Los Angeles Fast Food Moratorium

From Reuters: LA City Council passes a 1-year moratorium on fast food in several poor neighborhoods following a study that childhood obesity rates were 30% in South Los Angeles, West Adams, Baldwin Hills and Leimert Park compared to 21% in the rest of the city.

Although no existing restaurants are being closed down because of this law, and no provisions to promote the availability of low-cost healthy foods in these areas, this will make for a good case study of an interesting policy option. I'm interested to learn how the impacts of this will be evaluated.

On end-of-life care

To respond to some of Jay's thoughts on this matter: In the same way that preventive care and lifestyle change are undervalued (in terms of their health bang for buck reimbursed), end of life care is overvalued--or more correctly, consumers are willing to pay a steep premium for immediacy. In other words, from a purely rational standpoint, an additional year of healthy life (sometimes measured in a unit called quality-adjusted life years (QALY)) should be worth the same number of dollars whether it was "bought" using services applied in the 30th year of life or the 80th year, but in practice, we pay much, much more to extend life in the later years than we do in the earlier years.

This fact is not necessarily due to an evil empire, or even an irrational market. In fact, couldn't you argue that aggressive, expensive end-of-life care does not only serve the needs of those who benefit financially, but also serves the preferences of consumers who pay healthcare premiums? This is just a very rough idea, but what if the healthcare system was designed to take advantage of the loose purse strings we see at end of life to pay for better prevention? Perhaps rather than cutting back on end-of-life health care service utilization, payers (or policymakers through taxation) could skim a percentage of the profit margin realized for end-of-life care to pay for better preventive services or even directly compensate (or subsidize) individuals for healthy lifestyle choices. Not only might this help delay the onset of end-of-life care, it could keep healthy people productive in the workforce (and paying into the system) longer.

As strange as this sounds in a country where Social Security benefits for retirees are paid out of the payroll taxes of the current workforce, the premium we pay on end-of-life care could be harnessed to support better prevention in the current workforce. There are countless practical considerations that would go into this, but in the same way that individual IPAs and HMOs subsidize necessary but poorly reimbursed services with revenues from high margin procedures, a rational system could take revenues from potentially higher-margin (and "irrationally" over-reimbursed) end-of-life care to pay for valuable, but under-reimbursed prevention.

The end marks the beginning: how hospice helps me think about health policy

Why blog about health policy? Well, by way of explanation, let me tell you about my morning…

Before heading into the office, I visited a patient at home. I know that sounds old-fashioned and maybe even unsafe these days depending on the neighborhood. However, weakened by metastatic cancer, my patient would not reasonably have made it to see me in my office before his demise. I therefore decided that our best option was a home visit. We spent the first part of our visit discussing his physical health (controlling pain, managing shortness of breath and addressing nutritional issues) then transitioned later to his emotional and spiritual health (acknowledging fear and anger and achieving peace). He grasped that the cancer was inevitably going to overcome him physically and yet, he continued to fight for every last moment to be with his family, several of whom had traveled large distances to be with him. After talking some time thereafter with his children and wife and answering questions, I left for my office.

For the uninitiated, hospice is medical care that is provided at the end of life. I am not referring to chest compressions, being put on a respirator, or epinephrine (stat!); I am referring to making an informed decision to be comfortable and amongst loved ones at home when the moment of death comes. For some, hospice may seem antithetical to our modern-day technology-driven success-at-all-cost sentiments. These very sentiments are partly to blame for the crisis in healthcare spending (projected to surpass 20% of our GDP in the next quarter century!) that our nation faces today. The bottom line = we spend too much on dramatic end-of-life care that is high cost-low impact. Why not spend your dying moments at home with your family and friends in peace? Why suffer an unnecessarily “violent” death in the hospital? It seems clear, doesn’t it?

Somewhere between “duh” and “no duh” lies our ability to approach healthcare reform in a rationale way. Things seem so obviously fractured yet we, as the general public, continue to accept things as they are. To borrow quotes from a friend and a mentor, silence = consent and if we’re not at the table, then we’re on the menu. Now is the time to use our voices together and to sit at the table. Look forward to continuing this dialogue with you and “imagineering” real solutions that serve everyone’s needs, not just those who are (financially) benefiting from the way healthcare in the U.S. is delivered.

Cheers, Jaywon