As we look back over the past year and some of the amazing medical breakthroughs like wearable robotic devices, genomic sequencing and treatments like renal denervation that are improving people’s lives, it bears reflection on what else we could be doing better. Our world has changed more in the past century than in thousands of years of human history. We not only know more about our biology than ever before, but science and technology are unlocking the secrets of the very building blocks of our health. Somehow, in the midst of this incredible innovation, we’ve gotten fat, and not just a little. The result? Alarming rates of obesity and related chronic disease that threaten to crush us physically and financially.
But is it technology’s fault that we’ve become fat? A recent study by the Milken Institute that tied the amount an industrialized country spends on information and communication technologies directly to the obesity rates of its populations thinks so.
Most of us are guilty of a little overindulgence around the holidays but for many, overindulgence is a normal way of life. As economies transition to more sedentary, the physical movement that burned calories and kept us fit simply does not occur. Our lifestyles compound the issue — dual-income homes rely on the convenience of packaged meals, and our leisure activities have shifted to heavy “screen time” with movies, games and social media.
A trio of groundbreaking publications on healthcare came out this April. They are my required reading list for CEOs. First is a study published in last week’s Journal of the American Medical Association (JAMA) by Eappen and colleagues (including among them Atul Gawande). The study found infections occurred in 5 percent of all surgeries in an unnamed southern hospital system. For U.S. hospitals, this is not an unusual rate of error — even though it is about 100 times higher than what most manufacturing plants would tolerate. No automaker would stay in business if 5 percent of their cars had a potentially fatal mechanical flaw.
If that’s not bad enough, the second finding is where we enter the realm of the absurd: according to the study, purchasers paid the hospital to make these errors. Medicare paid a bonus of more than $3000 for each one of the infections; Medicaid got a relative “bargain,” paying only $900 per infection. But the real chumps were the commercial purchasers (CEOs, that’s you). Employers and other purchasers paid $39,000 for each infection, twelve times as much as your government paid through Medicare. Most companies could create a good job with $39,000, but instead they paid a hospital for the privilege of infecting an employee. How many good jobs haven’t been created so businesses can pay for this waste?
Most employers are far more hard-nosed about managing their purchase of, say, office supplies than they are in purchasing health care — even though, unlike healthcare, paperclips never killed anyone and no stapler can singlehandedly sap a company’s quarterly profit margin. Yet, according to the Catalyst for Payment Reform, only about 11 percent of dollars purchasers paid to healthcare providers are tied in any way to quality. The results reflect this neglect of fundamental business principles for purchasing: Quality and safety problems remain rampant and unabated in health care, while employer health costs have doubled in a decade. Continue reading…
The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.
It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.
Except when it doesn’t — and harms employees instead, which happens altogether too often.
Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.
I’ve been thinking about how to write this story for a long time. Should it be a book? A blog? A self-help guide? Ever since I realized I’d lost 60 pounds over the course of a year and a half, I knew I wanted to find a way to talk about it, and maybe help others. This is my first public attempt.
A note about the rounding of my roundness: My peak weight, shortly after I began weighing myself in 2010, was 242 lbs. My lowest weight since I started weighing myself has been 183.2 lbs — right in line with where I should be, at 6’3″ tall. I’m sure that I weighed more than 242 lbs. at peak, but frankly, I don’t care that I don’t have the data to account for those last 1.2 lbs.
Adam Davidson’s New York Times Magazine story, “How Economics Can Help You Lose Weight,” helped organize my thinking about how to finally write this. In his story, Adam explains that the rigid protocol his doctor puts him through acts as a kind of economic incentive for him to stay on the diet. I’m highly skeptical that the special liquid meals he can only buy directly through his dietician will help him keep off the weight. I tried all sorts of diets in the many years that I was overweight and though I never tried the Adam’s solution, it doesn’t sound like a recipe for long term success. At least twice, I lost weight and then gained it all, and more, back. (Meta note: I feel terrible writing that. Adam, I wish you the best. Maybe something you read here will help you keep off the weight you have already lost, and congratulations on that difficult achievement.)
