Last week, I appeared at the National Press Club an event sponsored by the Century Foundation, the AARP, and the Commonwealth Fund to discuss health care reform.

In preparing for that event, I came to realize that my vision of a national health policy has undergone refinement since I started my blog a few months ago. So here it is, although in abbreviated form:

• Any national health policy has to be based on the goal of maximizing health, safety, well-being, and productive capacity of all Americans.

• These goals, if achieved properly, will improve economic growth and competitiveness. They will not drain our economy, and we will not need to ration care to achieve them.

To achieve these goals, our health system will have to be based on six principles, all of which need to be followed:

• Americans need to know how to engage in healthy behaviors, and to be in an environment which encourages healthy behaviors in a healthy environment.

• We need universal, affordable, comprehensive health care coverage, and everyone needs to have that coverage. (more…)

I continue to be disappointed by the incompleteness of the discussion of issues in the national health care debate. There is abundant discussion of coverage and affordability, considerably less coverage of preventive and wellness, almost no discussion of what is needed to assure adherence to required treatment programs for chronic diseases, and little discussion of the issue of access gaps.

Everyone associates unnecessary emergency room visits with lack of insurance coverage. Certainly, many people in emergency rooms are individuals lacking insurance coverage. However, there are many people who have relatively minor illnesses or injuries, but who go to emergency rooms because they incur their medical condition after their primary physician’s office closes for the day or on a Sunday, when their physician’s office is most likely closed.

The first question we need to ask is why physicians have office hours comparable to the hours of business for American retailers over 40 years ago. The main reason is that the majority of medical practices are either sole practitioner or small groups, with little ability to provide Sunday or late evening coverage.

Beyond that, there simply are many areas that do not have what we have in Stamford, Connecticut, an urgent care center that is open seven days a week, the Tully Center, which is part of the Stamford Health System. I have been in communities as diverse as downtown Chicago, downtown Los Angeles, and King of Prussia, Pennsylvania, that have had no non-hospital-based urgent care facilities for minor illnesses and injuries. (more…)

The more I have studied the issue of obesity, the more convinced I am that one of the highest leverage points in attacking the problem is getting agricultural food subsidies changed.

We tend to blame individuals for their eating habits, particularly obese poor people. What we fail to take into account is the extent to which their eating habits are dictated by the relative costs of different foods, particularly the costs of unhealthy vs. healthy foods. We fail to understand that both the availability and cost of foods is heavily influenced by long-standing agricultural subsidies baked into federal laws and U.S. Department of Agricultural regulations.

I first learned about this in reading an article in my local newspaper, the Darien Times, about a lecture in Westport, Connecticut, at which Congresswoman Rosa DeLauro, among others, commented on the influence of agricultural subsidies on producing more sugar and grain-based foods. She and others commented that fruits and vegetables are considered “specialty foods” which are not given subsidies and therefore more expensive. (more…)

Recently, the Partnership for Prevention, an organization that is trying to promote prevention and wellness as key health care strategies, issued a report entitled A National Profile on Use, Disparities, and Health Benefits.

The value of preventive care is clearly demonstrated by the Report. Most interesting is the fact that, with respect to childhood immunization, an area of strong public policy focus, disparities based on race, ethnicity, and income have largely been eliminated. However, for other areas, like the taking of aspirin to prevent heart disease, adult immunization, colo-rectal screenings, and smoking cessation, there are huge disparities among races, ethnic groups, and income levels.

Medicare inadequately covers these treatments, but, beyond that, there has been inadequate focus on what the obstacles to adherence to recommended prevention and wellness approaches might be. Coverage and cost are certainly issues, but there are basic access gaps in our health care system.

