The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending

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.”

That brings us to the last bullet point.   Convention typically attributes more than 80% of healthcare costs to less than 20% of people, meaning that costly ailments are concentrated in a relatively small group.  Instead of this, the CDC’s data attributes 75% of costs to about 50% of the adult population, implying almost the exact opposite: the cost of chronic disease is widely dispersed.  Indeed, if you remove the rare diseases afflicting about 1% of the population but accounting for about 7-8% of cost, you come very close to parity between the proportion of the population with chronic disease and the proportion of total health spending attributable to chronic disease.

So What?

This urban legend, appearing verbatim more than a million times on Google, is among the single biggest causes of uncontrolled healthcare spending.

First, this statistic encourages employers and health plans to focus on the opposite of what they should focus on.  Penn State, citing this 75% statistic in their August 22 media advisory meeting as justification for its controversial wellness program, provides a classic example of this wrongheaded focus, with unfortunate consequences for the university’ reputation and employee relations, with no offsetting balance sheet benefit.     Overdiagnosis, overtreatment, and overprescribing are far more pressing issues in the commercially insured population than underdiagnosis, undertreatment and underprescribing in the name of “prevention.”  Regardless, the single-minded emphasis by employers and their benefits consultants on getting more employees to view themselves as chronically ill, or about to become chronically ill, contributes to medical overuse issues rather than addressing them.

Fanning these flames isn’t just a bad idea on its own.  It distracts employers from real issues such as provider pricing disparities, hospital safety, outliers (the small percentage of employees who really do account for half the cost–usually not due to a chronic ailment, though) and pharmacy benefit managers (PBMs), whose per-drug margins are about twice what they would be if anyone spent any time weed-whacking their obfuscations of rebates, implementation fees, etc. and simply negotiated the margin directly.  This whole misdirection brings to mind Peter Drucker’s lament that last frontier of good management in the American economy is the health care system.

Second, the implication that there is a 75% pot-o’-gold to be saved through prevention turns out to be anything but.  If you strip away the expenses of prevention and management itself (which represent a large proportion of that 75%), those aforementioned rare diseases, and unpredictable or uncontrollable exacerbations, you are left with about 7% of expenses fitting the category of events possibly preventable through wellness, even when wellness-sensitive medical event diagnostic code categories are defined broadly enough to include disease management-sensitive categories as well.  Achieving a 15% reduction in those categories – a feat rarely accomplished, which is why vendors never disclose this figure – would reduce overall spending by 1%, or about $60 per person or about one-tenth of the incentives commonly paid to employees to play along in these schemes.

What to do next?

It seems like all our posts end the same way:  stop poking your employees with needles.   We’ve analyzed wellness’s “ science,”  its math, its outcomes, its philosophy …and now its epidemiological premise.  Even as all their hokum has been debunked, the wellness industry has steadfastly refused to defend itself on this site or any other, because although many of the vendors appear to be incapable of critical thinking, they are smart enough to realize that facts are their worst nightmare.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

66 replies »

  1. You can always mix numbers and statistics up to create some kind of a rise. We’re all going to die at some point, the key is just to try and live our lives to the full and try to be healthy, get out running, eat well, lift weights etc. This is the key to long life.

  2. I think you do need to be careful what statistics are real and what are just written to cause a rise. Everyone needs to die of something and you’re hope it’s something painless and fast, right? The key is to stay healthy and continue daily walking, running, or weightlifting. You do that and you can extend your life quite a bit.

  3. “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.”

    This is one of the most idiotic paragraphs that I’ve read in a long time. By definition, chronic disease means that a person lives with a long-term illness that negatively impacts his or her quality of life. Chronic illness takes away both length of life and quality of life. I suppose we do all have to die in some fashion, but a long, happy life ended by a run-in with an 18-wheeler sounds preferable to a short life filled with pain and disability. Maybe healthcare is just as much about how one wants to live life as it is about how one wants to meet death.

  4. Believe it or not, there are vendors who say you’ll get an ROI overnight. Health Fitness Corp even says you get one before you put the program in place, if you intend to put one in place.

    Beyond that, I’m not sure of the relevance of a slide ending in 2004. Screens have a negative ROI — that math has been proven in Health Affairs. Extra PCP visits are a waste of money — just in JAMA. HRAs generate more testing, also drive costs up. If all 3 major wellness components drive up costs it stands to reason that wellness drives up costs.

    No legit academic journal has ever found savings from wellness and most find the reverse.

