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On our show last week, we discussed a list of 20 tips (http://www.ahrq.gov/consumer/20tips.pdf)to help you avoid medical errors. But who can remember 20 tips? One way is to create a checklist. Checklists help avoid errors. But there may be a simpler way to improve patient safety. The National Patient Safety Foundation (http://www.npsf.org/)has come out with the Ask Me 3 (http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/) program. The Ask Me 3 program is designed to encourage better communication between patients and their doctors. The program would have patients get and understand answers to three questions: What is my main problem? What do I need to do? Why is it important for me to do this? Patients ask their health care providers these three questions regularly. Doctors should work to make sure their patients understand the answers to these questions. People who understand health instructions make fewer mistakes when they take their medicine or prepare for a medical procedure. They may also get well sooner or be able to better manage a chronic health condition. Take responsibility to make sure you get great medical care.

University of Chicago Booth School of Business professor John Cochrane (http://faculty.chicagobooth.edu/john.cochrane/)says, there is a “coherent free-market, deregulated alternative (http://johnhcochrane.blogspot.com/)” to our current health care system, and that the “Affordable Care Act” isn’t the way to get there. Cochrane believes there are ways to assure that people with pre-existing conditions can get health care without the need for individual mandates. How can this be? We explore the possibilities with Professor Cochrane to see how regulation is at the heart of the problem, and that 1,000’s of pages of more regulations in the Affordable Care Act will likely only make things worse. Introducing more competition (http://www.cato.org/pubs/pas/pa-633.pdf)—both among insurers and providers of health care—would be a better solution.

The prices of some drugs are extraordinarily high. Patients may need those drugs but may find the high price, even just the copayment after insurance, to be unaffordable. What to do!? Drug company sponsored coupons (http://www.pharmalot.com/2012/03/prescription-drug-coupons-are-illegal-bribes/)that help cover the copayment can help rescue the situation. But are those coupons a good thing? The may increase the use of expensive drugs and cause drug prices to be higher than they would be if patients had more responsibility for paying the cost of care. We explore this issue with Wells Wilkinson (http://www.communitycatalyst.org/about_us/staff?id=0042), Director of Prescription Access Litigation Project and staff attorney at Community Catalyst (http://www.communitycatalyst.org/), a national consumer organization that works for access to quality, affordable care. Wilkinson explains that drug coupons may encourage overuse of costly medications when lower priced generic medications could work equally well. He also expresses concerns about the privacy implications of using these coupons.

In contrast to much of the rest of the U.S. economy, our health care system is a cobbled, poorly coordinated system. Health insurance is provided largely by government and by employers. Do employers, who have lots of experience with well working markets, have market-based solutions for health care problems? Our guest today is Helen Darling (http://www.ncqa.org/tabid/1470/Default.aspx)from the National Business Group on Health (http://www.businessgrouphealth.org/). The National Committee on Quality Assurance recently honored her for her leadership promoting health care quality as an issue of commercial competitiveness. She has helped American businesses become better purchasers of health care and has helped government and industry leaders understand the economic importance of health care quality. Dramatic increases in health care costs have been major problems for U.S. employers hurting growth and competition. Despite the high costs, the quality of care is uneven. Too often, Americans get care that is either less than optimal or that makes things worse. No one solution may solve this. There are dozens of potential solutions that can help. Large employers can help identify key targets, can provide onsite health support, and can encourage employees to participate in condition management. The lack of personal responsibility for health care costs is a central problem in the US health care system. Our system literally provides a blank check for health care coverage with little to no incentive for patients or their doctors to consider cost. This results in utilization that is off the chart. The Choosing Wise Initiative (http://www.abimfoundation.org/Initiatives/~/media/Files/2011-Forum/110411_ABIM%20Stewardship.ashx)identified five overused interventions that don’t add health. People should realize that some preventive tests and procedures may not be helpful and that a healthy lifestyle is.