For example, in New York City, our Management Services employees tend to work in Manhattan during the day, but live in the outer boroughs. Even if they have primary care physicians, those physicians do not tend to have evening and weekend hours, with the result that these employees use the emergency room for after-hours care. Emergency rooms are extremely hostile to people who use them for preventive screenings or immunizations. I know, because years ago, I needed to go to a medical facility to get allergy injections, and I was told that I did not belong in an emergency room because the ER was for life-threatening conditions, not for preventive care. (more…)

I am often asked about how we can be such passionate advocates for employer-based health plans, and, in particular, how we can actually operate in-house clinics with staff physicians.

We have been successful in operating our health plans because we believe healthy employees are a great resource.  We also believe that employees who have health problems can continue to be productive and motivated while they are coping with the devastating effects of chronic, degenerative, or even life-threatening diseases.

By actively investing in health and in helping those with health problems manage their medical conditions  we have been successful in keeping health cost increases well below market averages.

How do our employees feel about our health plans and our clinics?  Our medical program, including our clinics, is one of the most popular benefits we have, with a high degree of employee satisfaction.  Employees relate exceptionally well to our doctors and nurses.

One of the reasons is that we have insisted that our medical practitioners not only be highly competent and trustworthy, but that they have exceptional people skills.  As Malcolm Gladwell pointed out in his fascinating book, Blink, people sue medical professionals, not because they perceive them to be incompetent or because they just want a windfall from a non-meritorious lawsuit, but because they perceive the particular professional to be insensitive and uncaring.

Some outsiders are surprised that employees continue to patronize company-employed medical professionals and share sensitive information with them.  I do not know what these outsiders’ life experience with company medical professionals has been, but our employees trust our medical professionals not only to comply with HIPAA requirements, but to exercise the highest degree of discretion and trust possible. 

The one area where we encounter more privacy concerns is where we ask employees to share health information with their health plans by completing health risk appraisals.  Some employees do not trust any online data server because they believe it can be hacked into by people who have no right to the information.

We have had a long history of being a leader in secure handling of sensitive data.  We have managed billions of dollars of postage for millions of customers without ever having had our systems compromised.  We manage mail and print centers in which our employees have access to highly-sensitive health and financial data of millions of people, including our own employees, and we face the risk of major liability were we to allow that data to fall into the wrong hands.  Given the value we place on our brand reputation for trustworthiness, we have been pleased with the performance of our systems and processes.

We succeed because we use advanced security techniques and principles in safeguarding information.  One of our fundamental beliefs is that every security system needs to be “crash-tested” before it is deployed and to be tested continuously afterward.  We are vigilant about security breaches.  Those whose sensitive information we touch understand this, and have trusted us for decades.

What this all means is that you can’t look at aggressive employer-based health care in isolation.  A respect for the security concerns of employees goes hand-in-hand with employer-based health care.  At Pitney Bowes, we are willing to invest in secure systems and processes both because of our brand and reputation for trustworthiness, and because we particularly believe that the active management of employee health brings great rewards to our company and our employees.

Consistent with my philosophy of finding the “road less traveled,” one major area of interest for me is Alzheimer’s disease, which actually is the third-highest cost medical condition in our U.S. healthcare system, far more than HIV/AIDS and many other conditions that get more publicity and funding.

I should confess that I have a personal interest in Alzheimer’s.  I have had family members that either had Alzheimer’s or some other form of dementia.  I do not know whether my loved ones had Alzheimer’s because autopsies were not done, and, as I understand it, an autopsy is the only definitive way to determine whether a person has had Alzheimer’s.  Fairly definite diagnoses can be made through memory assessment, and the earlier memory assessment and diagnosis can be done, the more can be done for an Alzheimer’s patient.

I help advise the Boston University (BU) Alzheimer’s Disease Center, one of the slightly more than two dozen centers designated as a center of excellence by the National Institutes of Health in a highly-competitive process.  On June 20, I attended an advisory group meeting at BU Medical School.  I also visited a few university mail centers on this trip, and spent some time with one of our top sales professionals who has sold products to many colleges and universities. 

