Retail makes its case, telehealth and voice tech dominate: 6 takeaways from HLTH19

https://www.healthcaredive.com/news/retail-makes-its-case-telehealth-and-voice-tech-dominate-6-takeaways-from/566548/

Headlines at HLTH 2019 included a peek behind the curtain at the secretive healthcare division of tech giant Google from ex-Geisinger CEO David Feinberg, Uber’s newly inked deal with Cerner and a preventive health push by Facebook sparking renewed data privacy concerns.

On the government side, outgoing head of CMS’ innovation center Adam Boehler suggested industry will be pleased with his replacement and CMS Administrator Seema Verma promised further Medicaid deregulation and “humility” in government.

But the four-day conference last week also covered some broader themes, including retail’s presence in the industry, the rise of telehealth and voice tech and the challenges of interoperability. Here are six of the biggest takeaways from Las Vegas.

Retail still defining its role in healthcare

Executives from Walmart and CVS taking to the main stage at HLTH to tout their initiatives.

Walmart’s VP of transformation, Marcus Osborne, talked up the company’s first health superstore in Dallas, Georgia, which opened this fall. The center provide patients with primary care, dental care, vision care and psychiatric and behavioral health counseling, with the goal of providing an integrated healthcare experience in the traditionally underserved area. Lab services and imaging are available on-site, as are nutrition and fitness classes.

“When you give consumers options, they engage more,” Osborne said. “The healthcare system is designed to be complex when it should be simple.”

A primary care visit at Walmart Health Center costs a flat fee of $40. For an adult, getting a dental checkup and cleaning costs $50, and an eye appointment is $45. Therapy services are $1 per minute.

The store pits the Bentonville, Arkansas-based retailer directly against CVS Health, which is expanding its own health-focused clinics, called HealthHUBs, to 13 new markets by the end of next year.

Brick-and-mortar behemoths’ attempts to position themselves as the front door to healthcare are spurred by the increasing push of consumerism in healthcare.

“With the emergence of this retail health consumer, we’ve got to make healthcare more integrated than it’s been for several years now,” CVS CEO Larry Merlo said.

Limits of consumerism

But engagement is notoriously tricky, and consumerism can only take the industry so far. Healthcare startups providing a new way of accessing or managing care, like digital chat startups allowing consumers to talk via text with a remote physician or chronic care management companies, are struggling to establish trust with the consumer.

Hank Schlissberg, president of care manager Vively Health, a subsidiary of DaVita that assumes full risk for its population, compared the sea change in the industry to what’s happened with companies like AirBnB.

“I sleep in someone else’s bed. I shower in their shower. And we’ve convinced ourselves that’s totally normal,” he said. “All I want to do is provide people with free healthcare. And convincing people of that is much harder than we expected.”

Natalie Schneider, VP of Digital Health for Samsung, agreed, telling Healthcare Dive consumers are “routinely irrational” and don’t act in their own best interests. But “we’re seeing policyholders, health plans and others in healthcare not only account for this irrationality, but also capitalize on it” through incentives like providing a reward immediately following a healthy behavior.​

The wearables trend is a key example, experts said. Payers and providers alike are increasingly turning to the tech in an effort to engage consumers in wellness, fitness and preventive care activities. However, the ROI of trackers, whether from Apple Watch, Fitbit, Samsung or others, is still unproven.

“We’ve seen a lot of technologies and they’re often not that smart and very rarely wearable,” Tom Waller, who heads up the R&D lab of athleisure retailer lululemon, said. “We’re still patiently waiting for that perfect contextualization of data that will give us both a physical and emotional insight, and that we can use to augment an existing behavior to nudge someone in the right way.”

“At the end of the day, these patients are consumers, and consumers have been trained over the last 10 years to decide what quality they want, to decide when they want it and how they want to get it,” Robbie Cape, CEO of primary care startup 98point6, said. “Healthcare hasn’t caught up to that.”

Execution could stymie looming interoperability rules

Two rules to halt information blocking from HHS are expected to be finalized any day now. Despite the regulatory pressure, industry is “still a ways from true interoperability,” said Ed Simcox, CTO and acting CIO of HHS, due to a slew of factors like a lack of economic incentive for EHR vendors.

The rules would impose a slate of new requirements on healthcare companies. Payers in federal programs would have to provide their 125 million patients with free electronic access to their personal health data by the end of next year; healthcare companies would have to adopt standardized application programming interfaces allowing their disparate software systems to communicate; and any player found information blocking could be fined up to $1 million per violation.

Google Cloud’s director of global healthcare solutions, Aashima Gupta, warned that although the government might mandate new standards, that doesn’t mean industry will be able or willing to immediately adhere to them.

Additionally, the government is still playing catch-up to technology, and interoperability is no different, Pranay Kapadia, CEO of voice-enabled digital assistant Notable, told Healthcare Dive. The rules are the “right thing to do, and then there’ll be an evolution of it, and then there’ll be another evolution of it.”

​”This problem is much bigger than big tech or government or health systems or innovators,” Gupta said. “It’s an ecosystem problem. No player can do it alone.”

Despite the private sector’s uncertainly, Don Rucker, the head of the Office of the National Coordinator for Health IT, said interoperability had fostered price and business model transparency in every other U.S. industry over the past few decades.