  5. With all due respect to Nortin Hadler, his statement reflects the common physician’s ignorance of exercise’s impact on both novel and conventional risk factors, as well as many of the other things I’ve articulated elsewhere in other comments.

    Death rates in the US have been in steady decline since 1960, and it is only lately that we have become concerned that the decline may stop or slightly reverse.

  6. Peter: we agree completely that helping employees avoid healthy behaviors is a worthwhile endeavor. Indeed, it ought to be the core of a wellness strategy, but it isn’t in most places. Instead, employers poke (yes, biometrics as part of wellness is most certainly a fad), intrude see our post about Penn State), and coerce (with financial incentives). Then, they send their employees into the clinic in pursuit of care that the overwhelming majority of people don’t need. Completely lost on employers are salients facts such as that most people hate their work; workplaces are desultory; employers talk a good game about wellness but then neither support exercise nor serve healthy foods at affordable prices; and, they make little or no effort to help people manage the major work-family conflicts in their lives. You want to help people engage in healthy behaviors, teach employers to fix THOSE things.

    Sending employees to the doctor is no more supportive of healthy behaviors than is me taking my son to the pediatrician for no rhyme or reason. He goes only when it is obvious he has a problem that time and OTC remedies won’t fix. Otherwise, he lives in a house with 2 parents who lead by example and surround him with healthful choices. He’ll be fine in the long term, because he’s come to believe that exercise and eating “good” food before “treat” food is just the way it’s supposed to be. That’s how you teach healthy living.

  7. “right now the fad is to line employees up to poke them with needles in order to give them some diagnoses. Somehow telling people that they are sick is supposed to create a culture of wellness.”

    Not sure about the “poking” but helping employees avoid unhealthy behaviors seems a good thing. Vic Khanna avoids unhealthy behaviors and he’s a 20 year old masquerading as a 50 year old or so he says.

  8. Weight Watchers or any other weight cycling organization/program is another example of a workplace wellness fad, so are treadmill desks (or, my personal favorite, giving executives mini-bikes to put under their desks and telling to pedal away the day), and health risk appraisals.

  9. right now the fad is to line employees up to poke them with needles in order to give them some diagnoses. Somehow telling people that they are sick is supposed to create a culture of wellness. Never mind that the USPS Task Force, JAMA and every other reputable group says we are already drowning in preventive medical care and screenings (The Doctor Weighs In just blogged on it today).

  10. “and the MANY MANY fads we keep hearing about, for the most part, dont.”

    What fads are in workplace wellness?

  11. I hear you. My POV, shaped through personal experience, is that taking care my own health has always given me the strength and vitality to accomplish other missions. In my book, Ten Commandments of Faith and Fitness, which I co-wrote with Pastor Henry Brinton, of Fairfax Presbyterian Church, we advance the idea that people of faith often simultaneously bemoan the state of the world and believe that they’ve been condemned to a particular state of ill) health.

    We encourage people to envision themselves as the most important tool in their health toolbox, recognizing that when they take even the simplest steps to help and heal themselves, that’s when they can really muster the energy to move up to helping heal their communities, families, career paths, etc.

    I don’t want to blame victims as much as I want to compel people to reject the victim mentality by seizing upon personal health as a cause for which they don’t need a conventional workplace wellness program. Rejecting incoherent government messaging is an essential place to start.

  12. Vik, from Hadler

    “Health adverse behaviors and cardiovascular risk factors may relate to the proximal cause of death, but they account for less than 25% of the hazard to longevity. This outcome explains why multiple assaults on health-adverse behaviors and cardiovascular risk factors have uncertain effects on mortality rates. They might change the proximal cause of death, but they do not alter its timing.”
    I am not arguing against the kinds of changes that are being discussed here – but only trying to put them into the bigger context of what it means to be healthy – they are part of the pie not the whole thing – Jon

  13. Vik,
    Of course I am in complete agreement with what has been said about worksite wellness – I was responding to and have written further somewhere up the chain in response to what I felt was a trend towards blaming the victim for their lack of “optimal health” as a result of their failure to do whatever it is we see as the healthy behaviors de jour – most of which are constantly changing anyway and that is something to me that is just as unhelpful as the coercive nonsense that passes for health promotion at the worksite – and in fact I would argue that their may more important things than exercise and fruits and vegetables anyway – not that they don’t count – I have already mentioned SES and economic disparity(and with one out of 5 children living in poverty in this country and lots more living very close – that is considerably more than just the tip of the curve) but also relationships, career-well-being (according to gallup the most important well-bring factor of all and why of course the current worksite approach is so damaging as well as ineffective), etc. – So, i did not mean to get away from the purpose of the original post but it seemed to have strayed quite a bit anyway and I was concerned about what I felt like I was hearing – hope that helps to clarify – Jon

  14. Hadler’s statement is unclear. Is he talking about clinical prevention, which is almost always cost-ineffective and often only of marginal value, if any, at altering outcomes or prevention outside the clinic, which as Abraham Verghese of Stanford has written are the ONLY things known to improve outcomes and lower costs. They are exercise more, eat well, and don’t smoke. I love Hadler, but he is a physician and speaks mostly of what goes on in the clinic.

