Hello Health Launch Party 7.31.08 - a set on Flickr

Thanks to Jen McCabe Gorman for sharing. The party looks like a lot of fun, and let us hope it helps patients and their families and communities become more involved and engaged in their health. Congrats to Jay & Myca.

In my fielding of this data to various people, this part of the analysis has been by far the most controversial. Let’s first start with indirect costs added on top of direct costs, from the societal perspective, just for California. By indirect costs, we mean lost time from work (absence and short term disability), presenteeism (impairment while at work, to avoid being absent), and caregiving (21 million working men and women are caregivers in the US)

The indirect cost data is only for employed persons reporting the condition, which means it is a subset of the population (doesn’t include indirect costs for the non-employed, doesn’t include costs for the undiagnosed). The graph above is therefore a little bit off, because the medical cost is for all people, productivity costs just for employment related losses.

Now, a different look at the data, which averages costs across the entire employee population, from the employer perspective.

This is different because it takes into account prevalence, and spreads that cost over all employees, whether they report the condition or not. My explanation for the different way this data looks is that the medical cost per person for hypertensive employees is far less than for heart disease, but there are many more hypertensive patients in a population. In the employee samples used to derive this data, there’s a factor of 2 difference compared to heart disease (12.4 % vs 6.4 %).

The sources for this data are the same as previous charts (formatted for Zotero, below).

I have already been asked, “Ted, how can high blood pressure cause presenteeism at all?” and I welcome the skepticism. I reviewed the study below, which defined the term for our profession, and it includes a combination of employee studies, some done quite well, that ask about employee impairment and absences due to multiple conditions. This includes things like side effects of medications (which are a cornerstone of hypertension therapy). Questions, based on the study, were things like whether an employee performance was reduced by ‘losing concentration, repeating a job, working more slowly than usual, feeling fatigued, or generally “doing nothing”‘. The authors specifically chose tools that measured multiple conditions at once, so that comparisons could be made.

One novel study worth mentioning specifically is one by Bank One, that used administrative and computerized productivity records of its employees to explicitly measure productivity losses, in addition to using a health risk appraisal and claims data to come up with estimates. For hypertension, the estimate was 0.4 % in this one, which was right in the middle.

Based on my reading of the paper, I am accepting the methodology as supportive. As a student of LEAN, though, I know that the facts are best obtained on the factory floor, so my next interest is in working with an employer, and ultimately and employee, who experiences these conditions first hand. And I do mean on the factory floor, rather than the health system.

After creating this post, I realized that my A3 (coming next) has one inaccuracy. Fixing that, posting it soon.

1. An Unhealthy America: The Economic Burden of Chronic Disease: California. Take a look at the methodology here.

2. Goetzel, Ron Z, Stacey R Long, Ronald J Ozminkowski, Kevin Hawkins, Shaohung Wang, and Wendy Lynch. “Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.” Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 46, no. 4 (April 2004): 398-412.

Comment away, this can only improve with input.

In Augusta, Georgia, a national epicenter for Patient and Family Centered Care, as featured on “The Remaking of American Medicine.” It’s a really impressive place. I’ll be blogging more about it soon. Nothing provides more energy than patient empowerment.

February 10th through February 14th:

• Wal-Mart To Open 400 Retail Health Clinics With EHRs - iHealthBeat - WalMart to become an EHR vendor to itself?
• Life as a Healthcare CIO: Always Look on the Bright Side - Terrific guide to being glass 3/4 full. Save as Draft - priceless
• Medicine meets a culture gap - USATODAY.com - American Academy of Orthopedic Surgeons is taking a leadership role in cultural competency. The medical profession still struggles with this concept, unfortunately.
• Super Friends - Wikipedia, the free encyclopedia - Who wants to be who in the patient-centered physician world? I’d like to be one of the wonder twins.
• Life as a Healthcare CIO: Web Content Management Systems - Right on to a CIO of an IT Department with this approach: “2008 will be the year of Web 2.0 for all my organizations”

Since I have been writing and discussing the topic of transparency lately (specifically with regard to patient medical records), these two articles came to my attention following a discussion that occurred after my presentation at Johns Hopkins Medicine. We talked about when and how we inform patients about aspects of their care, and what the conditions might be for “beneficient deception.”

The first article, which deals with communication between care teams and patients with terminal diagnoses, talks about the importance of good communication not just at prognosis, but throughout the course of treatment. This quote caught my eye:

Many participants reported dissatisfaction with the communication process, especially at disclosure of the initial diagnosis. Six attributes were identified to be important in communicating information: playing it straight, staying the course, giving time, showing you care, making it clear, and pacing information.

We put a high price on the accuracy and compassion that should come with an initial diagnosis, clearly. In the work I am doing, it becomes more and more likely that this information may come in an asynchronous fashion, i.e. the patient may see the result at the same time, or even before their doctor does. In discussions to date, it has seemed that the focus has been on this custom - “doctor gets the information before the patient.” I think the focus instead should be on the factors cited above and our ability to “enhance decision making and keep control.” It’s not clear that the current custom absolutely supports that.

The second article is about the concept of “beneficient deception.” The context, though, is not exactly what I was thinking of, but I am citing it here anyway. It refers to the idea that a physician may adjust or misrepresent a diagnosis to ensure coverage for treatment. In the patient-physician communication world, my assumption is that it might be used to provide hope and a sense of control. I am tempted to agree with the authors of this article, that I find this hard to justify in the long term. Instead, I think about the physician leadership role in making this activity unnecessary. Our patients can guide us on the best way to be accurate and direct, and I think we will all benefit from these conversations.

Of course, your comments are welcome.