then on to Sydney that I can say, it’s REALLY far. It’s so far that the flight tracker couldn’t keep up; when it said we had 20 minutes left, the flight crew started serving “breakfast”. And when we reportedly had 0 time remaining to our destination, there was actually still an hour left. On top of it all, I knew that when I got off the plane, navigated through customs with my very heavy (though not fee-worthy yet) luggage, and found my hotel, I would turning around to head out to my first meeting.
I made it through customs, cursed my very-heavy-not-quite-fee-worthy luggage, and arrived at my hotel. The early morning was cool and misty, and the hotel, though spacious and clean, seemed grey and lonely. Once in my suite, it turned out that not one of the many electronic devices meant to connect me to home worked. The hotel wifi didn’t work. The password on my ipad didn’t work (I suspected my seven-year-old). My work phone, souped up with the international calling plan, didn’t call home. And the prepaid phone my most amazing in-country coordinator had purchased, loaded, and had delivered to me, did not work. And in general, by not work, I mean, there was a high degree of user error with a touch of technology fail. Right about now, I was thinking, what on earth have I gotten myself into?
Fearing I would sleep through my noon meeting if I let myself nap, I slowly sorted out (most of the) technology, showered, and got ready. And then I ventured out to find NSW Health – the health authority for the state of New South Wales – to meet the Director General, Mary Foley. Luckily, Mary Foley had energy for both of us, and soon I wasn’t at all focused on the effects of the 1,000 plane hours. I was transfixed by the intricacies of the Australian health system – a mix of public and private, state and federal elements, and I was buoyed by Mary’s passion for and knowledge of the history and current dynamics.
(Originally published at EisenhowersLastSmoke.com on 7/21/2013)
The foundation of Australia’s health system is Medicare, a public insurance system which entitles everyone to a level of health insurance. Most people I’ve spoken to call it a “safety net” rather than a true universal system. Medicare, by all accounts, has become sacred, though it has only existed in its current form since the 1980s. Alongside the public insurance system sits a private one, which almost 50% of Australians use.
This high level of adoption of private cover, in this country that offers universal public health insurance, results from a combination of government carrots (30% rebate of private insurance costs, which has recently become means tested), and sticks (premium increases for every year people over a certain income and tax penalties for high-income earners who don’t buy a private plan). There’s also a perception that you get more choice of doctors, even as a private patient in a public hospital (yes, you can use private coverage in public facilities), though that seems to be more perception than reality. You also have shorter wait times for procedures in private facilities using private insurance and lower out-of-pocket costs.
Australia’s federation creates further complexity. The states operate the public hospital system, which provide nearly all of the emergency care and most of the complex admissions. The federal government pays for outpatient and pharmacy benefits, whether those services are delivered in the public or the private system.
These were the sort of intricacies were coming my way within five hours of disembarking the plane from Los Angeles.
There is strength in this hybrid system in the form of vibrancy and flexibility. The many moving pieces provide a range of levers for policy makers to work with, but they also make it hard to put the pieces together in a cohesive manner that facilitates accountability for the whole system. Mary Foley put it well in describing the state’s challenge: “We are like the ambulance at the bottom of a cliff. We’re catching people, but it’s really hard to get the top of the hill to put a fence up.” Moreover, the state simply does not control the type of health care resources we commonly think of as part of the solution to hospital utilization growth – primary and most outpatient care.
And then it gets really interesting. Australian hospital funding is undergoing a radical transformation. Between 1929 and about 2012, the public hospitals had been funded by annual grants from the state, and the level of funding had had more to do with who lobbied effectively or worked their way onto the front page of the newspaper (remember those?). Even that lobbying only really addressed the margins; the bulk of funding was set. Hospital costs, and funding thereof, was a black box.
Under a new set of reforms, hospital funding is moving to “activity-based funding” or ABF, where state payments to hospitals now reflect the actual and anticipated activity, accounting for real utilization and population growth. This new approach uses hospitals’ own data on utilization, combined with the state price for services, and establishes what each hospital should need for resources. The state makes all this data completely transparent. They have unpacked the black box.
In the transition to the new system, the state is providing transition payments to keep hospitals whole, but it has also put them on notice that the jig is up. As Mary says, “We’re giving you this money. We don’t know what it’s for. You don’t know what it’s for. But we know it costs more (here).” Hospitals now need to account for why they cost more than the data suggests they should, and they will need to find ways to come into line with expectations.