    There isn’t any serious question that lifestyle impacts longevity, morbidity, and QOL.

  15. Peter, you did not read the statement carefully – This is from Dr. Nortin Hadler’s amazing book The Last Well Person – “Most prevention efforts may change the proximal cause of death but actually do little to change the length of life.” People can reduce the risk of MI doing those things – that doesnt mean they won’t have one – and many of those interventions are still quite controversial – For instance the latest research suggests that SFA have gotten a bad rap in terms of their effects on lipids and very low salt diets can actually make BP worse and cholesterol may have less to do with MI’s than we thought – (although many esteemed scientists never bought into that theory anyway) And then there was a recent article looking at mummy’s who were thousands of years old – way before Macdonalds and many of them already had atherosclerosis in their 30s and 40s. I have a PHD in exercise physiology and a masters degree in human nutrition and I am all in favor of moving and healthy eating for human health but there are no certainties when it comes to health and especially when it comes to nutrition the research is equivocal and ever changing and the one size fits all approach (especially one that focuses on vilifying the bad food de jour – which is likely to be different 6 months from now) in my experience is not scientifically defensible and impracticable and therefore unhelpful for most people – Coupled with the fact that SES and economic disparity overrun any of the other risk factors (as well as all of them together) that have been mentioned here – I am just trying to insert a bit of balance and “chill” when it comes to the complexities and uncertainties of living and dying – Some of what I hear on this thread has smacked of blaming the victim (people who don’t live the way we think they ought to) – and that is an approach I cannot support whether it comes from the medical community, the new age folks, the right, the left, the middle or anyone else – I have done all the things you discuss and more and I still have MS – Shall I spend a bunch of time blaming myself for something I must have missed, or do I get on with my life knowing that the universe and our lives are much more uncertain than we like to believe – Jon

  16. What you say is true, but the broad swath of the population falls under the bell portion of the curve. They account for most of the medical care spending, are the ones affected by the perverse and pervasively incorrect messaging of workplace wellness programs, and are the ones who have the most to gain by implementing the things that people are discussing in this tread (especially the simplest strategies). At the ends of the curve are the wealthy (who are the least likely to have unhealthy lifestyle habits and need the least help) and the poor (the most likely to have them and who need the most help).

    Unfortunately, this column was about the CDC and how it’s incompetent messaging has helped to promote workplace wellness programming.

  17. Actually, most people die of old or almost old age. 73% of all deaths in the US (2.5M per year) happen after age 65. So, most of us will make it to Medicare/SS age. The problem is that not many of us make it there healthy or have much healthful life to look forward to because we’ve been both nonchalant about taking responsibility and bought into things like the wellness industry’s obtuse messaging…”hey, just keep going to doctor as often as you can, because that’s really gonna make you healthier.”

    The medical care system will, of course, endeavor to keep us alive for as long as possible (it’s what we PAY them for).

    So, while it is true that death is not preventable, premature mortality (i.e., dying before expected based on population data and medical history) is preventable (or at least can be forestalled until much later in life) through the strategy you describe.

  18. Oh, I agree completely that the subsidy system is in grievous need of change. Not only does pronouncements like the CDC’s set people off in the wrong direction, the Congress, in its wisdom, has embarked upon outright harmful subsidy strategies such that, things like the USDA’s food pyramid and its successor, the MyPlate graphic, are political documents, not health guides.

    Absent changes in campaign finance and term limits, I don’t have an easy answer on how to break the cycle of subsidizing agribusinesses that should not any longer get financial support from taxpayers.

  19. Age clearly brings with it both physiologic changes and clinical decline, but they do not happen uniformly in aging adults, and fitness (specifically aerobic fitness) is one of the most important bulwarks against them.

    Further, in adults who maintain a high level of musculoskeletal strength, their ability to live independently is far greater than people who suffer age-related sarcopenia. Longitudinal studies of master weight lifters who continue to workout into their 70s and 80s show this quite clearly. Even though their rate of decline in muscle strength is the same as their non-lifting peers, they began their descent far stronger than their peers, and they maintain this edge, which attenuates loss of QOL.