“Healthcare is just about the last one to resist,” Rucker said. “I don’t think that will be much longer.”

Telehealth and voice tech: the belles of the ball

Telehealth was unsurprisingly a big focus at HLTH, with themes touching on expansion to complex care needs, followup visits and chronic care management and barriers like state physician licensure.

It’s an “efficiency mechanism” that can help a lot in areas like primary care, Teladoc COO David Sides told Healthcare Dive.

Voice-enabled tech was another focus of chatter in Las Vegas. The technology, which allows physicians free use of their hands while enabling them to take notes or write a script, for example, is currently experiencing heavy hype from industry and Silicon Valley as a way to streamline the heavy EHR and documentation requirements on physicians.

Talking is an “important element to how people interface with things,” Notable’s Kapadia said. “You have to think of things from a human perspective.”

Suki also announced at HLTH it expanded its relationship with Google’s cloud computing business. The digital assistant’s CEO, Punit Soni, told Healthcare Dive industry could expect to hear about two “very, very large deployment announcements” with health systems in the near future as providers become more comfortable levering the software to cut down documentation time for clinicians.

Solving for social determinants, preventive health

A slew of players rolled out initiatives targeting social determinants of health in Las Vegas.

​Uber Health is now available for providers to schedule non-emergency rides for their patients via Cerner’s EHR platform in a bid to provide better access to transportation for underserved populations. The one-year-old NEMT division of San Francisco-based Uber has roughly 1,000 partnerships across payers, healthcare tech companies and providers such as Boston Medical Center.

“You need to develop a benefit that serves the needs of your distinct population,” Jami Snyder, director of Arizona’s Medicaid and CHIP programs, said. The state recently partnered with ride-hailing company and Uber rival Lyft to provide rides for eligible Medicaid beneficiaries.

Kaiser Permanente rolled out a food insecurity initiative to connect eligible California residents with CalFresh, the state’s supplemental nutrition assistance or food stamp program. The integrated, nonprofit health system plans to reach out via text and mail to more than 600,000 Kaiser Permanente health plan members with a goal of getting 100,000 enrolled in CalFresh by spring 2020.

If the program is successful, Kaiser plans to expand it to the rest of the country, CEO Bernard Tyson, noting “healthcare across the ecosystem of health plays a very small part” in outcomes. “Things like behavior, genetics and where you live has a bigger impact.”​

On the preventive health side, Facebook launched a consumer health tool. Users plug in their age and sex in return for targeted heart, cancer and flu prevention measures, with information supplied by healthcare groups like the American Cancer Society.

The pilot for the $7 billion tech behemoth will be evaluated for six months to a year before being expanded to other preventable conditions to make consumers their “own health advocates,” Freddy Abnousi, Facebook’s head of health research, said. “The lion’s share of health outcomes is driven by social and behavioral variables.”

CVS is similarly working to combat SDOH factors by leveraging its reams of consumer data, Firdaus Bhathena, the retail pharmacy giant’s CDO, told Healthcare Dive. If someone doesn’t pick up their prescription, “there’s a number of ways we can engage with them,” including by text message or speaking to services in the local town, to see if transportation to the pharmacy, a lack of funds or some other issue is stopping the person from receiving the medication they need.

Funding disruption

Much of the industry runs today like non-healthcare companies ran 50 or 60 years ago, according to entrepreneur Mark Cuban.

“For that reason, they’re ripe for disruption,” Cuban said at HLTH.

Investors and startups alike are taking note. Venture capitalists, eager to fund new medical solutions and methods of care delivery, pumped $26.3 billion into more than 1,500 healthcare startups in just the first 10 months of 2018.

Providers looking to invest in new solutions or acquire startups are looking for a relatively mature corporate structure and an alignment with existing priorities in-house, according to Dan Nigrin, SVP and CIO at Boston Children’s Hospital.

“It starts with our organizational strategy,” agreed Rebecca Kaul, VP at the MD Anderson Cancer Center. An attractive startup presents “something that really drives change,” she said. “If you’re pitching a solution that isn’t at a given time part of our strategy, it may not be the right time for us to connect.”

Highmark Health CEO David Holmberg told Healthcare Dive its physicians lead system-wide conversations in what areas need investment. “Ultimately, that’s how you’ll get things to scale.”

Intermountain Healthcare is similarly interested in ways to manage and inject value into its operations. “We’re not interested in point solutions,” Dan Liljenquist, SVP of the Salt Lake City-based nonprofit provider said, adding he deletes and blocks emailed pitches he receives. “We’re interested in technologies that obviate the need for clinical interventions, that help people solve their own problems, and the way to do that is not a point solution but in a systemic, creative way.”

Payers have similar priorities and seek out companies to invest in that could provide value down the road. Cigna Ventures, which recently invested in precision medicine company GNS Healthcare, looks for new tools across the areas of insight and analytics, digital health and retail and all-around care delivery and enablement, for example.

“We’re looking for companies that are innovative and looking to solve important problems,” Tom Richards, global strategy and business development leader at Cigna, told Healthcare Dive, noting most companies start with a more focused solution and then expand.

