Photo Credit: Courtesy of Foundation for Healthy Communities
Kids at the Whitefield School walked one mile as part of New Hampshire's Foundation for Healthy Communities "Walk NH" initiative.

The Consumer as Captain: New England's Prospects for Health

New England: New Century, New Game

By Neal Peirce and Curtis Johnson

BY SHEER NUMBERS and fame, New England can be called America’s Healthcare Capital. Its world-renowned teaching hospitals -- among them Yale, Dartmouth-Hitchcock, and an astounding 16 located in and around Boston alone -- are just part of a super-cluster of leading physicians and health scientists. Massachusetts is center of the today's future-oriented bioscience universe and produces a third of all FDA-approved new drugs. New England has more of its workforce engaged in health care -- roughly 11 percent -- than any other region of America.

But what about the results? Are New Englanders much healthier than other Americans? Do they – or their employers -- find their health care more affordable? And are New England states free of spiraling Medicaid costs imperiling state budgets nationwide?

The answers: no, no and no.

Where is the disconnect? All the debate seems focused on connecting people to the medical services systems. Then it shifts to finding ways to control that system’s relentless rises in cost. What’s rarely debated is how to assure New Englanders better health, for more of their lives.

More spending and more treatment is not making Americans healthier. The U.S. spends more than twice as much per capita on health care as the average of 22 wealthy nations. We invest far more than any other country on doctors, labs, tests, and dispensed medicine. Yet we manage to trail similar countries in health-adjusted life expectancy. Some 100,000 of us die every year from hospital errors.

Surveys show New Englanders eat a little less and exercise a little more than average Americans – explaining their slightly better health indicators. And if they should require hospital treatment, some of America’s best are located there.

Still, the region is plagued with soaring costs and mediocre results. Don Berwick, a professor at both the Harvard Medical and Public Health schools, says consistently there’s so much confusion, danger, waste, and arrogance in America’s healthcare system that the only way to save it is to blow it up first.

That may be an extreme view, but Dr. Berwick is not alone. The system, say such critics as Dr. John Abramson of Harvard Medical School, is failing patients – its consumers. The driving force has become financial return for medical professionals and companies that make their living off drugs and treatment. “Doing a lot of cardiac procedures brings both prestige and income,” says Dr. Abramson, “while those funds are denied to more upstream solutions like good pre-natal care, or interventions to eliminate tobacco use, or increase exercise and improve diets.”

There’s clear evidence that the major chronic diseases of our time – heart disease, stroke, diabetes and many cancers – are largely preventable by smart diet, regular exercise, moderation in alcohol consumption and not smoking. Indeed, 70 percent of health outcomes are directly connected to lifestyle and environmental decisions, says the highly respected New England Healthcare Institute (NEHI). Add in the right use of primary care, early intervention and aggressive public health programs, and we’d no longer end up – as Dr. Jim Squires of the New Hampshire-based Endowment for Health notes – “with about a third of the population suffering from a chronic illness that’s not fixable.”

Today, NEHI’s CEO Wendy Everett candidly told us, upwards of 90 percent of all the healthcare dollars go to expensive hospital diagnosis, treatment, and surgical procedures – not prevention and public health.

What’s the effect of all that spending? Better health outcomes? Not according to data painstakingly compiled by Dartmouth Medical School professors Jack Wennberg and Elliott Fisher. Their long study of the medical treatment of senior citizens all over the U.S. shows that the more expensive and extensive care often turns out to be worse care.

Why is that?

The system is built on perverse economics. Explains Everett, “We rarely pay people to pay attention to managing our illness; so who’s supposed to check to see that you’re using that home monitor to regulate your insulin levels?” But Everett notes somebody will get paid if a toe or leg has to be amputated. “The trouble is that the economic benefits of real health-improving innovations don’t get distributed in a way that creates incentives for change.” No one’s paid to talk you out of smoking; but money is reserved for heroic efforts to stem the eventual lung cancer with chemotherapy and radiation.

Doctors doing basic care are also paid substantially less than specialists who provide the most expensive procedures. One result: a chronic shortage of primary care physicians, the “family docs” who may tap specialists from time to time but maintain a long- term understanding of their patients, providing the indispensable “human touch.” Today, the American College of Physicians warns, the number of primary care physicians is plummeting under pressures of schedules, insurers and less income than the specialists can command. And there’s a parallel, serious shortage of practitioner nurses – medical care professionals able to handle many cases, at substantially lower cost than physicians.

So powerful is the money in today’s system that a large number of community hospitals that produce quality service at lower costs are dissolving into large hospital firms or disappearing altogether. In many cases, a patient needing medical attention would get safer and more effective treatment at one of these smaller facilities, but how would any patient know?

Comparisons between hospitals and their quality of care are starting to show up on the Internet (example: www.healthgrades.com), but most of the data is still largely protected from public view or just plain too bewildering to understand. And when sick or injured, who’s in the mood for slow contemplation of hospital outcomes data?

Meanwhile, the entire system soaks in commercial incentives and misleading commercials for drugs, claims Abramson. “We talk about giving patients good information. I question whether most doctors have good information.” Author of Overdo$ed America, Abramson’s convinced that financial incentives have seriously compromised medical education and practice guidelines – even the independence of the Food and Drug Administration. Notice, he says, that MRI tests are now advertised during telecast football games.