It’s already having an impact. Hospital leaders are improving their cost accounting, finding hidden or unaccounted for costs and allocating properly; improving their coding now that reporting on services provided has real financial impact; and engaging their clinicians about how they operate. And people are starting to squabble with the next iteration of changes, which Mary takes as the sign that, incredibly, they’ve already accepted this new reality. It is no wonder Mary Foley gave up her lucrative private-sector career to spearhead NSW Health. She explained, just as had David Flanagan in describing his decision to start his mining company, “Sometimes you just have to grab an opportunity.”
Leaving that meeting, I had no question about my choice to grab this opportunity.
(Originally published at EisenhowersLastSmoke.org on 7/15/2013)
The summer after I turned 12, I went to camp somewhere in upstate New York. My mom took me to stay with my grandparents in Brooklyn , and then my grandfather (remember Ike) drove us to the city to meet up with the bus to camp. I had spent a lot of holidays and long weekends in Brooklyn, and had hardly been to any other part of New York, city or otherwise.
I remember the car ride to that bus clearly. I remember literally wishing it would go on forever. Not that riding around with my mom and grandparents was my tween ideal of a good time, but I was terrified of getting out of the car, and starting the new adventure I was about to have. Sleep away camp. For eight weeks. On my own – no sister with me, no school friends, no friends of friends. I wanted to go to camp, but I dreaded getting on that bus.
That 7th-grade feeling returned this past weekend, as I packed and repacked for my Eisenhower Fellowship to Australia, New Zealand, and Singapore. I’ll hit about 10 different places in at least three climates over about five weeks. I’ll meet dozens of new people, and I’ll probably spend a lot of time alone.
Don’t get me wrong, I want to go on the fellowship. In fact, I cannot believe how lucky I am that I was chosen to have this experience or that I have such a supportive family and employer to enable me to do it. But traveling across the world, to a place I’ve never been, on my own, is frankly, as terrifying as it is exhilarating. Actually, more terrifying.
The plane ride to L.A. is like the car ride to the bus. I’m packed. I’m going. It’s really here and this is really happening. And now, all I can do is put one foot in front of the other. Follow my itinerary. Get to my hotel. And start exploring Australia and its health care system in search of ideas and insights to bring back home.
One of the best things my mother taught me was that I could always come home. Whenever I left on any trip or adventure, of which there have been many, my mom has always assured me that I could come home if it was terrible. And I’ve always believed her, that if I needed to bail, there’d be no judgment, and maybe even plane fare or a ride. But of course, I’ve never taken her up on it.
So Oz, here I come. One foot in front of the other. A laptop, a camera, a notebook, (yes, like with paper inside), and way too many outfits. But did I bring enough shoes?
(Originally published at EisenhowersLastSmoke.org on 7/11/2013)
“How can I convince you to come visit New Zealand when you’re in Australia?” asked Eisenhower Fellow and a member of the New Zealand parliament, David Clark (@DavidClarkNZ). I have to admit it didn’t take much. Having been to New Zealand once before, I remember the lush scenery, delicious seafood, and collective obsession about the national rugby team. I also remember someone telling me that New Zealand has more sheep than people. (It turns out that is true: http://datamarket.com/featured/man-vs-sheep-new-zealand-myth/)
The New Zealand health care system is a primarily public system, with about 1/3 of the population buying private insurance to have a broader choice of clinicians [or treatment sites] and shorter wait times. The population – just about four million people (with nine times as many sheep) – is two-thirds of European descent and 15% Maori, the indigenous people of New Zealand. Notably, the Maori people are reported to have greater challenges accessing health care, with almost a quarter of Maori adults reporting that cost prevented them from seeking primary care.
So it’s not a perfect system. However, in a Commonwealth Fund exploration of seven industrialized nations, New Zealand ranked #1 in patient-centered care, with Australia at #2 and the US, not surprisingly, bringing up the rear at #7. And, they have the lowest per capita expenditure in this set, spending about 1/3 the amount of the US per capita.
As health care leaders in the U.S. talk a lot about “patient-centered” care without always, you know, involving the patient, I am keen to find out what puts New Zealand in the top spot.