  20. I would just like to inject a thought here – lest we forget – that all the interventions simple or not that are being discussed here – though they have some impact – pale in comparison to the effects of SES and especially economic disparity in terms of population health – Jon

  21. Re-introducing health and physical education into the educational system is essential. I am an advocate for having them as part of the core curriculum from pre-K right up through graduate and professional education. The idea that you should stop learning about how to maximize your health just because you’ve graduated from high school is absurd. We should find a way to help people embrace the idea of being ‘everyday athletes’ for their entire lives.

  22. I wish more people knew about the impact of exercise on mental health. As you point out, exercise is a critical antidepressive. I think that even many mental health professionals don’t know this. Nor do they understand that exercise not only make people feel better, it also makes them less bad (as measured on different mood scales).

    We may have to agree to disagree on the other impacts of exercise, because I think that they are substantially greater than you believe they are. Growing up as the son of a very mentally ill father, I can attest to the fact that, in the era long before Prozac and without any specialized knowledge at all, my father’s devotion to exercise was one of the only things that kept him tenuously connected to reality.

  23. Yes, at the end of the day, it is up to an individual to decide whether or not to make the effort to put lessons learned from population health data to use. But, when prominent government agencies, such as the CDC, spin data to suit political ends, you start to see people lose confidence about what to believe.

    This has made “health” a confusing and seemingly inaccessible commodity that everyone thinks they need specialized expertise to understand.

    Medical care is the commodity.

  24. Vik, Society does not support a healthy food system – it supports an unhealthy industrialized junk food system – with subsidies.

    ” I have never needed “society” or the medical care system to tell me (or reward me) to eat wisely, exercise, not smoke, or use alcohol in moderation.”

    Lucky you (and me) but many people need help – especially reducing weight.

    “My awareness and diligence (admittedly not common) has led me to, at age 55, have the strength and vitality of someone 20 years younger than me. Even if it does not prolong my life beyond what the actuarial tables say, my quality of life has been stellar.”

    Just hedging your bets Vik?

  25. I strongly recommend that you take a look at the work of Steve Blair and Tim Church, both formerly of the Cooper Institute in Dallas, where data from the long-running Aerobics Center Longitudinal Study continues to produce important insights. What’s powerful about the ALCS data is that it’s not an interventional study but a longitudinal analysis of a population to discern differences in morbidity and mortality, and it uses actual measurement of aerobic fitness (not self reported activity time, which is tripe).

    Blair, Church, and colleagues have shown repeatedly that fitter people live longer and use fewer medical care resources and the benefits of fitness transcend body composition (i.e., a fitter overweight/obese person has lower m/m than an unfit one and even than an unfit normal weight person), co-morbidities, etc.

    Actually, I don’t think that you and I disagree. I am totally supportive of doing the SIMPLEST things…eat modestly, exercise extravagantly, don’t smoke, and use only a little bit of alcohol. These are the simplest things because they are doable completely outside the framework of either government or medical care bureaucracies. If you don’t want to do them, don’t, it’s your choice and your loss. You are completely correct that people are confused; a lot of this confusion comes from the fact that the wellness industry has managed to make people think that “health” is a medical product, which it is not.

  26. I dont want more – Im just pointing out that the simple things work, and the MANY MANY fads we keep hearing about, for the most part, dont.

    Im also pointing out that even these simple things work less well than you would hope – perhaps not even well enough to be worth bothering with if they make you unhappy.

    So they are not “all it takes” – they are all that are available, and even if you manage to follow them (which most people don’t, even when they try – sustained changes in behaviour are really very hard to achieve and very rare) what will happen in terms your healthy aging and lifespan is a dice that is already cast.

  27. Indeed, and what obviously happened here was that the authority spoke what it knew people wanted to hear. Whenever that happens, any hope of critical thinking goes out the window, and the echo chamber takes over.

  28. Why do I need “society” to support my personal pursuit of health outside the clinic? I have never needed “society” or the medical care system to tell me (or reward me) to eat wisely, exercise, not smoke, or use alcohol in moderation. I have done so my entire adult life because it makes me feel great, and has led me have almost zero interaction with the medical care system. My awareness and diligence (admittedly not common) has led me to, at age 55, have the strength and vitality of someone 20 years younger than me. Even if it does not prolong my life beyond what the actuarial tables say, my quality of life has been stellar.