Several conclusions jumped out at me:

• While we want world-class research in trying to find breakthroughs for diseases like Alzheimer’s and we get it at institutions like BU, our government and other donors put ridiculous bureaucratic obstacles in the way of focusing on research and clinical care.  For example, as one college director of operations told me, universities and other research centers have to account for individual pieces of mail and other low-ticket items because of the government’s obsession with making sure that no dollar is “wasted.”  At the same time, no one in government thinks about the waste or opportunity cost of high-skilled researchers or physicians worrying about the cost of single letter or photocopy and charging it to the right account.
• Donors of all kinds congratulate themselves on restricted funding that is targeted only on research and not on “overhead” costs like administrative support, equipment, supplies, and facilities.  Yet, no institution can survive without some amount of overhead.  I have talked to many CEOs and Chairmen of non-profits who have seen the same thing I have.  Many worthy organizations hit a wall on their ability to accept restricted grants and perform on them because their funding for the necessary, but mundane, administrative tasks does not keep pace.
• Government funding for breakthrough medical research and clinical care is declining in relative and absolute terms, even when it would produce significant and measurable payback in future years.  Governments at all levels are so fixated on current-year budget-balancing activity that they routinely mortgage the future.  Medicare, in particular, ludicrously controls the payouts for individual clinical interventions for Alzheimer’s, and, I am sure, other conditions, to reduce today’s costs, but ignores opportunities for investments in health that will save on future costs.  By the way, this is one of the reasons I am strongly opposed to any “single-payer” health system in the United States.  Given our approach to democratic government, I have no confidence that politicians, who tightly control and micromanage Medicare and its clinical processes, would think beyond the current fiscal year in how they manage medicine.  If there were a single-payer, the whole medical system would make these dysfunctional trade-offs, instead of just the part controlled by Medicare.
• To a greater degree than many other centers of excellence, BU focuses on the less-glamorous activity related to bringing down the cost and devastating burdens of Alzheimer’s.  It focuses on genetic risk assessment, actions that might prevent Alzheimer’s, memory assessment programs to facilitate early diagnosis and treatment, and approaches that would slow down the progression of Alzheimer’s, as well as the needs of caregivers.  As a society, we are conditioned to have researchers look for “cures” for diseases.  I always think about the telethons for various diseases which use some variant of the phrase “there is no cure, but there is hope.”  I am glad that we care passionately about finding cures, but the more practical and better investment of resources has to be targeted at prevention and the infrastructure for early diagnosis and treatment. 
• The other concept presented to us was the notion that some of the capacity challenges for Alzheimer’s victims may not be memory-related, but may be perception-related.  For example, an Alzheimer’s victim may not have forgotten where he or she put the car keys.  That person may not be able to see the keys where they were placed.  That insight suggests that we can help Alzheimer’s victims to function by improving their perceptual capability with various kinds of tools.

I am confident that significant progress will be made in the next 10 years to slow down disease progression, and maybe even stabilize patient situations.  I would hope that we will see a time that the progression of this disease can actually be reversed.

In recent weeks, I attended and spoke at the Mackinac Policy Conference in Michigan, and visited Congressional staff experts on health care, as well as some of our elected representatives. I have seen two points of view expressed by different stakeholders. 

At Mackinac and in other forums where companies are faced with overwhelmingly large retiree medical obligations or onerous active employee medical programs that resulted from collective bargaining frameworks agreed upon decades ago, many company and union representatives expressed the view that the government should take over or  redistribute the burden of health care costs away from the employer.

On the other hand, in discussions with others who do not face this legacy burden, there is more recognition that an employer-based health program has a vital role to play in any future health care system.

We have been at a point at which our health care costs were overwhelming, since, up to the late 1980’s, we were paying close to 100% of both our employee and retiree health care costs, and, even today, we have a legacy population of close to 2,000 retirees who still have the pre-1990 100% plan. 