It’s also pretty cool to spend time with a member of parliament, particularly one who is committed to addressing issues of social mobility and reducing the wealth gap. Social and economic inequalities are fundamental contributors to the U.S. health system’s dysfunction, and New Zealand may have things to teach us here too.
(Originally published at EisenhowersLastSmoke.com on 7/7/2013)
My first question to Australian Eisenhower Fellow David Flanagan (@DavidFlanagan_) when we met on a chilly April morning in Philadelphia at the Eisenhower Fellowships opening session was uninspiring. “How cold does it get in the winter really?” Not that I was regretting my timing to visit Australia in its winter season or anything…”Let’s just say that this morning I went for a walk,” replied David, “and it was the coldest I’ve ever been in my life.” I was delighted to hear that a cool Philadelphia spring was worse than all the Australian winters of David’s life!
A few hours later, he stood up to introduce himself and explained that he believed the success of the iron-ore mining company which he had founded was based in part on the way in which they had engaged their community in the business. Not in a superficial public relations sort of way, but rather in an authentic and comprehensive manner that demonstrated a genuine respect and concern for the company’s neighbors. I leaned over to my husband who was sitting in on the introductions and said, “And that’s why I’m going to Australia!”
It seems that Australians have a culture and collective philosophy of civic engagement that transcends industry or issue. At least a subset of consumers in Australia actually believe they have a voice in issues that affect them, and that corporations and government agencies facilitate that voice. The Australian government is focused on “capacity building to enable individuals to exercise control in their environment and make appropriate health choices.” Australian health policy focuses on social determinants of well-being as well as physical and mental health, placing individual decision-making in the broadest possible context of health. The International Association for Public Participation (IAP2) is active in Australia, with certificate programs and public participation practitioner training to support government and corporate public engagement initiatives. Less obvious and more day-to-day, I’m told that when you ride in Australian taxi, you sit in the front seat, signaling equality between driver and passenger. Does that hold in the doctor-patient relationship as well?
Structurally, Australia’s health system combines a national health insurance plan, Medicare, with a private market for individual insurance, which gives subscribers more choices and more services. The government uses a mix of carrots and sticks to make sure people who can afford private “cover”, as it’s called, buy it. For example, if you buy private health insurance by age 30 you pay a lower premium for the rest of your life; each year after 31 that you sign on adds 2% more to the price of your health insurance. Moreover, high-income individuals who do not purchase private cover pay a Medicare surcharge.
And the Australians get impressive results. They spend approximately 9% of their GDP on health care, and they think it’s high. Of course, everything’s relative. Australia spends HALF what the U.S. spends on health care as a percent of GDP. Imagine what America could do with 9 points of GDP to invest in say, education, infrastructure, or technology?
Australians’ life expectancy is higher than Americans’ by about 3 years. At first blush that doesn’t sound like a lot, until you think about in terms of your own life or the lives of your loved ones. And their infant mortality is lower, at just over 4 deaths per 1000 live births compared to our 6. Again, not a huge number until you think of two American babies who don’t survive their first year despite the good fortune to be born in one of the wealthiest nations in the world.
Though the Australian system should generally be a point of pride, there is an asterisk next to the national health care record. Australia’s indigenous people, who comprise about 2% of the population, have a life expectancy approximately 15 to 20 years shorter than the national average, and disease burdens estimated at three times greater. But Australians are facing the issue. There is a campaign, for example, called Close the Gap, devoted to closing the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians within a generation. The Australian Department of Human Services has developed a dedicated help line and outreach strategies for Aboriginal and Torres Strait Islander people.
It should also be noted that Australians are not universally happy with their system. A doctor I contacted when I was planning my trip reported “disgust” with the way her father-in-law had been treated during a recent hospitalization. And a public involvement expert I plan to meet, Max Hardy of Twyfords ( http://www.twyfords.com.au/about-us/our-people/max-hardy) has suggested that Australia may be behind in consumer engagement. And he understands how vital it is. “Think of any challenge in our health system. Including consumers in a meaningful way is all about addressing those challenges more effectively.”
However imperfect the system may be, there should be much to learn from the Australians. As we approach 2014, approximately 12 million Americans are about to encounter the American individual market via health insurance exchanges. It’s a good time to understand what makes their individual market work, with approximately 50% of Australians buying in. Additionally, Australia manages to provide a universal safety net to provide for all citizens at a significantly lower cost. Even with that, they have marked disparities between their Aboriginal population and others, and they seem committed to doing something about the inequality. Here too, there should be much to learn about how to be sure the benefits of a high-functioning health care system accrue to low-income and minority populations, too. And with 48 meetings scheduled and counting in four cities over 15 days, I should have a lot to report. Stay tuned!
