NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

chronic disease

The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease:  The Power to Prevent, the Call to Control.   On the summary page we learn some shocking statistics:

  • “Chronic diseases cause 7 in 10 deaths each year in the United States.”

  • “About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”

  • “More than 75% of health care costs are due to chronic conditions.”

Shocking, that is, in how misleading or even false they are.  Take the statement that “chronic diseases cause 7 in 10 deaths,” for example.  We have to die of something.   Would it be better to die of accidents?  Suicides and homicides?  Mercury poisoning?   Infectious diseases?    As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.

The second statistic is a head-scratcher.  Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally.   Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.”   Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI  > the 95th percentile, which of course is mathematically impossible.

More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one?    Are they counting back pain?   Tooth decay?  Dandruff?   Ring around the collar?    “The facts,” as the CDC calls them, are only slightly less fatuous.   For instance, the CDC counts “stroke” as a chronic disease.   While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says.  Indeed it is hard to imagine a more acute medical event.

They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition.   Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death.    “Chronic disease” implies a need for and response to ongoing therapy and vigilance.  If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.”  And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”

Continue reading “The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending”

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Last week’s announcement by the American Medical Association’s (AMA’s) council on science and public health cheered me. It said that the AMA should not designate obesity a disease, because doing so was unlikely to improve health outcomes and because the most widely utilized obesity metric — the body mass index or BMI — was simplistic and flawed. It’s a reasonable and principled stance, which should have been the first clue that it was doomed.

The AMA’s board and delegates proceeded to snatch defeat from the jaws of victory by ignoring their own scientific council and labeling obesity as a disease. To be clear, the decision is almost purely symbolic; it has no legal force or authority, but it does up the ante in the debate with insurers and employers over what care elements should be covered and reimbursed. In other words, this is about money. Obesity: the new ATM for the health care system.

I’m just curious about where physicians have been for the past, oh, thirty years. Since 1980, as Americans have morphed into the fattest culture in the history of Western civilization, physician supply per 100,000 population has increased about 50%. Per capita medical care spending has increased from roughly $1,100 to over $8,400. 1980 was also the last time that roughly half of US adults were normal weight. Now, only about a quarter of American adults have a normal BMI.

Were US physicians blindfolded as they encountered patients growing incrementally larger with each visit? Were they keeping their mouths shut about the obvious — gee, I really think you should get out for some walking and limit the snacks — because they were awaiting a chance to make more creative use of ICD and CPT codes?

Continue reading “Obesity and the AMA”

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“Speed kills,” warns the traditional highway sign about the dangers of haste and traffic deaths. Now, we know that stress kills, too.

Toxic stress, at any rate. The human body’s response to normal amounts of stress—say, a bad day at the office—is likely to be brief increases in the heart rate and mild elevations in hormone levels. But a toxic stress response, stemming from exposure to a major shock or prolonged adversity such as physical or emotional abuse, can wreak far more havoc.

In children, science now shows that toxic stress can disrupt the developing brain and organ systems.

The accumulated lifelong toll of stress-related hormones sharply raises the risk of chronic diseases in adulthood, ranging from heart disease and diabetes to depression and atherosclerosis.

Thus, the message from a panel of experts to the Robert Wood Johnson Foundation’s Commission to Build a Healthier America was at once simple and challenging: Create a healthier environment for—and increase coping mechanisms and resilience in—the nation’s most vulnerable and stress-ridden children and families.

At a June 19 meeting in Washington, DC, the commission heard testimony from a child development specialist, an economist, and community development professionals, among others. Together, they described more of the social and economic effects of toxic stress, but also the evidence that significant investments in individuals, families and communities can turn the tide.

Continue reading “Toxic Stress”

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Robert Pear wrote in the Times that the refusal by “states to expand Medicaid will leave millions of poor people ineligible for government-subsidized health insurance…[1]” Indeed, the refusals will do that, as well as worsen what instead should be remedied. In the following I present a graph of two chronic diseases over the 50 states. Those states which have opted out of the Medicaid expansion are identified. Additionally each state’s poverty rate is indicated. The take-away is that populations in greater need are being further disadvantaged. A conjecture is presented as to why.

Please understand that refusal to expand Medicaid is not about state expenditures. Over the ten years, 2013-2022, every state would gain far more than it would spend for expansion [2]. Were all states to opt-in, the total ROI for the states combined would be almost 10,000% ($8 billion state expenditures in return for $800 billion federal).

