China - Blog IV

Thursday night I was scheduled to have dinner with my friend Gao Qiang, who until last year was China’s Minister of Health. He no longer has day-to-day management responsibility but continues to have significant involvement in health policy. He called to say he had meetings related to the earthquake so he needed to cancel our plans. I completely understood.

We were able to get together for a brief visit on Friday morning. He had only had two hours sleep the previous three nights. He said the entire government was focused on the rescue effort.

I was also able to spend time with Wan Gang, Minister of Science and Technology. We had met at the Third Strategic Economic Dialog last December but this was our first opportunity to spend time getting acquainted. We reviewed the existing relationship between HHS and the Ministry and laid out some areas where we have additional common interests.

During the middle of the day, I took a short break to attend a program at an International School on Internet Safety for Children. My wife Jackie volunteers full time for the ikeepsafe Foundation. The foundation has developed a book about internet safety using an Olympic Game theme and the book launch was held at the school. One of their sponsors has arranged to place several thousand copies of the book in schools.

The afternoon was spent in more meetings with government officials. I spent a productive hour with Minister Li and his Deputy Minister Wei. They reviewed with me plans they have to ensure food safety for the Olympics. It was rather extraordinarily detailed and well coordinated. The essence of the plan is if you touch any food during the Olympics as a restaurant, supplier, or processor, or transporter then you have to register and agree to certain standards. They have developed a tracking system that is the most elaborate thing I have ever seen. I can’t recount every component of the system but it includes GPS tracking of every truck carrying food, traceability of ingredients and an incident reporting system. I told Minister Li that if he could pull half of it off, his organization should be given a gold medal in food safety.

We also spoke at length about the progress on the implementation of our Memorandum of Agreement on food safety. We are making steady progress.

After our meeting, my good friend Vice Minister Wei arranged for us to see the Olympic park. What a treat that was. We went to a building where they display scale models of each venue. It was well presented. We then drove to several parts of the park so we could see the venues from close range. They are spectacular. The visit rekindled many of my Olympic feelings from 2002 when my home state of Utah hosted the Winter Olympic Games.

China will be stretched to manage the final preparations for the games and the earthquake recovery at the same time. It brought back memories of our Olympic preparations. The Olympics were only a few months after 9/11 hit. Suddenly the nature of the 2001 games changed. We would become the first major world gathering after the attack. Many were concerned that terrorists would use the Olympics as a target. We beefed up our security arrangements considerably during the final three months.

I rushed back to the Embassy to do a news conference. Regrettably, I was caught in Beijing traffic, which is simply unbelievable. I was about a half an hour late and that always makes me uncomfortable. The journalists were patient and seemed to understand the traffic problem. Most of their questions focused on import safety issues. There were 18 reporters there.

My final meeting of the day was dinner at Ambassador Sandy Randt’s home for members of my delegation. It was a terrific evening. Ambassador Randt has lived in the region for much of his professional career. He and his wife Sarah have been in China several times, starting in the 1970s. He also lived in Hong Kong for many years, speaks the language and is a terrific relationship builder. He is remarkably able and likeable; all good qualities for an Ambassador.

Our dinner conversation focused on China’s place in the next quarter century and a comparison of the unique challenges our respective countries face to maintain our economic momentum. We talked about the challenge of entitlement spending in the United States and the various disparities China will need to manage. It was an interesting conversation.

The best part of the evening was a conversation we had about music that we grew up with. Each of us named songs that took us emotionally back to our adolescence and the associated memories. My song was Strawberry Fields Forever, by the Beatles. It reminded me of sitting at a small drive-in on the outskirts of Loa, Utah where our ranch is located. I would go there on summer evenings to order food and play songs from the Juke box.

We all shared great memories. It was a terrific way to get to know each other.

Shanghai, China - Blog III

Traditional Chinese Medicine

I had planned to be with Minister Chen at a medical college where they teach Traditional Chinese Medicine (TCM). I have written before about my interest in this subject. I brought Dr. Josephine Briggs, who heads the Center for Complimentary and Alternative Medicine at the National Institutes of Health. Our purpose is to stimulate some scientific cooperation on how Western medicine can be informed by TCM.

We visited a large new hospital about an hour outside the Shanghai city center. It had 750 beds and is connected to the Medical School. We visited three departments at the hospital: the pharmacy, a general ward and the acupuncture center. At the acupuncture center, the management of the hospital had very cleverly identified some of the patients with Utah ties, people who had lived there during the time I was Governor. We walked through three small rooms and observed the treatment of a dozen patients for things ranging from knee problems and bells palsy, to infertility.