For example, chronic disease platform Omada Health, which raised $50 million in a 2017 funding round led by Cigna Ventures, started with diabetes, but has since expanded its care management services to hypertension, Type 2 diabetes and behavioral and mental health.

 

 

 

 

 

5 WAYS HEALTHCARE ORGANIZATIONS CAN ADDRESS SOCIAL DETERMINANTS OF HEALTH

https://www.healthleadersmedia.com/clinical-care/5-ways-healthcare-organizations-can-address-social-determinants-health

The National Academies of Sciences, Engineering, and Medicine has published a detailed report on implementing efforts to address the social needs of patients.


KEY TAKEAWAYS

Social needs play a pivotal role in patient outcomes.

Before setting strategies to address social determinants of health, healthcare organizations should assess their level of existing social needs activities.

Partnerships are a crucial component of addressing the social needs of patients.

Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.

Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.

“The consistent and compelling evidence concerning how social determinants shape health has led to a growing recognition throughout the healthcare sector that improvements in overall health metrics are likely to depend—at least in part—on attention being paid to these social determinants,” the National Academies report says.

The report outlines the “5As” strategies that healthcare organizations can implement to address SDOHs in the communities they serve. The strategies were developed by the National Academies’ Committee on Integrating Social Needs Care into the Delivery of Healthcare to Improve the Nation’s Health, Board on Health Care Services, Health and Medicine Division.

1. AWARENESS

The committee says awareness should focus on identifying the social risks and assets of specific patients and populations of patients.

“On the clinical side, patients visiting healthcare organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality,” the report says.

2. ADJUSTMENT

Instead of addressing social needs directly, healthcare organizations can pursue a strategy that focuses on adjusting clinical care to address social determinants of health.

“Many examples of adjustment strategies were identified in the literature, including the delivery of language- and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas,” the report says.

3. ASSISTANCE

Healthcare organizations can pursue strategies to connect patients with social needs to government and community resources.

“The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively,” the report says.

Intensive interventions include relationship building, comprehensive biopsychosocial needs assessments, care planning, motivational interviewing, and long-term community-based supports.

4. ALIGNMENT

Healthcare providers can pursue an alignment strategy that assesses the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes.

“The committee defined alignment activities to include those undertaken by healthcare systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes,” the report says.

5. ADVOCACY

Healthcare providers can form alliances with social care organizations to advocate for policies that promote the creation and distribution of assets or resources to address social determinants of health. For example, healthcare organizations can call for policy changes to overhaul transportation services in a community.

“In both the alignment and advocacy categories, healthcare organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable healthcare and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the healthcare and social care services available in the community,” the report says.

IMPLEMENTING THE FIVE STRATEGIES

Assessing the level of existing social needs activities should be a starting point for healthcare organizations that want to address social determinants of health, the chairperson of the National Academies committee told HealthLeaders.

One of the first steps healthcare organizations can take is identifying activities they may already have underway that fit the 5As, then expand or enhance those activities through greater commitment from leadership, investment of resources into supporting infrastructure, and strengthening of engagement with patients and community stakeholders, said Kirsten Bibbins-Domingo, PhD, MD, MAS, professor and chair, Department of Epidemiology and Biostatistics, UCSF School of Medicine, University of California, San Francisco.

“Healthcare organizations may not have activities in all of the 5As and should use this framework to develop strategies that will work within their local context. In all cases, it is critical to be aware that addressing health-related social needs of their patients is essential to achieving goals of high quality and high-value care,” she said.

“Partnerships are crucial,” Bibbins-Domingo said.

“Activities in the clinical setting should be designed and implemented in a way that engages patients, community partners, frontline staff, social care workers, and clinicians in planning and evaluation, as well as in incorporating the preferences of patients and communities. Establishing linkages and communication pathways between healthcare and social service providers is critical, including personal care aides, home care aides, and others who provide care and support for seriously ill and disabled patients.”

 

 

 

The U.S. has fantastic health care, the problem is….

https://www.optum.com/content/dam/optum3/optum/en/resources/articles-blog-posts/wf1341834-cmo-campaign-wyatt-decker-article-part1.pdf

Image result for The U.S. has fantastic  health care, the problem is….

In part 1 of an executive interview series, CEO and physician Wyatt Decker discusses his perspectives on today’s challenges and opportunities for reinventing health care.

IMAGINE THIS SCENARIO: there are 200 people in a room and each person has a serious health condition. Cost is not a barrier to each of these people receiving their prescribed treatment. A question is asked — how many of you would book a flight to a different country to get your care? You guessed it. No hands go up.

Dr. Wyatt Decker is chief executive officer of OptumHealth and an emergency medicine physician who brings more than two decades of service within the Mayo Clinic. He held dual roles as chief medical information officer for Mayo Clinic and CEO of Mayo Clinic in Arizona. Dr. Decker often conducts this experiment with audiences to underscore the quality of care delivered in the United States. We often hear about the problems of health care. No doubt, there are deep and serious problems. However, in scenarios like the one above, we understand that the quality of care delivered by our nation’s physicians is among the finest available. So why do we hear so much about what’s wrong?