If there’s any consensus on changes to be made to the system, it’s that good, solid, reliable information is the foundation to build on. Pressure is on to computerize all individual medical records and while keeping them private, make them portable. And to use information technology to catalog tests and treatments that actually perform best – something called “evidence-based medicine,” a particularly powerful tool if both medical professionals and patients are kept in the information loop.

To get everyone in the loop, the Rhode Island Quality Institute is linking all the healthcare providers, insurers and governments together around providing and coordinating the spread and use of better information. What might this effort mean? We could avoid “the needless repetition of tests…and get to a system all the doctors and clinics and hospitals can access,” says Dr. Pablo Rodriguez, associate chief of obstetrics and gynecology at Women and Infants Hospital in Providence. This winter, Rhode Island’s Gov. Don Carcieri weighed in with his support by investing $20 million to accelerate the information system, believing it will, among other things, reduce costs.

Using information to improve quality is also on the agenda of every major New England health plan. Charles Baker, CEO of Harvard Pilgrim Health Care, told us: “The demand for better performance will have enormous impact on a medical guild that hasn’t focused in a systemic way on differences in health outcomes. The genie is out of the bottle now. It just needs to be better fed.”

How could New England feed this genie?

First, a fierce focus on changing the system’s backwards incentives. There must be ruthless calculation of which procedures actually pay off in better health. One or more health plans could lead – re-engineering their award systems to compensate only medically proven best practice choices, ones with a track record of actually improving patients’ health.

Would that kind of reform be difficult? Yes! In a medical system encrusted with familiar approaches, encumbered with lofty egos, it would be much more difficult than rocket science. But if innovation, leading, are what New England’s all about, there’s never been a greater need.

To improve access to healthcare, Providence’s Rodriguez suggests New England states could work together to clear paperwork and create cross-state licensure for medical professionals. Why not also add in inducements to encourage more physicians and nurses into the dwindling primary care practice?

If federal Medicare and Medicaid waivers are warranted, it’s time to use the collective clout of the region’s 12 U.S. Senators and House delegation. New Hampshire’s Sen. Judd Gregg chairs the Senate Budget Committee. Rep. Nancy Johnson of Connecticut is the lead Republican chair on health care policy for the Ways and Means committee.

Governors should turn crisis into opportunity and seek federal government waivers to mix Medicaid funds with their own programs in order to cover people caught in the gap between employer-based insurance and Medicaid. New England would have the money to work on raising quality care while slowing down cost increases, expanding coverage and investing in community-based health programs that pay off in a healthier population. A new emphasis on primary care could be part of the mix. Let New England prove Americans can be both patients and consumers if treated with dignity and shown honest information about the likely consequences of various treatments. And that the region has the courage to lead the nation in critical reform.

Taking these steps require states to collaborate to get to scale that matters, and to line up political support. And it will require the kind of passion that former Maine legislator Sharon Treat has shown in taking her campaign for affordable prescription drugs national.

The alternative: watching the slow-motion reel of an inevitable train wreck. Health care imperils everyone’s budget. Employers that can are ducking out from providing medical coverage. And, as Theresa Alberghini DiPalma of Vermont’s Fletcher Allen Health Care Center puts it, “Medicaid is on a course to swallow the rest of state government.” The system is simply not sustainable.

Medical system changes, however, won’t achieve much unless accompanied by a major shift in personal lifestyles. Arkansas’ Gov. Mike Huckabee found that out when he shed 110 pounds after being told he had type II diabetes and would probably be dead in a decade. Huckabee launched a campaign for a healthier Arkansas, including school tests so all parents know about their children’s body mass, curbing sugar-laden drinks in schools, and food stamps accorded more value when they’re used to buy fruits and vegetables.

While each of the New England states may have some elements of an Arkansas-like plan in place, couldn’t the states together do it even better? Imagine a coalition of its distinguished public health departments, hospitals, universities, businesses, sports leaders and the region’s media -- united in defining agendas for better health, demanding more rigorous exercise and nutrition standards in schools, pushing for walkable environments, crusading against smoking and substance abuse, and helping low-income immigrant workers in hospitals and other service industries make a successful transition away from fast-food, fat-heavy, high-temptation America.

And why stop there? Earlier articles in this New England Futures series might have also been labeled as “health” stories. When we extolled the New England town with its walkable centers and neighborhood sidewalks, we were showcasing the region’s legacy assets for a healthier way of living. When we argued for a diverse energy strategy, and a transportation network that could result in a lower dose of petro-particulates in the air New Englanders breathe. And we’ve suggested that locally grown, natural foods – in strong demand by students at Yale and other universities across the region – are a path to a healthier diet and economy.

It’s time to connect those dots. And maybe it’s time to resurrect the ethos of the sturdy New Englanders of past times, who weathered raging blizzards, storms at sea, thin soils and the challenge of farming on rocky hillsides. People trim, creative, resilient, triumphant. Captains of their own health. Why not again?

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[Originally published March 2006]