Afterward, we gathered in a conference room to ask questions of the medical staff. I find it rather easy to grasp the portions of TCM related to medicine. They use naturally grown plants in combination to produce a therapeutic result. The components obviously have active ingredients that have some impact on the human body. Over the years they have developed patterns of what works in various situations. Diagnosis is done through a form of observation and intuition.

TCM deals with concepts that are thousands of years old, and involves assessment of more than physical well being. It strives to find balance within the various systems of the body. I don't understand all of it, but I think it is important to respect that their approach is different than ours, and to acknowledge there may be a lot we can learn. In medicine, it is important to understand why something works. It appears to me in TCM, it is only necessary to believe something works. What I hope we can do more of, is applying scientific methods to understand why Chinese methods work. Blending knowledge from the two should be our goal. We are working on a Memorandum of Understanding to do just that.

I will admit that what I learned about acupuncture-aided surgery went over the top for me. They do major surgery with the patient awake and alert using acupuncture instead of anesthetics. I didn't see an actual surgery, but they had clips of video.

The difference between TCM and Western medicine typifies the challenge of working cooperatively with the Chinese; two different philosophies and two different systems. Neither should attempt to change the other, but rather to make our systems interoperable.

I spent about an hour at a TCM museum, which was helpful in understanding the history and philosophies. I found it helpful to see the development throughout a few thousand years. They also had a group of students who talked about the teaching techniques used in training TCM doctors. It is critical to remember this is a method of treatment hundreds of millions of Chinese prefer. They don't trust Western medical techniques.

Secretary Leavitt tours a Traditional Chinese Medicine Museum in Shanghai

Diplomacy Speech

The most pleasant part of the day for me was a diplomacy speech I did at the medical school with 300 students. My goal in the hour we had together was to make friends with them. I told them about me and my family. Then I told them about my job. After that, I let them just ask questions about anything. It was great fun. They asked me about TCM in the U.S. We talked about the Olympic Games. I told them stories about when my state hosted the games. We discussed health costs in the U.S. I was very candid about my concerns. They asked me for advice on how to succeed in life. I gave them some thoughts about goal setting.

I concluded my talk with the students by talking about why I meet with students like them. It is to plant seeds of relationship between our countries to help each of them know us better and for us to understand them. The students responded well, and we talked for an hour, but it could have gone much longer.

A Personal Curiosity

On the way back to the hotel, we stopped to see an animal display at the convention center. My interest was stimulated because a friend of mine, Ken Bearing, donated all the taxidermy. It is a spectacular display of African animals including an elephant, a 20 foot man-eating gator, a hippo and many others. It is displayed in a spectacular way. They have had over a million visitors since it opened a year ago.

On to Beijing

Tomorrow, it’s a speech to the American business community and then on to Beijing for meetings with various government officials.

Shanghai, China Blog II

No matter the culture, people get themselves messed up on drugs. Yesterday in Shanghai, I visited a methadone clinic in Xi portion of the city. That apparently means "west side." It's the older part of the city. I've visited similar clinics around the world, so the physical layout and process wasn't a surprise. However, I was able to talk with a couple of the patients at some length.

They are now serving about 175 addicts. Each day, they come to the clinic, check in, (often taking a urine test to demonstrate they have kept their commitments), pay the dollar co-payment they make, and then proceed to a counter where they are given a green liquid drink in an 8 ounce plastic cup. They gulp it down, followed by a water chaser. It appears to be a ritual they follow each morning.

A male patient, who I estimate was 30 years old and whose Chinese name I wasn't able to catch, told me methadone has a bitter taste. However, he welcomes it. A jolt of bitterness appears to be a welcome trade for the angst heroin addicts endure dealing with the drug’s slavish pang. Through our interpreter, he explained he is a factory worker and has a family. He seems like so many other factory workers who live out their lives in Shanghai. I wanted to know more about him, and how he had found his way to this point, but a crowd had gathered and the intimacy of our conversation disappeared.

A woman, whose Chinese name sounded like Julie, (I'm sure it was something else--my ear for Chinese is poor), told me how glad she was to have broken the grip of her addiction. She appeared to be in her early 20's and wore stylish tight fitting jeans and giant pink sun glasses. Her teeth were stained in way that seems common here.

Julie told me she had a job now, working at a clothing store. "I don't have to worry about finding money for my habit any more."

"Do you feel better physically," I asked.

"Yes, and my Father says my face looks good again," was her response.

I asked how she felt when her body craved heroin. She described achiness, nausea and her entire body shaking uncontrollably." What an awful plague heroin is.

She was persuaded to seek help at the clinic by a volunteer who knew she had a problem. Addicts know addicts.

