Manipulating Hollywood

A recent Time piece on Harvard School of Public Health's campaign to persuade Hollywood filmmakers to take out smoking or to make smoking look unglamorous (where smoking is a necessary part of the script) was eye opening.

I never knew that Hollywood was persuaded once before to take up a public health issue. It bought into the designated driver campaign to reduce drunken driving accidents. And the campaign worked because it reaches basic human nature. As written in Time magazine:

"If there's one thing health experts know, it's that you don't influence behavior by telling people what to do. You do it by exposing them to enough cases of people behaving well that it creates a new norm. What made the designated-driver concept catch on in the 1980s was partly that Harvard and the ad agencies it worked with persuaded TV networks to slip the idea into their shows. There's a reason a designated-driver poster appeared in the bar on Cheers, and it's not because it made the jokes funnier."

Harvard which led that campaign believes there were obvious benefits to influencing the 'superpeers' of TV. "'The idea appeared in 160 prime-time episodes over four years,' says Jay Winsten, HSPH's associate dean. 'Drunk-driving fatalities fell 25% over the next three years.'"

The idea is elucidated by Robert Cialdini in his influential (for lack of a better word) book 'Influence': as more important or influential people do (or don't do) something, the more of mass public are persuaded to join in doing (or not doing) that same thing. The same idea explains why the 'superpeer', the composite person portrayed by films and other media, is able to influence teenagers' drug and sexual behavior.

As the article details, the campaign is working in Hollywood, albeit slowly. It's also building momentum as other organizations devoted to health and public safety join in.

"As Harvard closes in from one side, a dozen health groups including the American Medical Association are calling for reduction of smoking in movies and on TV, and 41 state attorneys general have signed a letter seeking public-service ads at the beginning of any DVD that includes smoking. Like smokers, studios may conclude that quitting the habit is not just a lot healthier but also a lot smarter."

Lesson: To change people's behavior, enlist people like Scarlett Johansson!

Should doctors be taught nutition?

"The public-health community has come to recognize it can’t hope to address obesity and diabetes without addressing the farm bill."

A thought-provoking quote from Michael Pollan's (of 'The Omnivore's Dilemma' fame) essay on how US farm legislation subsidizes -- and thus promotes -- the growth of corn, soy and rice, crops that allow for mass production of cheap food lacking nutrition and filled with calories (e.g., the twinkie) and thus directly (following the chain of events) lead to increase rates of obesity.

Healthcare workers can't overcome the legislative incentives. In other words they can't directly change what most farms raise. But they can promote diets more conducive to healthy living and less conducive to gaining unnecessary weight. That was my 'takeaway' from the essay.

I've often thought that med school (as well as dental school) needs to teach its students about nutrition. Not just what deficiencies in vitamins lead to (conditions we don't see often in this country like marasmus, goiter, scurvy and kwashiokor), but rather how taking in certain molecules are linked to better cardiovascular and mental health (like omega-3 fatty acid is) or how particular eating habits prevent cancer (as does eating a diet heavy in vegetables and fruits).

And schools ought not only teach these things, they ought to show these associations are in fact scientifically supported if not proven and encourage students to give these 'health tips' to patients when they are working in the outpatient or clinics setting. This would get the message out more effectively, and help the system convert to a more preventive health orientation.

Of course some will charge that there are nutritionists to do this type of promotion. I agree. They certainly do good. But if doctors aren't singing the same tune and are oblivious to what people ought to be eating to prevent becoming obese, then the message becomes diluted or weak.

So I'm not saying docs should be nutrition to replace nutritionist. Rather, I'm saying that docs ought to learn it so that everyone on the healthcare team is on the same page, and so patients are being taught from all sides what is good for the body.

Two articles on marketplace forces & the future of healthcare

An essay by Jonathan Cohn (who just published "'Sick: The Untold Story of America's Health Care Crisis - and the People Who Pay the Price") appeared in the NY Times back on April 1st. "What's the One Thing Big Business and the Left Have in Common?" is about the surprising alliance between big companies like Safeway and Wal-Mart and labor unions and Democrats.

In particular, the essay details the journey taken by Democratic Senator Ron Wyden of Oregon and Steve Burd, the hard-nosed CEO of Safeway. Especially interesting is Mr. Burd's story of how he became interested in wellness and preventive medicine because of his family's health history, and how he tried ingraining the habits he learned into his employees.