There are a lot of doctors out there. How do you find a great one? Do you rely on word of mouth? This week, we talk with William Liss-Levinson, Ph.D (http://www.castleconnolly.com/about/whoweare.cfm). about top doctors. Bill is Vice President and Chief Strategy & Operations Officer for Castle Connolly Medical Ltd. Castle Connolly helps people find and access great medical care. It researches doctors’ credentials and surveys doctors to find “America’s Top Doctors (http://www.castleconnolly.com

On last week’s program, Tom Hubbard (http://www.nehi.net/about/staff), Senior Program Director at NEHI, (http://www.nehi.net/about/) a national health policy institute and think tank, based in Cambridge, Massachusetts, spoke about some of the practical ways to reform our health care system. This week, we continue the discussion, focusing on how poorly some patients use their medications and what can be done to improve medication use (http://www.lulu.com/shop/display-product.ep?pGUID=6081955). Improving adherence to treatment is critical because it would improve outcomes and lower costs but there is no one solution. Research shows that patients are non-adherent for lots of reasons. Their total list of medications may not be right, doses may not be right, and review by a physician and/or pharmacist could help. Other barriers include side effects, complicated dosing, and very personal factors, such as costs, beliefs about medication effects, and cultural factors. Strategies to improve adherence will need to be customized to patients’ specific needs. Doctors, insurers and drug companies may all play a role. One key to improving outcomes may be to tie payment to successful treatment, putting more at stake for physicians. This is a contentious and exciting time in medicine!

On today’s program, Tom Hubbard (http://www.nehi.net/about/staff), Senior Program Director at NEHI, (http://www.nehi.net/about/) a national health policy institute and think tank, based in Cambridge, Massachusetts, joins us. NEHI has a diverse membership of 80 member organizations, including patient groups, doctors, health insurers and drug companies. These organizations have a shared interest in better patient outcomes and a shared interest in greater use of evidenced based medicine. A basic principle of health care reform efforts should be to maintain innovation. Health care represents a huge segment of the economy. Healthy workers are essential to our economy. Strides need to be made to promote better diet and fitness and reduce the problems of obesity and diabetes. There is massive documentation on wasteful use of health care resources. Some 30-40% of health care is wasted. The fragmented medical system results in needless repetition of tests. In order to “bend down the curve” of health care spending, there are about half a dozen things crying out for attention, including avoidable hospital readmissions, coordination of care and improved faithfulness to use of medicine. New organization models including medical homes and accountable care organizations may help. Next week, Tom continues the discussion, speaking on how well (or not well) patients use their medications. Improving adherence to treatment is critical, but there is no one solution. Research shows that patients are non-adherent for lots of reasons. Their total list of medications may not be right, doses may not be right, and review by a physician and/or pharmacist could help. Other barriers include side effects, complicated dosing, and very personal factors, such as costs and beliefs about medication effects. Strategies to improve adherence will need to be customized to patients’ specific needs. Doctors, insurers and drug companies may play a role. One key to improving outcomes may be to tie payment to successful treatment, putting more at stake for physicians. This is a contentious and exciting time in medicine!

Poor use of medication, also called poor adherence (http://www.medscape.org/viewarticle/588417), is responsible for medications not working nearly as well as they could. Patients don’t take their medications for a variety of reason, including forgetfulness, fears, side effects, costs, complexity (especially for older folks) and non-belief in efficacy. Our guest today is Rebecca Burkholder (http://www.nclnet.org/about-ncl/staff), Vice President of Health Policy for the National Consumers League; the National Consumers League is a nonprofit organization that has represented consumers and workers since 1899. The organization is preparing a national campaign to promote better adherence The goals of the League’s adherence initiative are based on focus groups that showed what was needed. The key issue was for patients was understanding medication better. There’s a lack of knowledge about the relationship between poor adherence and poor medical outcomes. Patients should speak to their doctors to make sure that the reason for the medication and the expectations of it are understood. The campaign will work to promote better adherence. It has over 100 public and private partners and will focus initially on 6 regions across the United States. There will be publicity, a website, many tools, and a pledge for better adherence. Listeners should consider assessing their own adherence and consider using the campaign tools if needed. A great resource is scriptyourfuture.org (http://scriptyourfuture.org).

The National Committee for Quality Assurance (NCQA) recently published a report (http://www.ncqa.org/tabid/1425/Default.aspx) on how state health insurance exchanges (http://en.wikipedia.org/wiki/Health_insurance_exchange)can help promote health care quality and reduce health care costs. Our guest this week, NCQA president Margaret O’Kane (http://www.ncqa.org/tabid/344/Default.aspx), describes what these exchanges can do. What are exchanges? The health insurance exchanges will be state run insurance plans that pool risk and make care more affordable. The details of these exchanges vary by state, some states having created non-government agencies. The exchanges will cover the poor and the employees of small employers. By providing information and competition, the exchanges will promote greater cost transparency, lower costs and better quality/value. People don’t like shopping for health insurance—it’s very complex—so having just a few choices and good information is key. The NCQA plays an important role by providing measures of quality that can be reported and compared across plans, for example, how well does the plan do with patients with diabetes, etc.

