Lumpkin calls for cultural change to improve health

Matt Burkhartt | Staff Photographer
John R. Lumpkin, senior vice president and director of targeted teams at the Robert Wood Johnson Foundation, delivers the morning lecture Friday in the Amphitheater.

New technological innovations in health care abound, John R. Lumpkin said in his morning lecture on Friday, and the United States is on the cutting edge. New techniques such as MRI-guided laser ablation for intracranial pathologies, which can remove formerly inoperable brain tumors, will save many lives. The U.S. leads the world in medical technology, but U.S. health and health care are relatively poor, Lumpkin said.

He should know: Lumpkin, a medical doctor, is senior vice president and director of targeted teams at the Robert Wood Johnson Foundation, the nation’s largest public health philanthropy.

“While we have the best medical science in the world, we don’t really have the best health care,” he said.

And despite relatively poor health and health care in the U.S., the nation pays dearly for medical care.

“We as a nation actually go into the hospital a little bit less than the average of the industrialized, more affluent nations, and we visit the physician and other care providers a little bit less than those in other nations,” he said. “But we do have, by and far, the highest cost for health care of any nation. Not by a little, but by a lot.”

Americans have a higher rate of mortality amenable to health care than other industrialized nations, Lumpkin said. The health care system is inefficient and rife with error. While the U.S. ranks highly at treatment of high blood pressure, cancer and stroke, and at controlling lipids, the nation ranks 35th in life expectancy, behind Costa Rica. And the U.S. ranks 34th in infant mortality, behind Croatia.

“I guess the good news is, is that we’re giving Hungary a run for their money,” he said.

The U.S. has the highest rate of diabetes in those under 20, and the highest rates of arthritis.

“And that’s for the nation as a whole,” Lumpkin said. “But these problems are compounded if you’re a minority or if you’re poor, to the point where your ZIP code may say as much about your life expectancy as your genetic code.”

Why does the U.S. do so much worse than other affluent countries?

“Every system is perfectly designed to get the results that it gets,” Lumpkin said, invoking Don Berwick. The U.S. health care system, he said, is perfectly designed to result in high costs and poor health outcomes.

The answer to this problem is not to advance medicine, Lumpkin said. Instead, he championed the power of cultural changes within and without the health care system.

CVS Pharmacy has committed to not selling tobacco products anymore, he said. As a result of health insurance legislation, 1 million Americans who did not have health insurance a year ago are insured today. Technologies that allow users to monitor their health using smartphones and other devices, giving them better communication with doctors and more awareness and control over their health data, are popping up all the time, Lumpkin said. Google is working on a contact lens that monitors glucose for diabetics, and new smartphone apps allow users to do everything from tracking and recording their body temperature to performing single-access electrocardiograms.

Such innovations require different models in the health care system, Lumpkin said.

”Right now, the only way clinicians are paid is if you come in that office, and they actually see you,” he said. “So we need to find a way to make this kind of virtual visits financially sustainable. Changing the payment system to reward clinicians for doing that instead of providing obstacles.”

On the lower-tech end of cultural changes to health care, Lumpkin cited examples of “walking school buses” to encourage kids to walk to school safely and community gardens to expand access to fresh fruits and vegetables. Programs like the Food Trust allow food stamp users to get double the value of food stamps on fresh produce, he said.

In closing the final morning lecture of the 2014 season, Lumpkin gave the audience a task.

“As you leave this area, this beautiful Chautauqua, and as you think about how easy it is to walk from one place to another, and you go home to your own communities, bring that back with you,” he said. “When you think about how easy it is to eat healthy and engage in other kinds of healthy activities, bring that back with you to your communities.

“Because when every community is created and structured in such a way so that every policy has a health consideration, we truly believe that we can then, as a nation, achieve a culture of health.”


Q: How is the Robert Wood Johnson Foundation using its endowment, or using its investing to support the culture of health?