    Preventing workplace accidents is an ergonomics/OSHA/worker’s comp issue, not wellness. Would you seriously entertain giving wellness vendors any control over the issue of carcinogens in the workplace? I wouldn’t. Drinking and driving and safer cars are not “wellness” issues in the space we are talking about, which is a series of assertions by a leading government agency that were wrong and helped to propel the current headlong rush to garbage-time workplace wellness programs. They are public health initiatives, and they have been wildly successful in ways that workplace wellness charlatans cannot even dream of. See: http://khannaonhealthblog.com/2013/03/05/wellness-is-risky-business-part-one/

    You may regard that one line as “stupid” (most wellness vendors and disease-specific advocates would agree because it skewers their mythology), but it is the most important line in the essay. Wellness, whether its a personal strategy or a workplace that bans both cigarettes and sugary soft drinks, is a strategy that can, at best, just help someone hedge their bets. You are going to die of something eventually, although, as a group, Americans are living longer than ever and age-adjusted death rates have fallen by about 40% since 1960 (which is not to say that they could not have fallen more with wiser policies or that the population’s current lack of fitness might not stall the progress).

    The most important things that people do can to improve their health lives are the decisions they make every day. Both the macro environment and micro environments (home, workplace) obviously matter, as does socioeconomic status (easy to decry, not so easy to fix).

  29. “And balanced diet, no smoking, little alcohol and lots of exercise is about the sum total of the “proven” interventions.”

    What more would you want? If that’s all it takes then that’s what’s works, along with preventing accidents.

  30. “But absent those strategies, there is virtually no hope at all of healthy, successful aging.”

    For the general population on a statistical basis – NOT that those strategies don’t work, it’s just people don’t make them work – correct?

  31. I dont agree Vik.

    I dont think there is enough evidence that anything but the simplest interventions DO improve health or lifespan. In fact, most of the evidence is the other way – most large interventional studies show little or no gain from whatever the change was. The classic study was with a low fat diet – 30,000 women, 8 years on a low fat diet and NO reduction heart disease, cancer or overall mortality.

    It is cross-sectional studies that mislead – they show that people who are slim, fit and have healthy lifestyles enjoy much better health and lifespan than those that dont. BUT thats not the same thing as taking the unhealthy people and imposing a healthy lifestyle.

    In the end, the focus on “wellness” and taking control of our lives is making people miserable. Worse, it is making them disengage from ANY kind of healthy intervention because they are so overwhelmed with health advice from every side – mostly coming from flawed cross-sectional study designs.

    Thats why the message needs to be: focus on a few simple things that will change your outcomes A BIT, but dont WORRY about it if you cant because in the end it doesnt make that much difference.

  32. Sorry Peter – I see the confusion.

    The situation is that the things we are told to do to be “well” have very little effect. Most have none at all (eat less eggs, eat more fish and so on and so on) or at least have never been proven to have any effect. Thats a very different position from the “Wellness Fad” which suggests every subtle variation our lifestyle has impact one way or another.

    But thats not to say that you have no control over your health or lifespan. Most is pre-ordained, but a little is available for you to control (a bit). And balanced diet, no smoking, little alcohol and lots of exercise is about the sum total of the “proven” interventions. Thats it. Ignore every other bit of advice you get.

    Even these interventions have only a small effect. The only really WORTHWHILE change (one that pays you back enough benefit to be worth doing things you dont enjoy for!) is increased exercise to ward off depression. 30 mins moderate exercise a day decreases risk of depression by more than 50%.

    Hope thats a bit clearer!

  33. i think what David posted was the 80-20 rule of wellness. Controlling that small number of items will, in a population, be responsible for 80% of healthspan/lifespan improvement.

    I’m not even sure anyone else knows what the other 20% is — there are a lot of items in that other 20% (some excellent candidates for inclusion suggested in these comments) but there are also some that will prove to be wrong (remember when eggs and avocados were bad?) so David’s point is, just focus on the 4 we all know we should focus on. You don’t need HRAs and biometric screens to do those things.

  34. “Your claim that what most people die of is preventable is not quite true.”

    So, eating a low fat, low salt, low sugar, low calorie diet with regular exercise will not prevent cardiovascular disease? That heart attack will just come anyway?

  35. David, the impact of fitness (specifically, aerobic fitness) on premature morbidity and mortality is overwhelming. You can find my discussions of this topic here on THCB or check out my own blog.