Medicare provides health insurance coverage to an enormous number of Americans. It is efficient, but very costly. If only something could be done to make it more innovative…. Something is being done. The Centers for Medicare and Medicaid Services, CMS, has an Innovation Center (http://www.innovations.cms.gov/)that is developing and testing new ways of paying for health care, new approaches designed to put incentives into alignment in order to achieve better health care quality at lower cost. Our guest today is Dr. William Shrank (http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/NonprescriptionDrugsAdvisoryCommittee/ucm106119.pdf), Director of the CMS Innovation Center’s Rapid Cycle Evaluation Group. Dr. Shrank explains how the Affordable Care Act (so-called “Obamacare”) has put into place a program to develop, test and implement new payment models to reduce cost and improve quality, to bend down the upward curve of medical care spending. Dr. Shrank explains that the current system pays for higher volume care, not higher quality or more efficient care. The “DRG” system was put in place years ago to pay hospitals for episodes of care, but it didn’t cover other health care costs. More holistic systems and perhaps accountable care organizations will provide a means to take extend the advantages of DRG’s to health care in a more global way. Dr. Shrank lets us know that the Innovation Center is seeking input and suggestions (http://www.innovations.cms.gov/Community/Share-Your-Ideas/index.html)through its website.

This week, we speak with Joe and Terry Graedon, whose radio program The People’s Pharmacy, provides patients a wealth of up to date, cutting edge health information, information patients might find difficult getting anywhere else, even from their doctors. Joe Graedon has a Masters in Pharmacology, and Terry Graedon, has a PhD in Medical Anthropology. Last week, in part 1 of this two-part program, we discussed their radio show and what doctors think about patients getting information from their show; this week, we discuss their newest book, Top Screwups Doctors Make and How to Avoid Them. (http://www.amazon.com/Screwups-Doctors-Make-Avoid-Them/dp/0307460916/ref=sr_1_2?ie=UTF8&qid=1321704765&sr=8-2)The People’s Pharmacy is more than just radio program. The Graedon’s have published about 15 books, starting with The People’s Pharmacy in 1976. Other books include: The People's Pharmacy Quick and Handy Home Remedies: Q&As for Your Common Ailments, Best Choices From the People's Pharmacy, The People's Pharmacy Guide to Home and Herbal Remedies, Dangerous Drug Interactions, and The People's Pharmacy, Completely New and Revised. Patients can also get information from the Graedon’s many podcasts, newspaper articles, and videos, as well as from a series of inexpensive guides (https://store.peoplespharmacy.com/guides.html)available through The Peoples Pharmacy website (http://www.peoplespharmacy.com/). The Graedons get inspiration for shows, books, and newspaper columns from letters they get from their listeners. Listening to others, they point out, is critical. There’s so much money around, in the health system, and the Graedons have developed a successful formula to keep from getting corrupted. Their principles include respect for people's ability to make informed decisions about their health, honesty and integrity in communication and actions, and care, compassion and fairness as the guiding principles for all institutions serving people. They don’t take a penny of drug company money, so they can be viewed as objective umpires and referees. Terry Graedon describes her concerned about direct to consumer advertising, particularly when it is related to serious health conditions. Driven by money, this advertising affects health care costs. The financial incentives in the health system can have a negative impact on health care, particularly the short visits with doctors. In contrast, on their program which airs on public radio stations, they have a full

The National Committee for Quality Assurance (http://www.ncqa.org/)(NCQA) has published its 2011 State of Health Care Quality Report (http://www.ncqa.org/tabid/836/Default.aspx)examining quality data from health plans that cover 118 million Americans. NCQA President Margaret O’Kane (http://www.ncqa.org/tabid/344/Default.aspx) joins us to report on the findings. The NCQA bases its reports on objective quality indicators reported by over 1,000 health plans across the country. The report found that preferred provider organizations (PPOs) are catching up with health maintenance organizations (HMOs) or measures like childhood immunization and diabetes care. Greater use of electronic health records has contributed to the improvements. The NCQA data help consumers find health plans that provide better value. Health care consumers—like you and me—can find more information at NCQA.org or at ConsumerReports.org.