"Burd says the results were impressive: in 2006, the first year of full implementation, employees who enrolled in the newer plans, with the greater individual cost-sharing, had their personal health-care bills drop by 20 to 30 percent, while the company's health bill for those employees shrank by 11 percent. (It is unclear what happened to the costs of people who stayed in the old plan.)"

A long time ago I told a group of friends that if the United States implements universal healthcare, it will be because of big business. Of course this sounds counter-intuitive. But it isn't since many companies spend more on their people's health than on anything else, and thus lowering healthcare costs is a corporate issue. This essay deflty elaborates on how some corporations want universal healthcare to look like (think Mitt Romney's "individual mandate" that requires every citizen to own a health insurance policy).

(The piece came to me thanks to my pal Vik R.)

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The Economist this week updates us on the retail health clinic in "McClinics". The growing popularity of the business model among consumers is based on the problems of how doctors' offices and ERs run.

"IN NO other industry is the relationship between the consumer and the provider as unbalanced as in health care,” says Joseph Maloney of Health Stop, a pioneering retail health-care chain. In a recent case study on his firm prepared by Regina Herzlinger of Harvard Business School, Dr Maloney observed that the typical patient frequently waits a week for an appointment, then an hour longer at the doctor's office or, worse yet, is forced to go to an emergency treatment centre. As Dr Maloney summarised, “Any dry-cleaner that operated this way would be put out of business.”

The article proclaims that the boom in the concept has just started, and is driven because it offers two things: convenience and low price. And Dr. Maloney says that a third reason that would compel more consumers to get their healthcare at these 'minute clinics' is consistency.

School does what it can to reduce childhood obesity

The tale of a Wyoming school district's proactive policies on reducing childhood obesity is detailed in the WSJ article "In Obesity Wars, A New Backlash" (sorry, subscription needed). The 'new backlash' comes from teachers (because soda machines are banned from schools including the teachers' lounge), parents (some are acutely sensitive to their kids being called fat by school) and kids.

However, the main proponent of the Healthy School Task Force policies at the school district, Dr. David Fall (a pediatrician who also serves on the school board), says that "the importance of the program 'outweighs any temporary hurt feelings'." Also he says there hasn't been public opposition to his committee's policies outside of a few negative comments, putting the backlash in a new perspective. Here's one person who's glad the school is helping him lose weight.

More power to Dr. Fall and his task force I say. Why? Because obesity is a medical issue. Obesity is associated with higher risk of heart disease and diabetes in adulthood, period. Are high blood pressure and high blood sugar bad? Yes, for these conditions impair the quality and the quantity of life. We think nothing of promoting those habits that reduce hypertension and hyperglycemia. Ergo, obesity is bad too and should be prevented.

Furthermore, as the doctor in the article says, kids who are obese are more likely to be unhappy; this study in a 2003 issue of 'Nature' journal adds to the body of evidence asserting that obesity causes mental health problems like depression.

School is the best place to teach kids how to be healthy and to help obese kids lose weight and improve their prospects for good health in the future.

Kids spend more time in school than anywhere outside of the home. School is where kids learn about all kinds of subjects deemed important by society like writing, reading, mathematics, history, natural science and so on. Why should health not also be taught? I can't think of a good reason not to teach kids those things that are scientifically proven to be good for the body (e.g., eating more fruits and vegetables is linked to increased longevity, eating less saturated and trans fats is linked to lower levels of cholesterol, etc.).

Plus at school kids gain habits that stay with them for life, like how to be social and work with others, how to read and how to write and how to learn. That's undeniable. Thus if healthy habits can be picked up by kids at school and if such habits will stay with the kids for a lifetime, should schools not do what they can to better ensure healthy habits are promoted at school? Yes.

I was all for taking fatty foods and sugary drinks out of school as Texas' agricultural commissioner did years ago (old post) and I am all for teaching exercise and techniques to reduce stress (after all chronic psychological stress is linked to eating more and obesity) because good diet and physical exercise means better health for these kids as they become adults. Go Dr. Fall and his team in Gillette, Wyoming!

Hospital invests further into retail clinics

The Houston Chroincle reports today that Hermann Hospital has invested more deeply into retail clinic company RediClinic, which operates clinics inside HEB stores here in Texas.

