Category Archives: policy

healthy habits, musings, nutrition, policy, politics

Katz: The power of the possible in public health

 

The case for the power of the possible in public health is clear, compelling and data-driven. Were we to commit to the policies required to eradicate tobacco use, establish moderate daily physical activity as the prevailing cultural norm and turn healthful eating into the new “typical” American diet, we could eliminate 80 percent of all chronic disease.

http://www.huffingtonpost.com/david-katz-md/healthy-life_b_1176506.html

David Katz, M.D.

Director, Yale Prevention Research Center

 

What If? A New Year’s Public Health Reverie

Posted: 12/31/11 11:50 AM ET
 

Democracy, it has been said, is the worst form of government except for every other form. As the long season of our political discontent drags on, the liabilities of consensus-based governance are on prominent display, salient among them a perennial lack of consensus. The situation seems unlikely to improve as a new year dawns, for it is, after all, an election year.

All of which serves to deepen the longing I suspect we each have cause to feel for a world where what we believe should be done, reliably gets done. Since Plato’s “Republic,” we have acknowledged that the challenges involved in conceiving what would make the world better are the lesser impediment to enhancing our destinies. Navigating such ideas, ideals and aspirations through the gauntlet of democratic dissent and past the intransigence of the status quo is the greater. The execution step is where good ideas all too often go to die.

The unnecessary death of good ideas — and of people — is much on my mind as the new year looms, with its promise of fresh starts. For far too long already, a failure to turn what we know into what we do has cost us dearly.

The case for the power of the possible in public health is clear, compelling and data-driven. Were we to commit to the policies required to eradicate tobacco use, establish moderate daily physical activity as the prevailing cultural norm and turn healthful eating into the new “typical” American diet, we could eliminate 80 percent of all chronic disease.

Do take a moment to let that sink in. Statistics have the capacity to be stunning and dull at the same time. We tend to need faces and names to get our passions going.

So consider this. If someone you love has ever had heart disease, cancer, a stroke or diabetes — there are eight chances in 10 that better use of feet, forks and fingers would have prevented that adverse fate outright. Viewed from altitude, eight out of 10 of us who have suffered through the anguish of a serious chronic disease with someone we love — wouldn’t have had to if what we knew about disease prevention were translated into what we routinely do about it.

Health promotion is what I do, so such musings are vocational on my part. But I, too, have loved ones laid low by chronic diseases that need not have occurred. So this is up close, and intensely personal.

As the new year dawns, then, my thoughts are irresistibly drawn to what might be. What if knowledge were power? What if what we know became what we do? Preoccupied by such reflections, I indulge myself in a reverie. Here’s what I would do if I were the philosopher-king of public health in 2012.

I would declare that a flood of factors — from highly-processed food, to labor-saving technologies, to clever marketing of insalubrious products — conspires against our health. I would proclaim that every person, family and community deserves to be protected by a levee of empowering, health-promoting tools and programs. I would call on personal responsibility for making good use of such resources — but I would acknowledge that before people can take responsibility, they must be empowered. As public health philosopher-king, such empowerment would be my job.

I would eradicate tobacco use. This pernicious scourge has taken years from life and life from years for far too long already. Those currently addicted to tobacco would need authorization from a physician to get it, and would at the same time receive every assistance modern science can offer to help them quit. But the substance, and any marketing of it, would be banned for all others. No young person should ever again be seduced into this calamitous boondoggle.

I would make everyone a nutrition expert by putting an objective, evidence-based, at-a-glance measure of overall nutritional quality on display everywhere people and food come together, and thus close every loophole to marketing distortions. Then, I would attach to this metric a system of financial incentives so that the more nutritious the food, the less it costs. The incentives would not constitute a new cost, but rather an opportunity for savings. They would be paid by the entities that currently pay the costs of disease care — insurance companies, large employers and the federal government. The costs of subsidizing cabbage are trivial compared to the cost of CABG, so says the king (not to mention the world’s leading health economists). Incentivizing healthful choices could save us a lot of money. Everyone can win.

I would make physical activity a readily accessible and routine part of everyone’s day. This can be done in schools with programming that embraces the time-honored adage: sound mind, sound body. This can be done in a way that honors personal preference for different kinds of exercise. In my kingdom, every school would have such programming.

So would every worksite. And every church. And little by little, we would do the requisite hard work on the built environment throughout the kingdom so that every neighborhood and town was designed to take physical activity off the road less traveled, and put it on a path of lesser resistance. This would cost money in the short term, but save both money and lives over time. Until this job was done universally, we would not just wait on the world to change — but would provide those in acute need access to the oases of comprehensivehealth promotion that already exist.