Patient education is critical to successful medical outcomes. Mark Becker (http://vivacare.com/info/about/vivacare_team.html), pediatrician and founder of Vivacare (http://vivacare.com/), a company that makes patient education material available through doctors’ websites, describes how the Internet can be used to better educate patients about their condition and treatment. Patients need to be empowered to care for themselves. We spend $2.4 trillion dollars per year on health care, yet very little to educate and empower patients. Patients are being asked to play a greater role in their healthcare decisions, but they often don’t have the information needed to make informed decisions. Sometimes, basic information, like the need for regular monitoring in diabetes, isn’t provided. Medications may not work because patients may not know how to properly use them. The right information needs to go to the right patient from the right source. Patient don’t need to know all the information given in medical school, and too often, basic, essential facts are lost in the noise of a package insert. Some 80% of physicians report that they provide patients insufficient materials! There are many potential solutions to this problem including more physician time devoted to patient education, greater use of physician extenders and other handouts. But the big gorilla is the Internet, the wild, wild West of health care information. Vivacare is working to make trustworthy, physician-approved information available through doctors’ websites. Other resources include WebMD, Google and the National Library of Medicine (http://www.nlm.nih.gov/medlineplus/). The future of patient education is bright, with video, interactive tools, quizzes and information linked to patients’ medical records all very much soon possible. While the Internet may be overwhelming, having a physician partner as a guide will help assure patients get good, high quality, trusted information.

A trusted patient advocate (http://www.npsf.org/download/PatientAdvocate.pdf)can help people manage the complexities of our health care system. Anne Llewellyn (http://www.patientadvocatetraining.com/staff/details.asp?id=14542), Editor in Chief of Dorland Healthcare, describes what patient advocates are and how they help people navigate a complex and fragmented health care system. Patient advocates are people who assist patients. Often, patient advocates have a background in nursing, social work, or pharmacy or can even be a retired physician. Patient advocates accompany patients to medical visits, help patients and their families understand diseases and their treatments, and may act as cheerleaders, encouraging better use of treatments. They may also help find additional resources. Patients can find patient advocates through the Professional Patient Advocate Institute (http://www.patientadvocatetraining.com/)or locally through advertisements or talks at senior centers. Currently, there are no license or certification requirements, so buyers have to beware. There is no rule of thumb or standard for the cost of a patient advocate’s services (though hourly fees may run from $75-200 per hour). Patient advocacy is a growing field, and there are opportunities for people to enter the field. Courses are available through the Professional Patient Advocate Institute.

A trusted patient advocate (http://www.npsf.org/download/PatientAdvocate.pdf)can help people manage the complexities of our health care system. Anne Llewellyn (http://www.patientadvocatetraining.com/staff/details.asp?id=14542), Editor in Chief of Dorland Healthcare, describes what patient advocates are and how they help people navigate a complex and fragmented health care system. Patient advocates are people who assist patients. Often, patient advocates have a background in nursing, social work, or pharmacy or can even be a retired physician. Patient advocates accompany patients to medical visits, help patients and their families understand diseases and their treatments, and may act as cheerleaders, encouraging better use of treatments. They may also help find additional resources. Patients can find patient advocates through the Professional Patient (http://www.patientadvocatetraining.com/)Advocate Institute or locally through advertisements or talks at senior centers. Currently, there are no license or certification requirements, so buyers have to beware. There is no rule of thumb or standard for the cost of a patient advocate’s services (though hourly fees may run from $75-200 per hour). Patient advocacy is a growing field, and there are opportunities for people to enter the field. Courses are available through the Professional Patient Advocate Institute.

Patient Centered Medical Homes (http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%20the%20PCMH_v2)are a proven way to reduce the cost of health care while improving health care quality. Dr. Paul Grundy (http://www.pcpcc.net/content/paul-grundy), Global Director, IBM Healthcare Transformation and the current President of the Patient-Centered Primary Care Collaborative (http://www.pcpcc.net/), describes how patient centered medical homes provides comprehensive primary care to people of all ages, broadening access to primary care and improving the coordination of care. Key components of a patient centered medical home include: 1. Responsibility and accountability for the ongoing care of patients 2. Accessibility to patients on short notice including expanded hours and open scheduling 3. Consultations using email and telephone technology 4. Using up-to-date and and evidence-based medical approaches 5. Using electronic personal health records 6. Systems to assure that patients get regular check-ups and early treatment/prevention measures so that costly emergency procedures and hospitalizations are prevented 7. Encouragement for healthy lifestyle decisions 8. Coordinated care to make sure procedures are relevant, necessary and performed efficiently. In our discussion, Dr. Grundy describes how health care costs are dragging American industry down and how industry and insurers got together to create more rational, effective, efficient and affordable health care systems. Grundy describes how patient centered medical homes are proliferating and how they have been proven to save money for industries that adopt them for their employees. Grundy also points out that changes toward patient centered medical homes are happening rapidly, in part because they make sense and in part because employers have big incentives to keep their employees healthy and to locate their businesses in regions that provide better (less costly and higher quality) services.