According to Dr. Decker, the real opportunities for reinventing health care lie in improving system access, increasing affordability and meeting consumer preferences. “ All of these things really require us to think deeply about how health care is delivered and how can we do it better,” he says.  In part 1 of a recent conversation, Dr. Decker shares lessons learned and offers his perspective on where today’s health care executives and clinical leaders should focus.


What is your take on the state of the health care industry today? What challenges are driving the need to rethink health care systems and delivery?


THE CHALLENGE OF HEALTH CARE ACCESS:  “ People want to get to a doctor or a health care team and they can’t. Either because they are underinsured or they don’t have the financial resources. They don’t know where to go or sometimes there just aren’t enough doctors or the right type of doctor, whether it’s primary care or a specialist available in their area to see.”

THE CHALLENGE OF HEALTH CARE AFFORDABILITY:
“ We hear a lot about affordability of health care and outof-pocket cost can be very high, but also the health care system itself is very expensive. So how do we make it more affordable for large employers, individuals, consumers and even the government itself? Can we get on a more sustainable path?”

THE CHALLENGE OF CONSUMER PREFERENCES:  “ Most people who’ve experienced the health care system feel that it isn’t focused around their needs, schedules or preferences. We’re entering an era where in most other industries there’s lots of personalization and consumer focus. Health care has been very slow to evolve. We need to make it an experience where people feel appreciated, valued and respected. Not just that they’re getting great quality care, but also that their preferences and needs are being met.”

“ Our nation’s care providers are deeply committed and among the best-trained in the world. But I also see them in a system that is struggling. Emergency departments are, at times, the last resort for people who lack resources and access to care. I’ve seen patients struggle to manage chronic conditions without the right support and how the absence of good guidance can create confusion.”

Clearly, the need to reinvent in all aspects of health care is top of mind for many. But it can be difficult to figure out where to start. Can you discuss where you think it’s smart for leaders to focus?


“ We should all be thinking about how we drive towards a health care system that really creates and adds value to people’s lives,” says Dr. Decker. Here’s his advice on key areas of focus.


PAYMENT MODELS:  “ Move towards payment models that actually reward the correct behaviors in health care. What do I mean by that? The pay-per-value model — rewarding groups of providers to keep people well and healthy — is far more powerful than the traditional fee-for-service model.”


LOCAL ECOSYSTEMS:  “ Recognize that health care is local. It’s important to create ecosystems that deliver great, connected care for individuals throughout the health spectrum. This means the patient and their health data move seamlessly between specialists, hospitals, ambulatory care centers, and so on. These kinds of networks and interoperability of data is crucial to create a successful health care system.”

SOCIAL DETERMINANTS OF HEALTH:  “ Health care outcomes are driven not only by the quality and capabilities of the health care provider, but also by social determinants of health. Good health care addresses things like access to good nutrition, social connections, transportation and more that can limit the ability for a person to get and stay healthy. For example, in-home health visits to help patients who have difficulty traveling or easily obtained referrals to social and community services can really enable success.”


From your perspective, what could health  care reinvention mean to a patient, provider  or health plan?


TO PATIENTS:  “ It means a health care system where instead of waiting for something to go wrong, there is a team helping you proactively flourish and be healthy. It means a simple phone call or an app or a video chat could advise you on when you might be at risk of developing a serious condition before you develop it. It means a system that  is always there for you, almost like a guardian angel. It helps you navigate the system and your journey towards health and wellness. It means all of this in a health care system that is easy to access, affordable, high-quality  and compassionate.”


TO PROVIDERS:  “ Providers have high rates of frustration and even burnout with their own profession. Reinvention looks to reduce the very heavy clerical burden driving these trends. Doctors today spend about two hours of clerical and non-visit care for every hour of direct patient care that they provide. However, when you talk to doctors, they find the most fulfillment in engaging directly with patients and making a difference in their care. Reinvention means relieving exhausted providers of administrative and clerical duties that don’t bring enjoyment or result in improved care  and outcomes.”


TO HEALTH PLANS:  “ Health plans are frustrated because they pay for a lot of care that evidence shows doesn’t improve outcomes or help patients on their journey to health and wellness. Payers are happy to pay for health care if it’s necessary. But it doesn’t make sense to pay for care that doesn’t add value. Reinvention means reducing this financial waste to bring down the cost of coverage for everyone.”

“ We have an opportunity now to make the health care system work better for everyone. Improve access and affordability for patients, allow doctors to spend more time with patients, and increase efficiencies within health plans. There’s an opportunity to help people connect the dots and get everyone working together.”

You’ve been a practicing physician and a business leader. Tell us the lessons learned from this unique vantage point.
“ I have spent most of my career as a practicing physician in busy, level 1 trauma centers and emergency departments. In that environment, you see health care at its finest and also how the health system can be challenging. I think in amazement of the times I’ve seen teams of people —  multiple physicians, nurses and technicians — come together as one unit to save someone from a major trauma. I also have great admiration for the persistence of doctors who save lives by diagnosing life-threatening conditions through nuanced symptoms.
I’m a deep believer that in health care, we need to place the patient at the center of everything we do. I always remind young doctors and medical students…imagine for a moment that your patient is you or a loved one. You’d want the doctor to listen and explain things in a compassionate and thoughtful manner. You’d want them to be focused. You’d want them to recognize your unique history and what’s important to you. The notion of putting the patient at the center of everything is something that I have carried with me throughout my career. I have also dedicated myself to developing better models of care and systems that allow doctors and care teams to function seamlessly, be high-performing and deliver great outcomes for patients.”