A: Thank you. The Robert Wood Johnson Foundation has been in existence for over 40 years. It’s the largest organization devoted to promoting health and health care for everyone living in the United States. When we periodically reflect on how we’ve done, and the changes we’ve been able to reflect, we’re beginning to think that we’ve had a dramatic impact. Before we got engaged in the field of long-term care, palliative care, there was no field. We’ve helped developed residencies and fellowships and that. We helped develop and support the hospice movement. But as we began to look back on that experience and on our experience with tobacco, we’ve begun to see that we were winning battles. But we weren’t winning the war. And we’ve stepped back and began to stayed focused on individual programs to building a culture of health. And we’re looking at new ways where we’ve got program manic areas called “bridging health and health care.” Because that’s critical. We have other program areas related to building demand for healthy places and practices because we’ve seen experience where policy changes at the top get resisted by people in communities because people don’t bother to talk to them. And so we’re looking for many different ways to use our resources in a broader extent. But our effort is to create the conditions where communities can adopt the culture of health. We cannot build a culture of health in every community in this country. But through our research, demonstration projects and demonstrating that it can be done, we create the basis for every community, to have people get together and have people focused on health.

Q: With the U.S. ranking so low in health stats, what nations rank at the top and what are they doing right that we’re not?

A: Well, the Scandinavian countries are actually ranked higher — Germany, a number of the European nations. And some of the things that they do is spend money on nonmedical determinants of health. They pay more attention to the availability of fresh fruits and vegetables. They pay more attention to having healthy communities. I think that we as a nation can make that fundamental change. We look to where they are doing the best in the world. But one of the things that I’ve learned in my many years in government, you’ll go to lawmakers and they’ll go, “That’s fine. But that’s Germany. That’s Scandinavia.” So we have to learn the best from other countries and apply it here and demonstrate that those approaches can work here because we know that they can.

Q: How will we pay for the technological innovations and reduce the health care costs at the same time?

A: Wisely. So, this is where it’s really critical and one of things that I think is undervalued in the Affordable Care Act is the development of what is called clinical effectiveness research. There are medical innovations that are introduced that are not necessarily dramatically different for everyone than what’s currently in place and costs significantly less. We need to change the equation that we don’t use things just because they’re new and better — in fact, those things have adverse impact. Take antibiotics. Every time a new antibiotic comes on the market the drug company wants everyone to use it. What happens is that the bugs become rapidly resistant to those antibiotics. A wise approach to that would be, much as the military does: you know, in the opening rounds of battle, they don’t shoot everything they’ve got. They leave something in reserve. All of these new antibiotics need to be held to the exact circumstances where, based upon resistance, they can be used specifically to make a difference. And I think if we look at our innovations and we look at our new technology, and not restrict it, but use it in a way that’s the most effective, so that we can have the best outcomes, is a way to control cost.

Q: You talked about sharing medical data. Do the same rules apply to mental health?

A: Absolutely. First of all, let me share one of my biases about mental health. We have this division that’s very sharp in our country that’s between mental health and “physical health.” We’ve had some advances, although it’s been poorly implemented in the Affordable Care Act and the Tech Act that’s moved to the point which what’s called “mental health equity.” In other words, insurance companies ought to pay for mental health services the same way they paid for someone who has diabetes or heart disease. But the differentiation between mental health and physical health is a fabrication. As we learn more and more about how the brain functions we find actual changes, epigenetic changes in the brain due to life experiences — or imbalances that exist. And we see that there’s an extension. And if we can get rid of the stigma that’s often associated with mental health, we can begin to collect the data and see what are the environmental factors, what are the chemical factors in the brain that lead to mental illness and what are the interventions. Schizophrenia is perhaps the best example. Schizophrenia can actually be prevented. There was a program that was developed in Maine where they took young men and women in their early teens and 20s who were showing signs of schizophrenia and they were able to get them into treatment early before their first psychotic break. And the majority of those individuals never had their first psychotic break. So as we learn more I think we can do more.

Q: Have you thought more about how public relations and advertising can be used to get the message out? And how do we counter the effects of what we call corrosive advertising which lead us into bad habits?