Empirically health is associated with income, so if you’re poor you’ll likely have worse health. Also it’s well known that chronic conditions are often comorbid, that if you have a chronic disease, you probably have more than one. Additionally, chronic disease is a major contributor to total health care costs. Continue reading “Letting the Data Speak: On Refusing Medicaid Expansion”

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According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.

In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.

We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.

And so does the obesity epidemic.

Continue reading “Unscience”

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The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.

The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.

But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.

In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.

That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.

Continue reading “The Only Way Out of the Health Care Wilderness”

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Now here is a novel idea to save lives and stop the cancer plague; stop trying!  Sounds as crazy to me, as it does to you, but this idea actually may have merit.  Some smart people are saying that we have spent too much money for little gain, thus it is time to give up and by retreating win more battles in the war on cancer, than by charging ahead.

The Cancer Prevention and Research Institute of Texas (CPRIT) is the second largest cancer research agency in the United States, after the National Cancer Institute, controlling a pot of $3 billion dollars, most of which funds basic science and clinical research.  At recent hearings, university scientists and leaders in biotech proposed that CPRIT cut back on the money it is pouring into laboratories.  As Professor John Hagan of the University of Texas proclaimed, “If people didn’t get cancer in the first place, CPRIT would accomplish much of its mission.”

This radical idea was echoed in a scary article in the September issue of Lancet Oncology, entitled “First do no harm: counting the cost of chasing drug efficacy.” This editorial reviewed data, which shows that between 2000 and 2010 many new cancer drugs produced marginal extensions in survival and simultaneously increased risk of treatment associated death and side effects. The Lancet authors emphasized the vital need as we develop new therapies to carefully measure both benefit and harm before FDA approval and for careful post-marketing follow up after drugs are released to the general population.

Now in reality no one is saying that we should shut down cancer research labs and simply hope for the best.  Eventually we will completely cure this disease and basic science, as well as the development of new therapies, is key to that future. Perhaps what we should hear from these words is an idea about a different balance in health and healthcare.

Continue reading “Stop Cancer Research?”

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Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

Continue reading “Rational Rationing vs. Irrational Rationing”

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We are entering the season of presidential politics, of bunting and cries of “What about the children?” and star-spangled appeals to full-throated patriotism.

So here’s mine: Do you count yourself a patriot? Do you care about the future of this country? (And while we are at it, the future of your hospital.) If so, bend your efforts to find ways to care for the least cared for, the most difficult, the chronically complex poor and uninsured.

“But we can’t afford compassion!” Wrong, brothers and sisters, we cannot afford to do without compassion. “But why should we pay to take care of people who can’t take care of themselves?” Because we are (you are) already paying for them — so let’s find the way we can pay the least.

The problem of the overwhelming cost of the “frequent fliers,” people with multiple poorly tracked chronic conditions, has always been that the cost was an SEP — “somebody else’s problem.” Now, increasingly, hospitals and health systems are finding that they are unable to avoid the crushing costs of pretending it’s not their problem, are not being paid for re-admits, and are finding themselves in one way or another at risk for the health of whole populations. They’re also facing more stringent IRS 990 demands that they demonstrate a clear, accountable public benefit.

At the same time, employers and payers are realizing that they end up paying the costs of the uninsured as well as those of the insured who are over-using the system because they are not being tracked. These costs become part of the costs of the system, and the costs are (and must be) shifted to those who do pay. There is no magic money well under the hospital.

Continue reading “Save the Country with Preventive Care”

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The Danish government’s now infamous “fat tax” has caused an international uproar, applauded by public health advocates on the one hand and dismissed on the other as nanny-state social engineering gone berserk.

I see it as one country’s attempt to stave off rising obesity rates, and its associated medical conditions, when other options seem less feasible. But the policies appear confusing. Why Denmark of all places? Why particular foods? Will such taxes really change eating behavior? And aren’t there better ways to halt or reverse rising rates of diet-related chronic disease?

Before getting to these questions, let’s look at what Denmark has done. In 2009, its government announced a major tax overhaul aimed at cushioning the shock of the global economic crisis, promoting renewable energy, protecting the environment, discouraging climate change, and improving health – all while maintaining revenues, of course.

The tax reforms make it more expensive to produce products likely to harm the environment and to consume products potentially harmful to health, specifically tobacco, ice cream, chocolate, candy, sugar-sweetened soft drinks, and foods containing saturated fats.

Some of these taxes took effect last July. The current fuss is over the introduction this month of a tax on foods containing at least 2.3 per cent saturated fat, a category that includes margarine, salad and cooking oils, animal fats, and dairy products, but not – thanks to effective lobbying from the dairy industry – fluid milk.

Continue reading “Denmark’s Fat Tax”

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