“ I have an appreciation for how powerful it can be when you work to reduce waste, create care that’s efficient and care that is patient-focused. Today I’m focused on an interesting juxtaposition — creating the right mix of scalable innovations that help our whole nation succeed in health care while also improving the personal and individual patient health care experience.”

STAY TUNED FOR PART 2  of this executive interview series to learn more about Dr. Wyatt Decker’s perspectives on the intersection of technology and health care, the human impact of transformation and physician burn-out.

 

 

 

 

 

 

Nobel Economist Says Inequality is Destroying Democratic Capitalism

Nobel Economist Says Inequality is Destroying Democratic Capitalism

Image result for Nobel Economist Says Inequality is Destroying Democratic Capitalism

At the launch of the IFS Deaton Review, a 5-year review of rising inequalities in the UK, Sir Angus Deaton decried extreme inequality and the system that allows it. “As it is, capitalism is not delivering to large fractions of the population.”

We are about to embark on a large, ambitious, and open-ended review of inequalities. We are bringing together a distinguished group of scholars and writers from different disciplines. Each thinks about inequality differently, and together they encompass a wide range of methodological, political, and philosophical perspectives. At a first stage, currently underway, the guiding panel is asking each member of this larger group to write about one or other aspect of the topic; this collective effort will be one of our main products. At the second stage, the panel will write a synthetic volume. We will think about inequalities broadly—note my use of “inequalities” rather than “inequality”—and will not be confined to the traditional economic concerns with measures of the distribution of income and wealth, important although those are. Our main focus is the United Kingdom, but there is a great deal of recent thinking and evidence from other countries, particularly the United States, Scandinavia, and other European countries, and we shall repeatedly have to assess its relevance, and are often asking authors or combinations of authors to make the links.

As at no other time in my lifetime, people are troubled by inequality. In 2016, Theresa May, in her first speech as Prime Minister, said “we believe in a union not just between the nations of the United Kingdom but between all of our citizens, every one of us, whoever we are and wherever we’re from. That means fighting against the burning injustice that, if you’re born poor, you will die on average 9 years earlier than others.” Jeremy Corbyn has called for a new economics to address what he called “Britain’s grotesque inequality.” President Obama said that he believed that the defining challenge of our time is to make sure that the US economy works for every American. Across the rich world, not only in America, large groups of people are currently questioning whether their economies are working for them. The same can be said of politics. Two-thirds of Americans without a college degree believe that there is no point in voting, because elections are rigged in favor of big business and the rich. Britain is divided as never before and, once again, many believe that their voice doesn’t count either in Brussels or in Westminster. And one of the greatest miracles of the 20th century, the miracle of falling mortality and rising lifespans, is no longer delivering for everyone, and is now faltering or reversing.

Yet when people say that they are worried about inequality, it is frequently unclear what they mean or why they care. Economists think they know what they mean when they talk about inequality, and they produce charts of gini coefficients of income and of wealth, and when other social scientists say that they have wider concerns, economists—among whom I count myself—have often been too ready to tell them that they don’t know what they are talking about. What we would like to do in this review, even with its large quota of economists, is to get a better understanding of exactly what it is that bothers people about inequality.

We will also think about how we might address concerns about inequality and which concerns need to be addressed. If the concern with inequality is simply envy—as is often claimed by the right—it is perhaps better to address the concern than the inequality. If the inequality comes from incentives that work for a few but benefit many, then we may want to do a better job of documenting the need for incentives and what they do for the economy as a whole. If working people are losing out because corporate governance is set up to favor shareholders over workers, or because the decline in unions has favored capital over labor and is undermining the wages of workers at the expense of shareholders and corporate executives, then we need to change the rules. Why are the myriad differences between men and women so persistent and so difficult to erase?

Given that we are just starting, it is perhaps presumptuous of me to say anything substantive at this point. But what I am going to say is what I myself think, or at least what I think today, and I look forward to changing my mind as we go; I wouldn’t be chairing this review if I didn’t expect that to happen. I am also perhaps too much influenced by my own work—particularly my recent work with Anne Case—and this work is primarily about the United States, though we have been doing quite a bit of thinking about how it applies to Britain.

At the risk of grandiosity, I think that today’s inequalities are signs that democratic capitalism is under threat, not only in the US, where the storm clouds are darkest, but in much of the rich world, where one or more of politics, economics, and health are changing in worrisome ways. I do not believe that democratic capitalism is beyond repair nor that it should be replaced; I am a great believer in what capitalism has done, not only to the oft-cited billions who have been pulled out of poverty in the last half-century, but to all the rest of us who have also escaped poverty and deprivation over the last two and a half centuries. It also provides our jobs and the cornucopia of goods and services that we take for granted. And Milton Friedman, whose starry-eyed view of capitalism has much to answer for, was not entirely wrong when he extolled the freedom that free markets can bring. Though history has not been kind to his view that equality would be guaranteed by using markets to pursue freedom.