A: Those are two sides of the same coin. We need to get smarter in the clinical world and were beginning to do that as foundation as we carry forward with our effort to effect social change. We know that attack ads are very effective. But what’s even more effective is hearing information from your neighbors, from your friends and from people that you trust. And so we have to start thinking about the movements, and that’s the reason that we’ve changed sort of what we’re doing. We’re looking at the policy components of it. The FDA recently passed new regulations recently for school lunches. So that potatoes aren’t considered a vegetable and meeting the requirements. And pizza, or ketchup. To get sugar-sweetened beverages out of the schools. Now this is a big challenge for schools, they’ve had to take out their fryers and put in steamers, and many districts have had some financial woes related to doing that. And there’s been some pushback. As the schools have adopted further regulation, there’s been some pushback. And what happened was there was some parents who began a social media campaign to complain about the food. Kids at school complaining about food? That’s news. Truth in matter, we just did a survey: 70 percent of students within those regulations think the food is just fine. What we need to do and what we should have done in that process, was to prepare the ground for that policy change. To get parents and students engaged in that policy change. And we learned this with tobacco. The best way to get students engaged in not smoking was to actually get them engaged and empowered with the movement. And where we did that they movements were much more effective. So we need to use social media, we need to use the regular media, we need to use media in order to get the message out and recognize that we have to counter and we have to do it smarter.

Q: Who in the United States, what communities are doing [this] right?

A: The first thing we did was develop a concept of the culture of health. Let’s find some communities that we can hold up and look at. We didn’t find any. We found wonderful communities like New Orleans, which after Hurricane Katrina has looked for ways to integrate their health care and mental health services in the community. We found communities in North Carolina that were doing outreach and reaching out to the students and getting them engaged in health. There’s a group of pediatricians in Alabama who are working to change the environment for fresh fruits and vegetables and who are working to getting kids engaged in doing their own gardening. And so we began to see the demand for all of these things in different places. We just think the challenge is, like I said before, is to bring it all together. And that’s going to be a part of the effort. So the good news is we’re not starting from scratch. The challenge is that we need to bring the learnings from every place in the country where innovations are starting to address health as a social issue. Bring those all together and share the learnings in every community.

Q: And how are you doing that?

A: Part of it is we’re going and getting messages out. We’re looking for groups of smart, engaged, committed individuals like here, and we’re sharing our message. But we’re also media, we’re using social media, we’re engaged in programs that identify communities that we have to award that we call (the) Culture of Health Community award. And we award that to five to 10 communities every year that have demonstrated progress toward building a culture of health. And we engage in health policy research and we publish that research so that people can see potentially what can work. And we fund a lot of evaluation of our program and others program to demonstrate an evidence base.

Q: When you present your message to different types of political groups if you sense a conservative audience or a liberal audience, do they hear you the same way?

A: Surprisingly no audience hears us the same. Because everybody has come to this point in their lives in a different way. They have a different set of life experiences. The challenges in a community in the South Side of Chicago, versus the one in Woneka, is totally different. But each of them have their own challenges in coming to a culture of health. And I think that’s the critical component, is that we craft a message, we provide the resources, the toolkits that communities can use, so that each can address a culture of health in the same way.

Q: And do you ask for proposals in certain areas and are you now saying, “If it doesn’t treat the whole, we’re less interested?” How does that work?

A: Well, the Robert Wood Johnson Foundation has been invested in philanthropy, and this is something we’ve been developing in the last 20 years. Twenty years ago if you would have came to the foundation and asked one of our staff members, “What business are you in?” the answer would have been “grantmaking.” Today, or at least I hope today, the answer would be “social change.” We’ve moved fundamentally away from “send us all your good ideas and we’ll see you through something interesting that we can find.” And if it’s in the area of improving healthcare quality we’ll be funding some programs we’ll be saying, “Here’s the fundamental social change that we’re trying to achieve.” For instance, one of our strategic objectives was that by 2015, that we will reverse the rising tide of childhood obesity. Well, when we look at programs now we want to see how they fit in in making the kind of social change, impacting the sugar-sweetened beverage consumption. Are they working with community development organizations to see if they have safe routes to school. And we’re looking at those things that line up strategically with the direction that we’re going. And that is the basis of our selection of programs.

Q: Why do we attribute death to tobacco use when the Japanese smoke five packs a day and live longer than Americans?

A: I was in Japan about 20 years ago and there were a couple of things that struck me. One was the vending machines they have for sodas, and the cans were teeny-tiny. People walk in Japan. People eat more healthier foods. They eat more fruits and vegetables. Pretty much there is nothing in your life where one single thing is going to kill you — except tobacco. One out of 3 people that use tobacco will die prematurely from it. And when you add in our high salt diets, our high intake of calories, our lack of exercise, it becomes truly a deadly killer.

Q: Does the Robert Wood Johnson Foundation have a comment to make about the inclusion of GMOs in our foods?