Secretary Leavitt signs a message in a book of patient stories at a methodone clinic in Shanghai

Bi-lateral Meeting and the Earthquake in China

My friend, the Minister of Health for China, Chen Zhu, had to cut short the day we had planned to spend together so he could get to the scene of the earthquake in Chaendu. We had a poignant conversation about this moment of crisis.

The Chinese government is not unfamiliar with, or unprepared for, this kind of disaster. In 1976, a similar earthquake killed 242,000. They have mobilized their army and civil society. Minister Chen was anxious to be on his way. It was gracious of him to host the meeting under those circumstances.

We had a significant list of agenda items, which we moved through in about an hour. Most of the items relate to the agreements we have or are negotiating on a range of issues.

Business takes longer in diplomatic meetings of this type because of language interpretation. I have found it is important to break my thoughts into short bits. Good interpreters have the ability to mimic your expressions and voice inflections, thereby providing insight into attitude as well as content. For that reason, both sides normally supply their own interpreters.

Our meeting was held in the Shanghai convention center, a new facility which appeared to have a set up for such diplomatic meetings. The United States is not as good as many other countries at diplomatic hosting. We don't have budgets for it, and I would like to see us improve our approach.

Over the years, I have come to know the interpreters and staff for the various ministries. Having been with people from the health ministry many times now, there is a good sense of warmth and familiarity.

I also visited a large hospital and attended a museum to learn more about Traditional Chinese Medicine, but I will write more about that in my next post.

Shanghai, China: Product and Food Safety

Written May 12, 2008

Well, this blog entry will break new ground for me. I'm writing it with my Blackberry while striding up and down on a stair stepper in a health club overlooking Shanghai, China. Before you jump to any conclusions about my accuracy with thumbs, be aware I'm going to send this draft to my colleague in Washington and have her clean up my double letters and typos. With the day’s schedule it is likely the best, perhaps only, opportunity I will have.

Yesterday, I gave a speech to about 800 representatives of manufacturing companies from around the world who supply a major retailer in the United States, the Target Corporation. It was a significant chance to once again send the message that if producers desire access to American consumers; they will have to meet American standards.

I spent the afternoon with a local office of the General Administration for Quality Supervision, Inspection, and Quarantine (AQSIQ), a rough equivalent of a Chinese Customs and Border Protection. This is the entity in the Chinese government with specific responsibility for the safety and quality of imported and exported food. The people I met with had spent a significant amount of time in the United States, and understood our processes reasonably well. A half day is long enough to learn some essential facts, but not enough to draw conclusions. Most seaports have a similar feel around the world. Actually, most of the large unloading cranes are made in Shanghai.

HHS Secretary Mike Leavitt joined by Chinese inspectors looks at chicken shipped from the U S to the Port of Shanghai China's largest port

Not surprisingly, the Chinese see our concerns about the safety of food imports differently than we do. They repeatedly mentioned they require certificates before goods are shipped out of China, and point out we don't. They also want us to accept AQSIQ certificates as proof of the safety for Chinese food exports to the United States. I won't take that on in a blog, but it does indicate why it is important to understand the perspective of others. One learns a lot being able to talk with people on the ground.

I'm not going to get into a travel log, but there are a couple of observations worth making. This is an amazing city: incredibly vibrant and modern.

The Chinese are serious city-builders. They do infrastructure faster than anybody in the world, I think. They can just throw so many people at projects, and exercise such absolute social control, that they can move in a way that gives them a significant comparative advantage. In making that statement, I do not discount the negative environmental compromises, or the impact on human beings, but they have a clear set of priorities, and when they decide to move, things happen.

For example, they are building 150 miles of subway within the city in the next two years. Compare that to Boston’s Big Dig.

They decided to build a deep-water port about 18 miles off the shore of Shanghai on some islands. In order to get the goods from the port to the mainland, they needed a causeway. It will take them three years to build the causeway. It would take more than three years in the United States just to scope the work.

I was at the port when the earthquake struck. It was felt in the upper floors of our hotel, but not at the port. I visited the area of the earthquake last December. I am checking in at the White House to see if there are ways I can be helpful on behalf of the United States, and when I meet with the Minister of Health later today [Wednesday, May 13], I will express my condolences from all Americans for the loss of life here.

The disasters here and in Burma are frightening examples of how vulnerable we are as human beings.

Today, I'll visit a hospital and school of traditional medicine, and meet with a large group of students. Tomorrow, I'll meet with American businesses in Shanghai to discuss product safety, before I leave for Beijing.

Value-Driven Health Care Interoperability

I thought you might be interested in a brief report on our progress related to electronic health records (EHR). They are a critical element in making the health care system become value-based.