But we need to think about repairs for democratic capitalism, either by fixing what is broken, or by making changes to head off the threats; indeed, I believe that those of us who believe in social democratic capitalism should be leading the charge to make repairs. As it is, capitalism is not delivering to large fractions of the population; in the US, where the inequalities are clearest, real wages for men without a four-year college degree have fallen for half a century, even at a time when per capita GDP has robustly risen. Mortality rates are rising for the less-educated group at ages 25 through 64, and by enough that life expectancy for the entire population has fallen for three years in a row, the first time such a reversal has happened since the end of the first world war and the great influenza epidemic. Less educated Americans are dying by their own hands, from suicide, from alcoholic liver disease, and from overdoses of drugs. Morbidity is rising too, and they are also suffering from an epidemic of chronic pain that, for many, makes a misery of daily life.

In Britain, these inequalities are not so stark, at least not yet. But median real wages in Britain have not risen for more than a decade. One decade is much better than five decades, but we surely do not want to wait to find out whether the American experience will be replicated here. There have also been prolonged periods of real wage stagnation in recent years in Italy and in Germany. In those countries too, increasing overall prosperity is not reaching everyone. And as I noted above, democracy too does not seem to be working for everyone. The sense of being left behind, of not being represented at Westminster, is much the same as the sense of not being represented in Washington.

In Clement Attlee’s 1945 cabinet—the cabinet that implemented the Beveridge Report and built the first modern welfare state—there were seven men who had begun their working lives at the coal face. When labor MPs from Glasgow set off to London, local bands and choirs came to the station to see them off as if they were going to war, which indeed they were. Only three percent of MPs elected in 2015 were ever manual workers, compared with sixteen percent as recently as 1979. The union movement, which once produced talents like those in Attlee’s cabinet, has been gutted by the success of postwar meritocracy. Attlee’s warriors would today have gone to university and become professionals; they would never have been down the pit, nor in a union hall. Meritocracy has many virtues, but, as predicted by Michael Young in 1958, it has deprived those who didn’t pass the exams, not only of social status and of the higher incomes that degrees bring, but even of the kind of political representation that comes from having people like themselves in parliament. Young wrote, “The bargaining over the distribution of national expenditure is a battle of wits, and defeat is bound to go to those who lost their clever children to the enemy.” He referred to the less educated group as “the populists” who, in turn, refer to the elite as “the hypocrisy.”

What does history tell us? Not surprisingly, we have been here before. There have been several episodes where capitalism seemed broken, but was repaired, either on its own, or by deliberate policy, or by a combination of the two.

In Britain at the beginning of the 19th century, inequality was vast compared with today. The hereditary landowners not only were rich, but also controlled parliament through a severely limited franchise. After 1815, the notorious Corn Laws prohibited imports of wheat until the local price was so high that people were at risk of starving; high prices of wheat, even if they hurt ordinary people, were very much in the interests of the land-owning aristocracy, who lived off the rents supported by the restriction on imports. The Industrial Revolution had begun, there was a ferment of innovation and invention, and national income was rising. Yet working people were not benefitting. Mortality rates rose as people moved from the relatively healthy countryside to stinking, unsanitary cities. Each generation of military recruits was shorter than the last as their childhood nutrition worsened, from not getting enough to eat and from the nutritional insults of unsanitary conditions. Churchgoing fell, removing a major source of community and support for working people, if only because churches were in the countryside, not in the new industrial cities. Wages were stagnant and would remain so for half a century. Profits were rising, and the share of profits in national income rose at the expense of labor. It would have been hard to predict a positive outcome of this process.

Yet by century’s end, the Corn Laws were gone, the rents and fortunes of the aristocrats had fallen along with the world price of wheat. Reform Acts had extended the franchise, from one in ten males at the beginning of the century to more than a half by its end, though the enfranchisement of women would wait until 1918. Wages had begun to rise in 1850, and the more than century-long decline in mortality had begun. All of this happened without a collapse of the state, without a war, or a pandemic, through a gradual change in institutions that slowly gave way to the demands of those who had been left behind.

America’s first Gilded Age is another case. It also shows that the fundamental rules of the game can be changed. In the Progressive Era, four constitutional amendments were passed, all designed to limit inequality of one form or another. One instituted the income tax, one gave women the vote, one prohibited alcohol—strongly supported by women, who believed that alcohol abuse was an instrument of their oppression—and one an electoral reform that instituted the direct election of senators, as opposed to their previous appointment by state legislatures that were often dominated by business.

I have already mentioned the case that is most on my mind, the construction of the modern welfare state by Attlee’s government after the Second World War. The Great Depression, like the stagnation of wages in the early 1800s, spawned a large literature on how to modify or abolish capitalism, and according to one version of the story, it was Attlee’s government that tamed the beast and that made it possible for the tamed beast to deliver the unprecedented shared growth that many of us grew up on. Joe Stiglitz has recently written that he grew up in the golden age of capitalism though, as he wryly notes, it was only later that he discovered that it was the golden age. And, of course, it wasn’t a golden age—at least in terms of material living standards or in terms of health—but perhaps it was such in terms of the rules of the game that allowed growing prosperity to be widely shared. I don’t think that anyone would argue that the late 1940s was a golden age in Britain— there was bread rationing, petrol rationing, and to a young Angus Deaton, the terrible deprivation of sweet rationing, but the safety net that was built in those years played a role in fairly sharing, and perhaps even in helping generate, the prosperity that was to come.