But we changed direction in 1990 when I took over responsibility for Human Resources.  We have been a laboratory of sorts in trying new approaches, and I feel we have a great story to tell.  At the same time, I am frustrated because the media, and, too often, elected officials focus too narrowly on the underlying issues.

The purpose of a health care program should be that the people covered by it are as healthy and productive as they can be. Obviously, health care system access, coverage, and cost are critical to making sure that the health care system plays its role in maximizing health and productivity.  But these components are not enough.  While many who propose solutions to the health care crisis will discuss health improvement, it is an after-thought or a component of one of these structural solutions.

Discussing health care without discussing the root causes of deteriorating health is as incomplete as confronting a widespread failure of a mass-market product like brakes on an automobile by focusing on abundant, affordable brake repair shops, and, failing that, making sure that the government steps in to negotiate with all the brake repair shops.  Imagine if those discussing the massive brake failure problem generally failed to ask why the brakes failed in the first place.

We need to ask why Americans are not as healthy as they can be before we confront the issue of how we treat the diseases and injuries that indicate that health deterioration.  In other words, it’s about health, not health care.

What’s making us less healthy?

Let’s start with obesity caused by bad eating habits and inadequate exercise and fitness.  Obesity drives diabetes, cardio-vascular diseases, and orthopedic problems, as well as contributing to injuries.  In fact, the Robert Wood Johnson Foundation and other authorities clearly point out that chronic and complex diseases arising from lifestyle-related conditions like diabetes are the most significant contributors to our spiraling health care costs.

Beyond obesity, lifestyle-related health conditions, such as those brought on by smoking, alcohol and drug abuse, including performance-enhancing drugs drive up our costs.

We tolerate unhealthy communities with environmentally-induced conditions, like the significant increase in asthma in high air-pollution areas.

We are one of the most violent societies in any developed country in which a war is not being fought.

All of these conditions are preventable, and, if we were to improve our health to a level comparable to other developed countries, our health care costs would be far lower, and most of the problems of coverage and access would melt away.

With respect to obesity, I read a great book recently called Mindless Eating: Why We Eat More Than We Think by Brian Wansink.  Wansink has a great quote in the book:  “The best diet is the one we do not know we are on.”  He makes a number of points strongly supported by scientific study and common sense:

• We gain weight not because of short-term eating binges on unhealthy foods, but because we consistently ingest slightly more daily calories than we burn off.  Likewise, we can lose weight if we burn off slightly more calories than we consume.  For example, if our calorie intake to maintain our existing weight is 3500 calories per day, a 100-calorie swing up or down makes a difference of 10 pounds more or less over a year.
• The most sustainable weight-reducing diet is one in which we consume between 100 and 300 calories less than we burn off.  Diets based on depriving ourselves of kinds of foods that we enjoy or significant calorie reductions below maintenance level are not sustainable, or unbalanced diets in which we do not eat certain food types like carbohydrates are not healthy or sustainable. I know, because I have lost weight on many different diets in which I have deprived myself of foods I liked, but ultimately could not sustain them.
• Many techniques can reduce the marginal intake of the food that makes a difference between weight gain and loss, and many are as simple as not putting ourselves in situations in which eating is the easiest thing to do.  Some techniques are as simple as buying, or keeping, or measuring smaller quantities of food.
• Some highly-appearing foods are highly likely to result in overeating if easy to access, such as desserts and other sugary foods, simple carbohydrate foods like pizzas and pasta, and snacks.  The best approach to those foods is to reduce ease of access.

We tried many of these techniques at our Company facilities and they work.  For example, the healthy food is easy to find and the foods that we tend to overeat, like cookies, cupcakes, and potato chips, are harder to find.  We are very careful with portion control.  We follow traditional retail merchandising techniques by putting foods we want people to eat, like fresh fruits, right near the check-out counter.

Outside the cafeteria, we make bottled water readily available everywhere, but make sodas and snacks from vending machines hard to find.  We eliminated food service at breakfast meetings, and significantly reduced the quantities of the food we provided at luncheon meetings. 