 “Busting some myths about consumer and community engagement in health decision-making,” Melissa Sweet, Croakey, Nov. 16, 2012
(Originally published at EisenhowersLastSmoke.com on 7/4/2013)
On this Fourth of July holiday, while Americans celebrate our nation’s independence and an excuse to eat juicy hamburgers with minimal guilt, I am packing for a trip that will take me pretty much as far from the U.S. as possible. In just a week, I’ll be setting off on my five-week journey to Australia, New Zealand, and Singapore to study their health care systems and what role consumer empowerment has in the effectiveness of these systems.
Why go anywhere else? Don’t we have the “best health care in the world?” While I hear this notion quite a bit, most often from elected officials in political debates, data abounds to the contrary. The U.S. ranks #37 on the World Health Organization’s World Health Report, two slots above Cuba and 32 slots below Malta, a set of islands south of Sicily, and a member of the European Union.
Need more to go on? Well, the U.S. spends 18% of our GDP on health care , which is almost double the average spent in Organisation for Economic Co-operation and Development (OECD) countries and a third more than the next most spendy country, the Netherlands. Yet, in the U.S. we have 45 million people without health insurance. We rank 33rd in the world for life expectancy. And we rank 34th in the world in infant mortality: we have almost 7 deaths per 1000 live births per year . (We’re just behind Cuba on this one.) If you’re not a data wonk, then I invite you to think about your own experiences at the doctor’s office, hospital, or on the phone with an insurance company. Tell me your experience feels “best in class”. (Seriously, tell me: I’d love to know where that is). According to Gallup, 67% of Americans rate their health care coverage as excellent or very good. That's not too bad, but we could do better. If that were a test score, it'd be a C- at best.
The chest-thumping patriotism espoused by politicians – “We’re the best in the world” – strikes me as a funny expression of love for country. If we’re truly invested in our country and our kids, a more nuanced approached might involve recognizing our weaknesses and taking examples anywhere we can. So, I am going to see what’s happening in a few of these countries that are beating us on these lists. And patriotism aside, I’m wicked competitive. I take our wholly mediocre health performance personally.
I’m certainly not the first one to get this idea. In search of a health care system that works better than ours in the U.S., author T.R. Reid set out on a similar journey, which he chronicled in The Healing of America. He quickly realizes “better than ours” does not sufficiently narrow down his choice of destinations! Reid actually dedicates his book to President Dwight D. Eisenhower, citing Eisenhower's willingness to use the best ideas, wherever they may have come from, as his own inspiration. Eisenhower reportedly demanded bigger thinking and better ideas for the U.S. interstate highway system based on what he had seen of the German autobahn. No matter that Germany had been an American enemy or that he observed the superior German highway system while at war. Their way worked better, and we ought not settle for less.
Many of us curse the number of cars that fit on these superhighways as we travel to our July 4th destinations. But the fact is, we have a better highway system because someone had the vision and pragmatism to look abroad for ideas and then to do the most patriotic thing possible: insist on the best for America.
To that end, I’ll go back to packing for a trip looking for ways to engage Americans in their health care. Over the next week I’ll post more about where I’m going and why, and in the meantime, you can get a preview here.
I’m also looking forward to grabbing a burger. Happy 4th, everyone!
(Originally published at EisenhowersLastSmoke.com on 5/26/2013)
It turns out, as my mother reminds me, there’s another “Ike” in my life who gave up smoking cold turkey. My grandfather, Isaac, the patriarch, the heart and force in my extended family, was a smoker. He smoked 2 ½ packs per day back when cigarettes were unfiltered, and warnings were nowhere to be found. He was strong as an ox, and smoked at a time when cigarettes symbolized vitality – think Marlboro Man.
My mother was 10 years old, living with her parents and two younger sisters in Brooklyn (which I learned from an early age was apparently the best place on earth). She’d probably prefer I didn’t say the year. They were in the kitchen when my grandfather came home for dinner. He said, “I gave up something of the devil today.” They were supposed to guess what he had done, and it was my mom who figured it out. “Yup,” he said. “I quit smoking today.”