Every school would teach children and their parents the skills required to identify and choose more nutritious food. Every cafeteria would be designed to encourage, without forcing, better choices. School food standards would be unimpeachable — and a slice of pizza would not qualify as a serving of vegetables.

Businesses would adopt schools (as they now adopt highways) to provide the resources required for state-of-the-art health promotion programming, and so that parents and children could get to health together. We are otherwise unlikely to do so at all.

Guidance to nutritious restaurant meals wherever they are available would be at the fingertips of all, in the service of loving food that loves us back. In my kingdom, we would not mortgage our health for the sake of dining pleasure — nor vice versa!

Robust economic modeling would be conducted to guide biomedical research so that it translated most efficiently into measurable and meaningful improvements in the human condition. In my kingdom, such data would drown out diatribe, epidemiology would trump ideology, and we would prioritize the practices subtended by the best data, not propagated by the loudest shouting or dictated by the deepest pocket.

In my kingdom, every clinician would be trained to be expert in lifestyle counseling, and serve as an effective agent of health-promoting behavior change.

We would construct a comprehensive sandbag exchange so that every one of us, no matter what we do or where we do it, could contribute to the levee. In my kingdom, no one would be part of the problem because everyone would be part of the solution. And as sandbagsaccumulate, we would gather evidence to know just how much needs to be done to turn the toxic tide of chronic disease. We would devise the tools needed to disseminate effective strategies, while honoring the need for local control and customization.

We would take patient-centered care to the next level by establishing a mechanism for participant-centered research, giving the true “beneficiaries” of biomedical research a chance to call the shots. We would shift subsidies and marketing from foods with the longest shelf lives, to foods that extend the shelf lives of the people eating them! We would pursue our health in conjunction with efforts to preserve the health of the planet. We would do what it takes to find ourselves eating food, not too much, mostly plants.

In my kingdom, we would do this, and more, until the 80 percent of all chronic disease we know we can eliminate were actually eliminated. Until forces that conspire against years of life, and life in years, were banished. Until eight times in 10, the phone did not ring with bad news; the ambulance did not need to be called; the anguished visit to the ICU or CCU did not need to happen. And then, we would figure out what we could do about the remaining two!

The best way to predict the future is to create it. We cannot create what we don’t first conceive. From Plato to Dr. Seuss, we have been invited to consider what the world could be like if the right people ran the zoo.

And yet we are right, of course, to renounce the tyranny of Plato’s philosopher-king — for tyranny it would be. Along with the absolute power required to implement good ideas at will comes the power to do the same with bad ideas — and it can, at times, be awfully hard to tell them apart. And then there’s the fact that absolute power corrupts absolutely. The benevolence of despotism is not to be trusted. Which leaves us thankful for our democracy — dysfunctional though it may be at times.

Still, it is vexing to stand at the gulf yawning between what we know and what we do. It is painful to concede that knowledge is not power. It is tantalizing to imagine a world where that translational divide is bridged.

And so I do. I ponder the power of the possible as the New Year dawns — and invite you to join me. We don’t need a philosopher-king to change the world, just a small (or preferably large!) group of thoughtful and committed citizens. That could be us. This could be the year. What if?

-fin

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz

healthy habits, nutrition, policy, politics

Fixing obesity :: Hard, yes. Complicated, no.

We are drowning in copious quantities of poor-quality (even willfully addictive) calories, and labor-saving technologies all too often invented in the absence of need. We have run out of time to see that this is like the other kind of drowning, a clear-cut case of calamitous cause-and-effect, albeit in slower motion, playing out over an extended timeline.

We could fix obesity. It’s hard, because profit and cultural inertia oppose change. But it’s not complicated. (And maybe it isn’t even as hard as we tend to think.)

As we look out at an expanse of bodies sinking beneath the waves of aggressively-marketed junk and pervasive inactivity, wring our hands and contemplate forming more committees — I can’t help but think we’ve gone right off the deep end.

 

http://www.huffingtonpost.com/david-katz-md/obesity-epidemic_b_3292179.html

David Katz, M.D.

Director, Yale Prevention Research Center

Fixing Obesity
Posted: 05/17/2013 12:05 pm
 

Earlier this week I spoke at a symposium on nutrition and public health at the Tuck School of Business at my alma mater in beautiful Hanover, N.H., Dartmouth College. Among others on the panel with me was Richard Starmann, the former head of Corporate Communications for McDonald’s. Those with even a modest number of Katz-column frequent flyer miles can readily guess how often he and I agreed.