The hospital believes retail clinics can be profitable because patients would be sent with conditions too complicated to be dealt by NPs in a retail setting or referred to Hermann doctors for long-term management.

Since RediClinic got its start about two years ago, Memorial Hermann-affiliated doctors have provided oversight for the nurse practitioners who provide care inside retail stores, said Mischer, who previously served as the chief executive of Hermann Hospital for two years.

"Their taking an economic interest in the company evolved over that period of time," he said.
Memorial Hermann Chief Executive Dan Wolterman said Tuesday that the foot traffic into the retail stores was part of what attracted him to RediClinic.

I believe this is really smart of Hermann.

And it is completely opposite of the reaction of a group of tired pediatric residents who last fall complained about these clinics and how they would force many of them to keep longer hours or odd hours and compete with them on price. I sympathize with the pediatricians and their concern over how retail clinics would affect their careers.

But I cannot sympathize with the pediatric residents' position. These retail clinics aren't a bad thing at all if operated properly.

They promote preventive care, which means people who go there will less likely become acute sick. And if retail clinics succeed on a large scale, this will relieve pressure off overworked and understaffed ERs. Furthermore this will save taxpayer funds which could be used to provide other services or could be returned to taxpayers. So retail clinics will make possible preventive care which will save society money. Seems like a win-win situation for the consumer-patient, the hospital and the taxpayer.

(I wrote about the growing industry twice already, once in April and once again in September.)

Where there's a will, there's a wii!

In addition to vending machines and fast food at school, video games have been the scapegoat of childhood obesity. This is intuitive since in general video games require players to sit in front of the screen and compel no physical activity. And too many kids, as the cliche goes, spend hours playing video games.

There's probably some truth in that commonly held perception. However, the Nintendo Wii has changed the way video games are played and may, as a by-product, compel physical activity so strenuous as to help overweight children lose weight.

This was the gist of a recent WSJ article on the Wii entitled "A Wii Workout: When Videogames Hurt".

The new console has been wildly successful, selling out at stores and winning high marks from critics and game buffs. But as players spend more time with the Wii, some are noticing that hours waving the game's controller around can add up to fairly intense exertion -- resulting in aches and pains common in more familiar forms of exercise. They're reporting aching backs, sore shoulders -- even something some have dubbed "Wii elbow."

In one study printed in Pediatrics this past year, Dr. Lorraine Lanningham-Foster and her team found that playing one physical activity oriented video game in particular, "Dance Dance Revolution," helped lean kids burn more calories than spending the same amount of time on a treadmill while watching TV.

So the idea of physical activity oriented video games helping overweight kids lose weight, based on the observations that many kids don't like to get physical activity outside or their parents feel it is unsafe for them to and that kids seem to get involved deeply in video game play, is promising, as is the idea of using video games to give all kids in general a chance to develop physical exercise habits.

I'm currently helping with a project to create a 'wiimnasium' -- an exercise facility of physical activity based video games -- at the local children's hospital. Stay tuned.

Going to the bazaar for medical services

"Bargaining Down That CT Scan Is Suddenly Possible" in the 27 Feb 2007 NY Times gives an interesting peek into a new business: helping consumers who must pay for procedures bargain down the prices of those procedures.

Companies like MyMedicalControl.com find the rates insurance companies pay hospitals for procedures and use those prices as baselines when they bargain on behalf of consumers. What is the payoff for the company? A "35 percent collection fee" off of what is saved, apparently.

And the payoff for the consumer? Lower medical bills. According to the article, "[f]rom a typical claim of $1,100, Mr. Cahill said, the company shaves an average of $232." That's substantial.

Another company called Vimo.com uses federal Medicare data to arrive to its estimates for procedure prices and points to one reason this business is even possible: better access to data via the Internet.

Recent legislation from state governments provide another reason. "Rudimentary information is increasingly available to consumers. Thirty-two states now require that hospitals provide pricing information to the public."

There are critics who charge that improved price transparency won't help reduce overall healthcare costs. I'm not sure what to make of it, but for the many people who must pay out of pocket because of lack of insurance or because they use a Health Savings Account, it seems increased price transparency and the business services that have sprung as a result of this does help protect the wallet.

And as the article points out, this service is likely to grow fast. Why? Because more healthcare costs are coming straight from -- for better or worse -- more people who are obviously more sensitive to costs and have less power than insurance companies in making sure they are paying a fair price.