Just having electronic health records isn’t enough. The systems have to be interoperable. Interoperability means that different computer systems and devices can exchange information.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats. Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

The number of hospitals and larger physician practices employing electronic medical records has grown. However, we continue to have a serious challenge with small- to medium-sized practices where fewer than 10 percent of these practices currently have health IT systems.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

We are experimenting with different methods of changing the macro economics of reimbursement so that small practice doctors share the financial benefits.

We are also beginning a pilot program that provides Medicare beneficiaries with personal health records.

Finally, HHS is signaling that in the near future, payers like Medicare cannot reimburse doctors at the highest level unless they can interact at the highest level of efficiency.

A good example of this is e-prescribing. The software exists in nearly all pharmacies and in many doctors’ offices. It saves money and lives. It’s time to fully implement e-prescribing.

I’m hoping Congress will give HHS the ability to establish e-prescribing requirements as part of Medicare legislation in June of this year.

Learn more about Value-Driven Health Care.

Value-Driven Health Care

Over the last three years, I have been visiting different communities where groups have formed to pursue the measurement of quality. Generally, it has been a few curious doctors, convinced if they had a way to measure quality they could improve the outcomes. Other times, it would be a group of large payers looking for metrics that would allow them to negotiate lower prices. The best of these organizations however, are the places where all the stakeholders are working together.

The collective result of all these groups working independently was a large number of measures but not much standardization. Our progress was highly fragmented.

Great effort has been made recently among medical organizations, insurers, government, employers and unions to develop what I will collectively refer to as the “quality enterprise.” I’m referring to organizations like the National Quality Forum, the AMA Physician Consortium, the Ambulatory Quality Alliance and Hospital Quality Alliance and others.

I am a big advocate of this kind of collaborative stakeholder process. I think it is the best way to arrive at national standards. I often restate the commitment of HHS to adopt endorsed measures when they are available and to adapt our activities as they are adopted.

While progress is being made, gaining agreement on a modest number of uniform measures has taken a fair amount of time. Frankly, the process remains complicated and slow. Hopefully, it will gain speed as experience is gained.

However, we need standardized methods for quality measurement and very soon.

As health care’s largest payer, I believe HHS has a duty to push the envelope and I want to tell you about a project we have initiated.

HHS is in the process of doing an inventory of all the quality measures we are currently using someplace in HHS. We intend to harmonize the measures we are using, and then we plan to publish our set so everyone can see our current and planned measurement thinking.

I hope this will have the effect of accelerating the velocity of the quality standards process.

With standardized quality measures laid beside standardized price measures like I wrote about earlier this week, consumers will be in a position to make value the most rewarded virtue in health care.

Learn more about Value Driven Health Care.

Single Price Health Care

I often talk about the need to make “value of care” rather than “volume of care” the best rewarded virtue in health care. I want to elaborate on what I mean in using the word value.

A couple of days ago, I listened to a consumer report on CNN evaluating hybrid cars. The reporter was discussing an independent evaluation someone had conducted to determine the relative merits of several models. They had created criteria to hold each car against as a means of measurement. Then the price of each one was compared. The car that scored the best quality at the lowest cost was determined to be the best buy, or best value.

Given the proper information, consumers should be able to make similar comparisons on health care. Until recently, little information has been available for use by consumers. That is changing. Great effort is now being made to evaluate the quality of services a patient gets in different settings.

It takes both quality and price information to determine value. The problem in determining price is that the billing system is simply insane.

I’ve tried to imagine using the way we bill health care in any other part of the economy. To continue the automobile analogy, let’s just speculate on what would happen if we transformed the automobile industry to adopt the health care pricing structure?

The dealer would say to a customer, “We don’t really know the price and we haven’t got a way for you to compare this car for quality but we know you need it, so come in and we'll give you the car.”

Then about three weeks later, the customer would start getting bills. There would be a bill from the people who made the car’s body. Another bill would arrive from the transmission people. Everyday more bills would arrive from seat makers, the paint people, and the folks making the sound system.

Then when the bill from the dealer comes, there would be a charge for time spent in the show room, a separate charge for the salesman’s office with a $27.90 cent item for the coffee you drank while there.

Gratefully, they don’t sell cars that way. All those costs are packaged and managed by a car company. Consumers get one price they can understand.

Some of my friends in the practice of Medicine will find my analogy troubling, pointing out that health care and a car purchase have significant differences. Okay, the analogy isn’t perfect, but let’s not miss the point.

The way we price health care cannot be understood by a human being of average intelligence and limited patience. And I think it’s also time we began to challenge the assumption that health care is all that different from other things consumers buy.