A: No. That has not been an issue that we’ve addressed, and we’re very focused on activities where were focused on building a culture of health. And one of things that we’ve learned very early on is that we cannot boil the ocean. And we can’t address every single issue.

Q: Do you have a perspective of fraud and abuse in the health care system?

A: Yes, it’s bad. We’re not sure what percentage is related to the cost and care of fraud and abuse. The studies that we have founded have shown it to be a relatively small percentage. But when you talk about a small percentage of a 2.6 trillion dollar industry it becomes significant. But, at least in my experience, looking at the Medicaid program, most of the fraud and abuse is by the provider, not by the recipient. So we need to be very careful about that.

Q: There are many questions about dramatic change to the health care system, there are questions about the single-payer system, there are questions about if we have to keep the same system and just modify it, there are questions if whether or not we’re going to have problems as long as we are in a for-profit situation in the health care system.

A: Yes. Let me unpack that: We have a health care system which is a for-profit health care system and it drives a fair bid in the innovation that we see. It also drives some of the excesses and some of the fraud that we’ve seen in some of the abuses. There is some very good work that is done by the Dartmouth Health Atlas, where they’ve looked at a comparison of communities. In communities for certain types of surgery, the strongest variable leads to increased care, that leads to increased utilization is how many surgeons are in a community. And on the same hand, do we think that a single-payer system makes a lot of sense? When my wife was in solo practice, one physician, she had one full-time person that did nothing the whole time but fill out the bills. Because every bill had to be filled out separately to every insurance company. That cannot be good use of our national resources. But one of the things that I’ve learned from working in the emergency department to state government, is, when working in government, reality comes up to you and smacks you right in the face. And sometimes you can’t miss the opportunity to grab something that helps advance the cause, because you know something else would be so much better. I don’t think we have a political environment where a single-payer system is a viable option. I think it’s great that people continue to push for it because we need to know what is possible. But remember the situation we’re in right now. If this were the situation today, the Affordable Healthcare Act would not be passed. I am a believer in incremental progress as long as you keep your eye on the goal.

Q: The money that is gaining the increased percentage of our GDP, where is that money going?

A: We’re talking about something that is approaching about 20 percent of our total economy. Hospitals and health care in many communities are the single largest employer. You go to communities outside many of the major cities, there’s huge industries that are built. Some goes to profit, but a lot goes into medical research. So it’s a complex industry and its no different than any other industry in this country, and that’s why the major focus of this industry ought to be the health of the nation, and not just be the better treatment for the illness.

Q: If it’s not the standard of culture yet, how do we as patients go in and create that in our community?

A: There are two ways: acting individually and acting as a group. Acting as an individual, you have to ask questions. We’ve put up a website in which we call, and one of the things is that if you go to that website there is something called “flip cards.” These are cards that are designed to be put in a waiting room so people are sitting out there can make a choice — “I want to talk about my heart,” or “I want to talk about my sexual problems.” So that you can take that card with you in your visit and you can give it to the clinician so that when you go in there people many times are overawed, their issues can be raised. That’s what you can do individually, but collectively we need to change the incentives. And there are incentives in the Medical Care Act for patient-inspired medical homes. And we need to expand that. Not just in medical homes, but patient-inspired clinical homes, whether they’re physician led or nurse-led clinics. We need to look at that by creating the conditions in which the change to more patient-centered care can occur.

Q: Our public schools allow the opportunity to reach so many people across the country and provide physical health. How do we bring back physical education, provide health food and innovate in all schools?

A: I learned two quotes that sort of center me with dealing with issues around the education system: The first is that “it is easier to change history than it is to change the history of the department.” And the second is that “It is easier to move a graveyard that to change the curriculum.” Having said that, really we’re talking about social effort and social change. And that means the schools change from having physical education every day to the situation we are in now. And it took generations for that to occur. And it will take generations for it to change back. And that means those of us that need to take the time to sit in on school boards. You’re selected or you volunteer or you get elected. It means those that are on those school boards can be educated, can get information, can have people on the community to raise the issue. It all requires commitment. And this is the kind of commitment that goes on, day to day, in communities across the country, and one of our goals in our foundation is to provide the evidence base so that they can make the arguments about how important this change is. Because despite the fact that we have this increase in anti-science movement in this country, we also think that there’s a fundamental and fertile ground for evidence-based policy, if enough of us get behind it.

— Transcribed by Mark Oprea