Alcohol is served for a limited period of time at after-work parties, and is served in relatively small glasses or cups.  Cocktail periods at parties are relatively short, and we try to get as many functions held at our Company dining facilities and as few at outside facilities as possible, especially restaurants that make their profits on alcohol and desserts.

With respect to fitness, we give away pedometers and encourage people to participate in 10,000 steps-per-day programs, and we subsidize fitness facilities, including fitness centers in our Headquarters and our Technology Center. 

We prohibit smoking at Company facilities, and we actively promote smoking cessation programs.

People like our health programs, and we have many inspiring and emotionally-satisfying stories of employees whose lives have been turned around by our programs.

I do not believe in coercing good behaviors.  I am appalled by companies that threaten to fire smokers or refuse to hire them in the first place.  I am also appalled by what I have heard about companies that humiliate obese people by communicating their Body Mass Index to them, and by requiring them to go into fitness programs as a condition to a better job.  They are unhappy enough being obese.  Why pile on?  I believe in the carrot, rather than the stick.

I also find it ironic that I go to many health-related conferences and the same junky food we talk about stopping our children from having at school is served at coffee breaks and lunches at the conferences. 

What I have tried to do is to create a culture of health. Helping people with diet, fitness and exercise, and lifestyle issues like smoking and drug abuse are obvious.  Alcohol consumption is more challenging, because it is less clear whether the right answer is no alcohol consumption or modest alcohol consumption, particularly of red wine.

My approach to alcohol has been to try to establish a culture in which individuals can make the appropriate health decision whether to refrain or to consume modestly.  Many companies, including ours, had a culture from previous generations in which heavy alcohol consumption was associated with fun and being sociable.  What I’ve tried to do is to make the decision whether to refrain or to consume moderately a personal choice, and to make sure that people at our Company know that heavy alcohol consumption, especially when coupled with driving, is a serious problem.

We try to create a culture of health at home as well with our children in terms of what they eat and drink.  The foods we serve and buy, the peer groups with which they connect, and the welcoming environment we create are more successful than the silly rules I see at the schools these days.  Letting children have a celebration with sweets once in a while is not going to change the culture of health, especially if schools monitor the portions served.  At the same time, schools need to focus on physical fitness, smaller food portions, and a better mix of healthy, tasty foods than they have today.

We take long walks with our children and have nice conversations.  One of my favorite movies from the 1980’s was The Karate Kid because the hero was training without realizing it, as he was doing chores.  Fitness needs to be fun and to be accomplished as part of something else.

One of my colleagues on an outside board of directors told me about an analysis someone had done about adult lives 50 years ago and why adults were not as obese then.  They expended from 50-100 calories per day more energy on day-to-day living tasks because automated solutions were simply not available then.

Think about the days before TV remote controls, automatic garage door openers, automatic car windows, electric or gas-powered lawn mowers or snow removers.  Those extra 50-100 calories per day gave adults a 5-10 pound per year head start over us in terms of weight management.  I replicate that with the 10,000 steps program, and stay in motion as much as possible.

I would love to see politicians focus on creating a national culture of health, as opposed to trying to rearrange the deck chairs on the Titanic by coming up with a different way to distribute the pain of current health care costs. 

I am pleased with some of what I see in Congress with the thinking of many U.S. Senators on both sides of the aisle.  Senators Wyden, Whitehouse, Coburn, and Smith are among those trying to find solutions that focus on health, as well as health care. I am also pleased that Senator Clinton spoke favorably about our health care program. 

The good news is that there is a lot of momentum to reform health care.  In our rush to enact a much needed health reform bill I hope we do not inadvertently knock out programs like ours that actually are working to reduce costs and achieve health improvement at the same time.  Let’s deal with the legacy issues that plague some of our older companies and, by the way, our government employee health plans, but let’s not let those legacy issues drive the broad health care reform agenda.