    I actually think that the problem is the obverse of what you state: the problem is not that people overestimate what they can control it’s that they underestimate how much they can shift risk, but too many don’t want to do the work. Your last paragraph is a nice summary of what it’s all about. For the people who do those things, the data are quite clear that the upside potential is MUCH greater than the downside. Is it assured? Of course not. But absent those strategies, there is virtually no hope at all of healthy, successful aging.

    I liken it to the person who envisions a comfortable retirement but fears saving and then investing in the financial markets. It’s not a perfect strategy, and it requires some tolerance for discomfort as well as knowledge, skill, and effort, but it beats every other strategy out there, and it helps to tilt the cards in your favor.

  36. “All the evidence shows that we have very little control at all.”

    “So dont smoke tobacco, drink alcohol in moderation, eat a balanced diet controlling body weight/fat percentage, and exercise regularly. Beyond that, its time to disband the “wellness” myth,”

    David, I find your comment confusing, first we don’t have control, then you tell us how to get control.

    If wellness does not extend our years would it at least make our years more healthy?

  37. Mitch…stay tuned. I should have a column up soon on Big Sugar. Your closing thoughts are right on point. It is time to shift the dynamics of government policies that, along with the gibberish promoted by CDC, have helped to lead current state of affairs.

    Your personal strategy is also right on. I tune my own strategy to hew to what the American Heart Associations calls the characteristics of ideal cardiovascular health. They are four behaviors (exercise; a high quality, calorie-managed diet [your is but one way of achieving that]; maintaining a healthy body weight [achievable ONLY if you do the first two things]; and not smoking. Then, there are three clinical metrics: normal blood pressure, normal blood glucose, and normal blood lipids.

    In middle age and older adults, the difference in mortality between people with all 7 characteristics and those with 0 is 80%. So, in other words, if you manage all 7 seven elements of ideal CV health, you have an 80% lower risk of mortality than someone who does none of them. And, this does not even take into account the novel effects of diet and exercise (on things such as endothelial health and blood coagulability that we don’t measure for routinely) and things that we don’t know how to measure for at all, such as the epigenetic impacts and maintenance of telomeres and mitochondrial health.

    Those last two things are especially powerful because they are essential to, as you put, ensuring that health-span and life-span align.

  38. Back to the message: The Legend….The Myth. An authority speaks and statements are accepted. But the facts…the math…do not support the statements. “Just the facts, ma’am, just the facts.” I always especially appreciate the “mathematically impossible” zingers.

  39. Assuming that the solution is to 1)educate people on the impacts of the industrial revolution and how food scientists have destroyed our food supply. 2)educate people on tobacco, alcohol , balanced diet controlling body weight/fat percentage, exercise etc” , the real issue becomes health literacy. We don’t learn this stuff in school like phys ed. Providers don’t do this since the billing codes were non existent until recently. The payers or employers are paying for this. So we still need to answer the question “Who is going to be responsible for health literacy ” . The employer,payer , provider ? Any one of them will need outside help as “health care literacy” is not their core competency. Should we replace introduce more of these topics as part of our educational system and introduce an incentive system for healthy citizens ? How about a tax break if individuals above 40 keep their clinical indicators in compliance ? until we do things differently, the wellness industry are going to keep their piece of the pie.

  40. Wow, Im surprised reading these comments just how much 21st Century man (and woman) thinks they are in control of their own health and lifespan. Whether by healthcare (drugs, surgery) or lifestyle (diet, exercise).

    All the evidence shows that we have very little control at all. The reason this is an excellent article is because it exposes the entire “wellness industry” as a modern fad.

    Look at all the interventional studies on diet – I stress “interventional” (all the cross-sectional studies dramatically over-estimate impact, as discussed here: http://www.tcpinnovations.com/drugbaron/another-grim-day-for-big-science/). They show very small impact (or none at all) on rates of major diseases like heart disease or cancer, or on lifespan, from major interventions like lowering fat content, eating more fruit and vegetables and so on.

    Probably the only truly worthwhile wellness intervention is the impact of exercise on mental health. Regular exercise dramatically decreases depression and even more serious mental health problems, even in high quality interventional study designs.

    So dont smoke tobacco, drink alcohol in moderation, eat a balanced diet controlling body weight/fat percentage, and exercise regularly. Beyond that, its time to disband the “wellness” myth,

  41. As usual Al and Vik, excellent post.

    While there is the large issue of inefficiency and waste, and misguided wellness and prevention initiatives, the biggest issue I think is a combination of poor diet (primarily, not solely) and demographics; the population is aging. The sick care system deals with the symptoms, not their cause.