That safety net is needed just as much today. Globalization and automation are challenging us today just as they did in the early 19th century. Safety nets are most needed when change is rapid, and it is one of the reasons why America is doing so much worse—most obviously in deaths of despair—than are wealthy European countries. But what is happening today is also a real threat to Britain and to Europe.

The argument that Anne Case and I are making in our new book is that less-educated white men and women in America have had their lives progressively undermined, starting in the 1970s, and showing up, since 1990, in rising numbers of deaths from suicide, alcoholic liver disease, and drug overdoses. African Americans experienced a similar disaster thirty years earlier and the improvements in their lives since then have protected them to an extent. In the face of globalization and innovation, many of us would argue that American policy, instead of cushioning working people, has instead contributed to making their lives worse, by allowing more rent-seeking, reducing the share of labor, undermining pay and working conditions, and changing the legal framework in ways that favor business over workers. Inequality has risen not only due to wealth generation from innovation or creation, but also through upward transfers from workers. It is not inequality itself that is hurting people, but the mechanisms of enrichment.

How much is this a threat in Britain? Some of the mechanisms of enrichment are not operative here. The US wastes about a trillion dollars a year on a healthcare system that is very good at enriching providers, hospitals, device manufacturers, and pharmaceutical companies, but very bad at delivering health. You do not have that problem. The US has licensed pharma companies to sell opioids to the general public, including for chronic pain, which ignited an epidemic of addiction and death with a cumulative death toll larger than all Americans lost in both World Wars. You too use opioids, but usually in hospitals, not in the general population. Yet the opioid manufacturers are following the model of tobacco manufacturers, and working hard, when blocked in the US, to expand elsewhere. Purdue Pharma has a subsidiary, Mundipharma, that agitates on behalf of the greater pain relief that they argue opioids can bring. As I write this, Matt Hancock, the Minister of Health, noted that “things are not as bad here as in America, but we must act now to protect people from the darker side of painkillers.” The BBC news report on this carries a chart showing the extraordinary geographical inequality in opioid prescriptions in England, with prescription rates five times larger in Cumbria and the North East than in London. As the briefing note for this launch shows, deaths of despair are rising in Britain, particularly in less successful parts of Britain, just as they are in other English-speaking countries, though the numbers (and death rates) are small compared with the US.

What about wages? The US has extensive business lobbying, which the UK does not have, or at least not in the same overt form. (The US also had very little prior to 1970, so it could happen here too.) As in the US, unions have become much less powerful in Britain, a decline that many have welcomed, but their countervailing power in boardroom decisions may have protected wages and working conditions. Unions provided social life and political power for many people who have less of both today. The replacement of stakeholder capitalism by shareholder value maximization is widespread in the US and has been remarked on here, too. Paul Collier has noted that Imperial Chemical Industries, once the crown jewel of British industry, used to boast “we aim to be the finest chemical company in the world,” but that, before it was lost to takeovers and mergers in 2006, it had changed its slogan to “we aim to maximize shareholder valuation.”

In Britain, as in America, some cities and towns are doing much better than other cities and towns, and the easy mobility that tended to keep these differences in check seems to have been much reduced. America has no city that is as dominant or as uniquely prosperous as is London.

Political dysfunction in Britain is different, but there is a common thread that many voters believe that they are not well represented. And there are sharp differences across groups, with age, education, ethnicity, gender and geography important in both countries.

I think that people getting rich is a good thing, especially when it brings prosperity to others. But the other kind of getting rich, “taking” rather than “making,” rent-seeking rather than creating, enriching the few at the expense of the many, taking the free out of free markets, is making a mockery of democracy. In that world, inequality and misery are intimate companions.

 

 

On average, older adults spend over half their waking hours alone

On average, older adults spend over half their waking hours alone

Americans ages 60 and older are alone for more than half of their daily measured time – which includes all waking hours except those spent engaged in personal activities such as grooming. All told, this amounts to about seven hours a day; and among those who live by themselves, alone time rises to over 10 hours a day, according to a new Pew Research Center analysis of Bureau of Labor Statistics data.

In comparison, people in their 40s and 50s spend about 4 hours and 45 minutes alone, and those younger than 40 spend about three and a half hours a day alone, on average. Moreover, 14% of older Americans report spending all their daily measured time alone, compared with 8% of people younger than 60.

While time spent alone is not necessarily associated with adverse effects, it can be used as a measure of social isolation, which in turn is linked with negative health outcomes among older adults. Medical experts suspect that lifestyle factors may explain some of this association – for instance, someone who is socially isolated may have less cognitive stimulation and more difficulty staying active or taking their medications. In some cases, social isolation may mean there is no one on hand to help in case of a medical emergency.

People ages 60 and older currently account for 22% of the U.S. population – 73 million in all. It’s estimated this share will rise to 26% by 2030, fueled by the aging of the Baby Boom generation. The well-being of older adults has become a topic of much interest both in the United States and in other developed nations, particularly as it relates to social connection.