Patient Centered Medical Homes (http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%20the%20PCMH_v2)are a proven way to reduce the cost of health care while improving health care quality. Dr. Paul Grundy (http://www.pcpcc.net/content/paul-grundy), Global Director, IBM Healthcare Transformation and the current President of the Patient-Centered Primary Care Collaborative (http://www.pcpcc.net/), describes how patient centered medical homes provides comprehensive primary care to people of all ages, broadening access to primary care and improving the coordination of care. Key components of a patient centered medical home include: 1. Responsibility and accountability for the ongoing care of patients 2. Accessibility to patients on short notice including expanded hours and open scheduling 3. Consultations using email and telephone technology 4. Using up-to-date and and evidence-based medical approaches 5. Using electronic personal health records 6. Systems to assure that patients get regular check-ups and early treatment/prevention measures so that costly emergency procedures and hospitalizations are prevented 7. Encouragement for healthy lifestyle decisions 8. Coordinated care to make sure procedures are relevant, necessary and performed efficiently. In our discussion, Dr. Grundy describes how health care costs are dragging American industry down and how industry and insurers got together to create more rational, effective, efficient and affordable health care systems. Grundy describes how patient centered medical homes are proliferating and how they have been proven to save money for industries that adopt them for their employees. Grundy also points out that changes toward patient centered medical homes are happening rapidly, in part because they make sense and in part because employers have big incentives to keep their employees healthy and to locate their businesses in regions that provide better (less costly and higher quality) services.

Our medical care system can accomplish miraculous things. Surgeons can operate on the vessels of the heart, clearing blockages and installing appliances to keep the vessels open. We have new medicines and new treatments designed to catch disease early or prevent it altogether. But do these miracle treatments do anything of value? Do people live longer or better? Are we getting our money’s worth? In part two of a two part series, we’re joined again by Dr. Nortin Hadler (http://tarc.med.unc.edu/facultymem.php?id=25), author of the books Rethinking Aging: Growing old and living well in an overtreated society (http://uncpress.unc.edu/browse/book_detail?title_id=2220) and Worried Sick: A prescription for health in an overtreated America (http://uncpress.unc.edu/browse/book_detail?title_id=1545). Dr. Hadler is a brilliant physician, board certified in Internal Medicine, Rheumatology, Allergy & Immunology and Geriatrics and is Professor of Medicine and Microbiology/Immunology at the University of North Carolina In this episode, Dr. Hadler discusses the issues of screening tests. He makes clear that it is hard to take well people and make them healthier. The bottom line is that people not only need to be better educated health care consumers, we also need to rethink what it means to be health and to get past medicalizing everything. We should be celebrating and enjoying our lives.

Our medical care system can accomplish miraculous things. Surgeons can operate on the vessels of the heart, clearing blockages and installing appliances to keep the vessels open. But do these miracle treatments do anything of value? Do people live longer or better? Are we getting our money’s worth? In part one of a two part series, we’re joined by Dr. Nortin Hadler (http://tarc.med.unc.edu/facultymem.php?id=25), author of the books Rethinking Aging: Growing old and living well in an overtreated society (http://uncpress.unc.edu/browse/book_detail?title_id=2220) and Worried Sick: A prescription for health in an overtreated America (http://uncpress.unc.edu/browse/book_detail?title_id=1545). Dr. Hadler is a brilliant physician, board certified in Internal Medicine, Rheumatology, Allergy & Immunology and Geriatrics and is Professor of Medicine and Microbiology/Immunology at the University of North Carolina In this episode, Dr. Hadler describes some of the difficult issues faced in assessing the quality of health care interventions. He describes in detail the issue of coronary artery bypass grafting. The bottom line is that people need to be better educated health care consumers.

The basic principles of economics explain why our health care system is in distress. Insurance, tax laws, and lack of competition contribute to the problem. In this second part of a 2-part series, we discuss solutions to our health care crisis based on an understanding of the underlying economic principles. We are joined again by Dr. Robert Whaples (http://www.wfu.edu/~whaples), Professor and Chair of Economics at Wake Forest University and director of the EH.net economics history (http://www.nytimes.com/2008/07/29/health/29well.html)website. Dr. Whaples is also the lecturer in The Teaching Company course, Modern Economic Issues (http://www.thegreatcourses.com/tgc/courses/course_detail.aspx?cid=5610) (which I heartily endorse). In this episode, how changing tax laws, the structure of our insurance system and increasing competition can help address this crisis.