    My own hope is that my healthspan equals my lifespan. To do that I stay reasonably active (I walk 20 miles a week or so plus a little exercise) and am careful about what I eat, I am a paleo/primal guy. No grains, no sugar or other sweeteners, no legumes, almost no industrial or processed food. Very little alcohol. Works for me.

    We need to change the structure of food policy to discourage the consumption of healthier foods and subsidize more healthy options. We do it with tobacco and alcohol, why not high fructose corn syrup/sugar added anything just for starters?

    Absent this we are re-arranging deck chairs on the titanic.

  42. HI Mary,
    I am not sure if you are replying to my post – (right above yours) or to Al and Viks original – I have been doing worksite wellness for two decades and would be happy to make suggestions – let me know – thanks – Jon

  43. As luck would have it, a post similiar to this one just appeared on The Doctor Weighs In. While we talk about all the waste and over-focusing on prevention in the workplace, this post talks about how over-focusing on prevention hinders efforts in primary care. Same issue, different venue


  44. No mention of age here in any of these discussions. Last I checked we don’t have a fountain of youth, magic potion or pill, that prevents or reverses aging. Truth be told, all things wear out. Dependent on numerous factors both intrinsic and extrinsic in all the infinite combinations, we all wear out at different rates.

    So what is health? What is disease? What is chronic illness?

    In what situations, circumstances and the decisions we make actually help our patients?

    So where does age factor in?

  45. As usual your wellness posts are dramatic, well-reasoned and even humorous but we who are in this field and follow you need more guidance on what to do as opposed to what not to do. Surely someone out there is doing something worthy

  46. In our system, I have been a: clinician, analyst, regulator, advocate, political advisor, strategic planner, message developer, critic, and, in the cases of both my parents, a care director/manager.

    So, yes, my personal experiences run the gamut. I have seen and heard an awful lot, from the surgeon who once told me that he knew before he even entered an exam room what the patient’s insurance was (his charts had a special code on the cover, so that he could immediately refer Medicaid and uninsured patients out) to docs who knowingly and routinely put patients on lengthy treatment protocols even when they knew full well that the patient’s needs were not commensurate with the intensity of care. Why? Because it was reimbursable.

    We have built a house of horrors if you are not connected, savvy, extremely diligent, and somewhat belligerent. And a lot of that house is built of principles and aphorisms that are not worth the paper they’re written on.

  47. It’s funny because it’s true, sadly.

    Far too many of us have encountered such situations. Are you speaking from personal experience?

  48. Peter 1 – You may not like the “you have to die from something” line but it is an important one in this context. Your claim that what most people die of is preventable is not quite true. In fact, there is very little that we do in preventive medicine that increases longevity (see Dr. Nortin Hadler’s books). Most prevention efforts may change the proximal cause of death but actually do little to change the length of life. And the kinds of worksite interventions that are being discussed in this post do even less, because they end up promoting overdiagnosis and overtreatment which increases costs and is as likely to disturb health as improve it. And though your goals for prevention are laudable there are decades of evidence demonstrating that you don’t get to them through the coercive, incentive laden strategies that are all the rage today in the workplace wellness field. Aside from not improving health these approaches (Penn State as the latest example) end up decreasing employee engagement (leading to huge losses in creativity and productivity) and likely increasing employees stress related health complications – exactly the opposite of the well-meaning goals you are suggesting – Jon

  49. I received an email from someone who if you are a journalist and want to write a stoy on wellness, would speak not-for-attribution, but doesn’t want this comment traced to him for obvious reasons.

    Al, I’ve been forwarded your postings by [someone who knows both of us] and you need to do more. i work at Schlumberger in Cambridge, where wellness is considered a huge joke. (I noticed your posting on BP, where it appears to be an even bigger joke — they are one of our customers.)

    We lie on the forms to collect our $10 monthly insurance premium discounts. Lately they’ve started doing health fairs. I showed up at one and the tech spent 10 minutes trying to squeeze blood out of my finger and then the result came back that there was insufficient blood to give me results. They wanted to give me a tetanus shot becasue I forgot the last time I had one. I said I had an overseas trip scheduled in a few days and could they be sure there would be no side effects. “Absolutely none,” I was told…and then within 24 hours I got sick and missed my trip. [Al here: So much for wellness increasing productivity.]

    We have a gym here but we are only allowed to use it noon to 1 PM and after 7 PM because the idiots who designed it put it on the second floor and it bothers the person on the first floor right below it, who filled out a Risk Report and had us shut down. He refuses to move officies because it will increase the amount of distance he needs to walk to get to his lab.