For many common procedures and conditions, consumers should be able to ask for and receive a firm, single price, and expect providers to stand behind it. Such a system would promote coordination and accountability and allow apples–to-apples comparison.

It can be done. Last year, Medicare paid for 255,000 knee operations. Incidentally, we paid for 95,000 heart bi-pass operations and 95,000 lung cancer treatments. Believe me. When you pay for 255,000 of anything, you know what medical supplies, services, procedures and facilities somebody getting a knee operation is going to use; and so do the medical providers who perform them.

I believe HHS has a responsibility to push the envelope on this. We will soon publish information on top Medicare procedures by cost and volume as part of an efficiency measurement roadmap for the department. Medicare is also developing a demonstration that would establish bundled payments for hospital-based episodes of care.

Participating hospitals would be able to competitively bid for episodes, then savings would be shared with beneficiaries who choose hospitals providing services at below the per episode rate.

This not only holds the potential to improve quality and reduce costs by encouraging physicians and hospitals to work together, but also encourages more informed consumer decision-making.

Viet Nam – Blog IV

Today, I’ll finish the ten observations about Viet Nam I promised.

Observation Seven: The Viet Nam government appears to have taken the threat of Avian Influenza seriously. They seem to be doing what they can. Inherent in that observation is the acknowledgement that they don’t have the capacity to do much. However, I have now been in two small village areas in Viet Nam during different visits. The first was where a family of five contracted the virus. The second visit was in an area where H5N1 was in the poultry population. In both cases, I was impressed by the response.

On this trip I met Mr. Chien, who I’m guessing by the fact that he started in the chicken raising business 18 years ago, is in his late thirties. He appears to be a natural entrepreneur. He started with 200 chickens in 1991 and now has over 11,000.

We walked through his operation while he showed me how he vaccinates his chickens. He told me about the morning he found 100 out of 200 breeder hens dead. He didn’t know what it was, but he called a vet from the Province who determined it was avian influenza.

Vaccinating a chicken

We went back to his house where a group of his friends from the area had gathered to talk. I asked about how the village reacted when they understood what they were dealing with. Mr. Chein said, “Our children were afraid, and we were afraid for them.”

There is no question if the H5N1 virus begins to spread efficiently, person to person, all of southeast Asia is highly vulnerable including Viet Nam. However, we have a much better chance of catching it quickly there, than in other countries in the region.

Observation eight: There are promising signs that Viet Nam may have acted fast enough to avert a major spike in HIV/AIDS cases. Viet Nam is one of the 15 countries in the President’s Emergency Plan for Aids Relief. I’m told the decision was made to invest aggressively in Viet Nam because it looked like HIV/AIDS was just about ready to spike dramatically. Over the past four years, our investment has increased from $17 million to $88 million a year.

I was pleased to learn we are spending much of that amount on building infrastructure and people. The reports I received were quite positive.

I visited a clinic in a section of Ho Chi Min City where they are starting a program to focus on intravenous drug users. A high percentage of the HIV/AIDs in Viet Nam comes from the use of dirty needles. The approach is to help people stop drug use, hence having fewer risks generally. They use a system of peer educators; kids that have had a drug problem but overcame it. I spent about an hour talking with them. I saw the use of this technique in Africa. They have teams of people who are HIV positive trying to convince others to “know their status and get tested.” It seems very effective.

When I met with the Health Minister, we discussed the fact that rapid response HIV/AIDs tests are not being used in Viet Nam. I hope we made some progress in persuading them.

Observation Nine: The rapid increase in the price of food is becoming a big problem in Viet Nam. I mentioned in my blog entry on Indonesia what a problem the rising price of food has become. I simply hadn’t focused on this as an issue until this trip. Rice is now more than $700 a ton, more than three times the rate of five years ago.

Apparently there are many contributing reasons for the price going up. There is a growing problem with various pests and viruses that adversely affects the crops. Also, there has been a series of weather-related matters, which have been part of the problem too. This could become a major issue worldwide if it continues to develop.

Observation Ten: Viet Nam is a young country and I saw a disproportionate number of women emerging in leadership roles within the bureaucracy. I don’t know if that is true within the Communist party however.

More than 60 percent of the population is under 30 years old. As one moves around Viet Nam, it is highly evident. If they can find a way to educate this group and provide an economic system where they can succeed, the youth of their population is a huge asset because they are hungry to succeed.

I gave a lecture and answered questions at the Hanoi School for Public Health. It was a delightful hour. The students were more than willing to engage. Apparently attendance at the school is highly competitive with many applications for each slot. Again, it interested me that the group I spoke to was nearly three quarters female.