Not surprisingly, time alone is closely associated with living arrangements, for both younger and older Americans. About one-in-four adults ages 60 and older (23%) live alone today – 16.7 million in all. These older adults say they spend, on average, about 10 and a half hours alone each day – almost twice as much time as those who live with a spouse. More than a third (37%) of older adults who live alone report spending all their measured time alone. Among those who live with someone other than a spouse, the average amount of alone time a day is seven and a half hours. (The 3% of older adults who are living in institutionalized settings are not included in this analysis.)

There are significant variations by age, gender and education in time spent alone daily, driven in part by differences in marriage and living arrangements. For instance, people in their 60s report 6 hours and 32 minutes of alone time, compared with 7 hours and 28 minutes for people in their 70s and 7 hours and 47 minutes for people ages 80 and older. These age differences are due in part to the fact that that older people are far less likely to live with a spouse or cohabiting partner – 64% of those in their 60s do, compared with 59% of those in their 70s and 36% of those 80 and older.

Older women spend more time alone, on average, than their male counterparts, and this gap widens markedly at the oldest ages. This is largely due to the fact that women ages 60 and older are more likely than their male counterparts to live alone (28% vs. 18%) given their longer life expectancies and higher rates of widowhood – and this gap in living arrangements also widens with age.

While there aren’t significant gender differences in time spent alone for people in their 60s, for instance, women ages 80 and older spend about eight and a half hours a day alone, compared with 6 hours and 40 minutes for comparable men. When it comes to the share spending all measured time alone, there are no gender differences among all people ages 60 and older, but again a gap emerges at older ages – for people ages 80 and older, 20% of women report spending all measured time alone, compared with 13% of men.

This gender pattern in alone time reverses once gender differences in living arrangements are accounted for, suggesting other factors are also in play. While 43% of men 60 and older who live alone report spending all of their time alone, this share is lower for women who live alone (34%). And among those living with someone other than a spouse, 21% of men report spending all measured time alone, compared with 12% of women. The fact that older women are more likely than men to be involved in activities outside the home such as going to church or volunteering may partly explain this pattern.

Differences in time spent alone also emerge across educational levels. People ages 60 and older who have a high school diploma or less education spend, on average, 7 hours and 18 minutes a day alone – about 45 more minutes than their counterparts with a bachelor’s degree. These patterns reflect in part the fact that less educated people are less likely to be married and living with a spouse than their more educated counterparts. (This is true among younger adults as well.) About half (51%) of adults ages 60 and older with a high school diploma are living with a spouse, compared with 59% of those with some college education or an associate degree and 67% of those with a bachelor’s degree.

 

 

 

Drivers of Health, a New Project

Drivers of Health, a New Project

Image result for social determinants of health

There is broad consensus that the U.S. spends too much on health care. Some feel that we would be better served by investing more on factors outside of the health system that affect health — so-called social determinants of health.

However, we lack reliable evidence to indicate where and how much to invest. Should we spend more on education or on the environment? Housing or nutrition? While there have been attempts to quantify the contribution of various factors to health, most have significant methodological limitations and do not incorporate more recent evidence.

As part of a Robert Wood Johnson Foundation-funded project, my team and I have organized a series of workshops to consider these questions. The first meeting “Refining the Question, ‘What Affects Health?” will be held on Monday, June 17, 1-5:15pm at the Weston Princeton in Princeton, NJ. David Cutler and Paula Braveman will speak about the wide range of factors that influence health and engage with the project’s committee — led by Ashish Jha and Sherry Glied — and others in attendance who wish to contribute. Details and registration on the DriversOfHealth.org website. Please RSVP and attend!

I would greatly appreciate it if you would share this invitation and project with anyone you think may be interested — your department, students, and other colleagues, friends, family, neighbors, etc.

Also, please explore, share, and revisit our project website, which includes an interactive (and more interactives to come), ways to engage on the project’s topics, and a blog that we will add to every week.

The Drivers of Health: What makes us healthy?

The Drivers

 

What makes us healthy?

We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?

In the 1970s the Centers for Disease Control and Prevention tried to answer these questions but had little rigorous science to guide it. Though we know a great deal more today, they still have not been fully answered. This is no mere curiosity — knowing what makes us healthy will help us direct investments into the right programs.

Over the years, many frameworks have been developed to illuminate what affects health. The relationships are so complex that no single framework captures everything. To get us started on this research project — and our broader conversation about what drives health — we created a model that allows us to explore some of the dimensions of these drivers, and their relationships to each other.

The Framework

We developed our framework by reviewing research on factors that influence health and surveying similar projects and tools from prominent organizations . It is not meant to be complete, but a starting point that allows us to think about what drives health and how.

Indirect vs. Direct Factors
Many things affect health, some directly and others indirectly. Government/policy, income/wealth, education, and racial identity don’t necessarily affect health in an immediate way. They are indirect factors that tend to affect health through complex pathways. Those pathways usually involve other factors that more immediately affect health. These are the direct factors such as occupation, health care access, and health behaviors.

Why these Outcomes?
There are many possible health outcomes. The framework includes four examples—age-adjusted mortality, life expectancy, quality of life/well-being, and functional status. These outcomes are commonly studied, prevalent in the literature, and reflect the kinds of things people care most about.

The Drivers