    But we’re not allowed to say anything because wellness is next to Godliness here. They’ve created their own empire. So please help expose this.

  50. Most people just don’t “get sick”, they acquire illness usually over time from stuff, mostly preventable, in their life. Fixing the “stuff” is extremely difficult and not supported by society.

    In the 70s I read a book called the “Politics of Cancer” whose author (Dr. Samuel Epstein) said we already know what causes cancer, carcinogens in our environment, but no one wants to eliminate them as that would rub the wrong noses.

    The stupid line I hate is, “You have to die from something”, yes everyone dies , but when people find out they could have lived longer and healthier if the actions of people around them did not contribute, they rightly get angry.

    Preventing workplace accidents are not wellness waste, reduce/eliminate exposure to carcinogens is not wellness waste, safer cars is not wellness waste, drinking and driving enforcement is not wellness waste, eating better food is not wellness waste – preventing all the stuff other people cause is not wellness waste. But society never spends what it takes to fix the “stuff” because it seems to mostly affect the unseen “other guy” and there’s too much money to be made from not fixing it.

  51. Apologies for firewall. Write directly using the instructions on website if you want these for your own reaearch

    Also hu please take another looksee. It says a large percent is already due to prevention and mgmt. which is exactly what you are describing . Your vignette makes our point very well

    You also describe a patient at the other end with 5 admissions for renal failure. A workplace wellness program wouldn’t be any help there either

  52. Truly excellent piece. This is such an extreme mis-use of statistics, it deserves your harshly-worded deconstruction. And as you say, it is a misconception that is as damaging as it is pervasive.

    You guys may be interested to read my own piece on a similar topic entitled “Better drugs cannot cure healthcare system woes”: http://www.tcpinnovations.com/drugbaron/better-drugs-cannot-cure-healthcare-system-woes/

    The message is exactly the same: we spend billions on R&D to find better cures, bur the principal limitation in the health of the nation is how we use the tools we already have. The healthcare system is broken at many levels, not just in the US but in every major Western economy – and there are many different funding models behind them. The issue is not how we fund healthcare, but the drivers of increased spending with decreasing returns on that expenditure due to structural inefficiencies.

    Your articles does a great job in clearly highlighting that. Its a big tide to turn, but every small step helps!

  53. Very unsettling to read that chronic disease is not the biggest problem in health care when you are seeing 80 to 90% of patients in a primary care practice with chronic pain, diabetes, hypertension, heart disease, chronic lung disease, anxiety, depression and obesity and you are feeling overwhelmed trying to manage these conditions on a daily basis. Where is this person coming from?? How many people have they seen who have had 5 back surgeries are morbidly obese and have renal failure from their uncontrolled diabetes??

  54. Well-preserved in drugs and alcohol. 😉

    I guess I have good DNA. My dad lived to 92. Mom to 90.

    You could work me up until you found SOMETHING to code and bill for, I guess.

  55. Because the link guiding us towards the Wellness Sensitive Events paper has a firewall, can you cite some examples of ICDs or illnesses companies and policy folks might mistake for remediable, but do not respond to interventions. I would be interested in learning more.

    As you state above, because many conditions lie in a causal chain, ie, A causes B, and B causes C, and so on, “sensitive” can mean many things to many people.

    Also, for commercially insured folks, at least based on my experience–considerable–illnesses such at HTN and depression remain problems of underdx and underRx, just as much as the over set.



  56. @bobbyg

    Do you consider yourself well and if so, is it because you are a good preventer, or that you have good dna, or thatbyou have bot been worked up and over?

  57. Bobby: that’s a great Q&A.

    Our “health” care system is designed, as Otis Brawley has alluded, to take people in, chew them up, and reduce them coded, categorized, reimbursable entities. The thing about this that really stinks is that the government, in the form of the CDC, should have been helping to teach people how to stay out of the medical care machine, rather than, shoving them into it with deceit.

  58. ” Overdiagnosis, overtreatment, and overprescribing are far more pressing issues in the commercially insured population than underdiagnosis, undertreatment and underprescribing in the name of “prevention.”

    Q: “What’s the definition of a ‘well person?”
    A: “A patient who has not been adequately worked up.”

  59. Just like the HIT movement, prevention is not cost effective. That is why most insurance carriers do not cover any. It is a glorious concept for the dreamers but in reality, it is extremely costly for a year of life gained, if any.

    Prevention and HIT attract zealots who worship their programs as if religion. It ain’t all they proclaim it to be. Sort of the false facade and veneer.