Now that I’ve managed to make weight loss sound simple, and sound smug about my success (I’ve stayed within the 183-192-pound range for more than two years now), what’s my big secret? It’s data. Just like I said in the headline, I keep a Google Doc spreadsheet in which I’ve religiously logged my weight every morning for the last three-plus years, starting on January 1, 2010, when I knew I had to do something about my borderline obesity.
I find myself, probably like many of you, spending way too much time in front of my computer.
When I do face-to-face meetings, my colleagues and I typically met around some conference table, sometimes at an airport lounge (nothing like getting the most out of a long layover), and quite often at coffee shops (hello Starbucks!). But that means that the most common denominator across all these locations wasn’t the desk, or, the keyboard, or even the coffee. The common denominator in the modern workday is our, um, tush.
As we work, we sit more than we do anything else. We’re averaging 9.3 hours a day, compared to 7.7 hours of sleeping. Sitting is so prevalent and so pervasive that we don’t even question how much we’re doing it. And, everyone else is doing it also, so it doesn’t even occur to us that it’s not okay. In that way, I’ve come to see that sitting is the smoking of our generation.
While this may seem like a silly question, the Center for Science in the Public Interest (“CSPI”) has filed a petition with the FDA urging the agency to regulate the amount of sugar (including high fructose corn syrup) in soft drinks. According to the executive director of CSPI, sugar is a “slow-acting but ruthlessly efficient bioweapon” that causes “obesity, diabetes, and heart disease.”
If soft drinks are a problem, surely cupcakes are too. A twelve-ounce can of Coca-Cola contains 39 grams of sugar. A seasonally-appropriate red velvet cupcake from Sprinkles contains 45 grams of sugar—and who can eat just one? National cupcake consumption increased 52% between 2010 and 2011, and U.S. consumers ate over 770 million cupcakes last year. Sugary soft drink consumption, on the other hand, is down 23% since 1998 and 37% since 2000.
While the FDA can’t regulate sugar as a bioweapon, it probably could regulate sugar as a food additive.
Under the Food, Drug, and Cosmetic Act, a food additive is “any substance the intended use of which results or may reasonably be expected to result—directly or indirectly—in its becoming a component or otherwise affecting the characteristics of any food.” This broad definition would include sugar. The FDA does not, however, regulate food additives that are “generally recognized as safe” (“GRAS”). Presumably the FDA considers sugar to be GRAS—for now. Continue reading…
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.
A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state. The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index. It is a simple sum of the two numbers.
The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population. My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.
Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years. This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.
States with a Pain Index in the top decile are: Texas, South Carolina, Louisiana, Mississippi, and Arkansas. Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.
My advice to policy-makers: Get ready! My advice to health care CEOs: This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.
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.
Twenty years ago, in order to keep presidential candidate Bill Clinton’s campaign on message, James Carville hung a sign in their “war room” that read:
Change vs. more of the same
The economy, stupid
Don’t forget health care
While point number two swiftly entered the national vernacular, the other two slogans have equally influenced the U.S. political landscape, especially since 2008. Four years ago, the country was on the precipice of transformation. Meaningful change was promised, and opportunities for significant, long-lasting reforms were abundant. Americans, particularly the millennial generation, turned out in record numbers to vote, and hope for the future was palpable. America, like a patient suffering from a debilitating chronic disease, seemed finally ready to put in the time and do the hard work to get healthy before that fatal heart attack occurred. After decades of procrastination, we heeded Carville and health care system overhaul became a top priority.
Pause: The State of America’s Health
Obesity prevalence increased 137 percent over 20 years, from 11.6 percent to 27.5 percent of the population. In 2008, more than one-third of children and adolescents were overweight or obese. The medical care costs of obesity in the U.S. totaled about $147 billion in 2008 dollars.
Diabetes has almost doubled in prevalence since 1996, rising from 4.4 percent to 8.7 percent of the adult population. For children, the prevalence of Type 2 diabetes increased 21 percent from 2001-2009, while Type 1 diabetes rose 23 percent. Estimated total diabetes costs in the U.S. were $174 billion in 2007.
Asthma diagnoses grew by 4.3 million from 2001 to 2009, and 9.4 percent of children currently have asthma. Asthma costs in the U.S. grew from about $53 billion in 2002 to about $56 billion in 2007.