He had visited a customer – he owned a paper goods distributor and was generally out on the road selling all day at that time – and he noticed his customer was fidgety, watching the office clock. Apparently the conversation went something like this:
My grandfather asked why he was watching the clock. “In 10 minutes, I can have a cigarette,” the customer said.
My grandfather: “Why?”
The customer: “My doctor said I should give up smoking.”
My grandfather: “If you want to give up smoking, just give it up!”
The customer: “You son of a bitch. You’re standing there smoking a cigarette and telling me I should just give it up!”
My grandfather: “You’re right.” And he decided to quit. Just like that.
Though my grandfather was 33 at the time, and as far as I know never had another cigarette, he died almost 50 years later of metastatic lung cancer. But the quality of life until he got sick was outstanding, and he no doubt added years to his life through the sheer force of will that led him to quit.
What was it about these two Ikes that gave them the will to stop smoking? Can this behavior be taught? Or augmented? Or is it simply innate? According to the American Cancer Society, 70% of smokers want to quit altogether, yet only 40% will try this year, and even fewer will succeed. Only 7% of smokers succeed in quitting on their first try, and only 3.5% quit cold turkey. These data suggest my grandfather and the namesake of my fellowship were rare indeed, and that making healthy decisions is damn hard. We can’t necessarily sit back and count on consumers to make “the right choice.” We need to be realistic about how hard it is, and then help people translate good intentions into effective actions.
Originally published at EisenhowersLastSmoke.com on 5/13/2013)
Dwight David Eisenhower – the 34th president of the United States, five-star general and war hero, the father of the American super highway, and the great pragmatist. He was also a chain smoker who reportedly smoked four packs of cigarettes a day – in a time before warning labels or a clear scientific link between smoking and health hazards was established. In 1949, before he became president, Eisenhower’s personal physician advised him to cut back to one pack per day. After a few days limiting his smoking, he decided counting cigarettes was more difficult than not smoking at all, and quit “cold turkey”. With this decision, and the subsequent will to stick to it, he likely extended his life substantially.
Decades earlier, Eisenhower had also demonstrated command over his health care decisions. In his teenage years, after a knee injury had caused a severe infection, doctors urged an amputation. Eisenhower refused, and recovered. Whatever his reasons – fear, calculated risk-taking, stubbornness, or all three – he made his own decision and was willing to bear the consequences.
Eisenhower, as an early empowered health care decision maker, seems a fitting inspiration for my quest to improve the U.S health care system through consumer empowerment, not least because the fellowship created in his honor is supporting my particular journey. Eisenhower Fellowships (www.efworld.org) was formed in 1953 to celebrate Eisenhower’s 63rd birthday, in his first year as President. The organization was founded by a group of Pennsylvania businessmen as an international exchange program to honor Eisenhower’s dedication to world peace. Eisenhower Fellowships identifies, empowers, and links outstanding leaders from around the world, helping them achieve consequential outcomes across sectors and borders. Eisenhower called it “possibly the most splendid birthday present I have ever received.”
Anyone who interacts with the U.S. health care system, let alone works in it, knows the industry is ripe for some “consequential” changes. It is well known that the U.S. spends more than any other industrialized nation, as a percent of GDP as well as in absolute dollars, on health care, yet we have no better health outcomes to show for it.
There are numerous, interrelated causes for the health system’s underperformance, and seemingly infinite avenues for change. My passion, and my focus, is on how to empower consumers – to awaken Americans to the notion that they have direct and increasing financial responsibility for their health care decisions. With that financial responsibility comes a concept we know well in other consumer markets: market power. When consumers demand change, and vote with their wallets, the market often responds. My Eisenhower Fellowship will take me across the world – to Singapore and Australia – to explore how those countries’ systems and societies have effectively leveraged consumer power as a critical ingredient in their health systems’ success.
“Eisenhower’s Last Smoke” will chronicle my journey to find tools, strategies, and approaches to help American consumers make the right health care decisions for themselves. Whether the lessons other countries have to offer are small and incremental or broad and dramatic, I’ll be on the lookout for tangible solutions to help U.S. consumers bring about systemic improvements, in the spirit of Ike himself.
Originally published at EisenhowersLastSmoke.com on 5/13/2013)