One point Mr. Starmann made, more than once, was that rampant obesity and related chronic disease was enormously, intractably complicated and would require diverse efforts, a great deal of private sector innovation, minimal government intercession, lots of time, lots of money, and many conferences, committees and panels such as the one we were on to fix. I had trouble deciding where to start disagreeing with this one.

For one thing, if you have ever served on a committee, you likely know as well as I that the surest way to never fix something is to convene a whole lot of committees and panels to explore every possible way of disagreeing. Just look at our Congress.

But more importantly: Obesity is not complicated. And neither is fixing it. Hard, yes; complicated, no!

Before I make that case — emphatically — a brief pause to note the essentials of informed compassion. Yes, it is absolutely true that some people eat well and exercise, and are heavy anyway. Yes, it is absolutely true that two people can eat and exercise the same, and one gets fat and the other stays thin due to variations in genetics and metabolism. Yes, it is absolutely true that some people gain weight very easily, and find it shockingly hard to lose. Yes, it is absolutely true that the quality of calories matters, along with the quantity. Yes, it is absolutely true that factors other than calories in/calories out may influence weight and certainly health, including such candidates as the microflora of our intestinal tracts, exposure to hormones, GMOs, and more.

But on the other hand, once we contend effectively with the fact that we eat way too many calories, that “junk” is perceived as a legitimate food group, and that we spend egregiously too much time on our backsides rather than our feet — we might reasonably address only the remaining fraction of the obesity epidemic with other considerations. I am quite confident that residual fraction would be very small.

Which leads back to: We can fix obesity, and it isn’t complicated.

As a culture, we are drowning in calories of mostly very dubious quality, and drowning in an excess of labor-saving technology. I have compared obesity to drowning before, but want to dive more deeply today into the implications for fixing what ails us.

Let’s imagine, first, if we treated drowning the way we treat obesity. Imagine if we had company executives on panels telling us why we can’t really do anything about it today, because it is so enormously complicated. Imagine if we felt we needed panels and committees to do anything about epidemic drowning. Such arguments could be made, of course.

For, you see, drowning is complicated. There is individual variability — some people can hold their breath longer than others. Not all water is the same — there are variations in density, salinity, and temperature. There are factors other than the water — such as why you fell in in the first place, use or neglect of personal flotation devices, and social context. There are factors in the water other than water, from rocks, to nets, to sharks.

The argument could be made that anything like a lifeguard is an abuse of authority and an imposition on personal autonomy, because the prevention of drowning should derive from personal and parental responsibility.

The argument could be made that fences around pools hint at the heavy hand of tyranny, barring our free ambulation and trampling our civil liberties.

We would, if drowning were treated like obesity, call for more personal responsibility, but make no societal effort to impart the power required to take responsibility. In other words, we wouldn’t actually teach anyone how to swim (just as we make almost no systematic effort to teach people to “swim” in a sea of calories and technology).

Were we to treat drowning more like obesity, we would have whole industries devoted to talking people into the choices most likely to harm them — and profiting from those choices. One imagines a sign, courtesy of some highly-paid Madison Avenue consultants: “Awesome rip current: Swim here, and we’ll throw in a free beach towel! (If you ever make it out of the water…)”

If we treated swimming and eating more alike, we would very willfully goad even the youngest children into acts of peril. An announcer near that unfenced pool would call out: “Jump right in, there’s a toy at the bottom of the deep end! And don’t worry, the pool water is fortified with chlorine — part of a healthy lifestyle!”

I could go on, but you get the idea. But you also, I trust, have reservations. As you recognize that treating drowning like obesity would be ludicrous, you must be reflecting on why drowning isn’t like obesity. I’ve done plenty of just such reflecting myself, and here’s my conclusion: time.

The distinction between drowning in water, and how we contend with it, and drowning in calories and sedentariness, is the cause-and-effect timeline. In the case of water, drowning happens more or less immediately, and there is no opportunity to dispute the trajectory from cause to effect. In the case of obesity, there is no immediacy; the drowning takes place over months to years to decades. It’s a bit blurry.

Really, that’s it. If you disagree, tell me the flaw — I promise to listen.

We have the time perception of our ancestors, contending with the immediate threats of predation and violence on the savannas of our origins. We are poorly equipped to perceive calamitous cause-and-effect when it plays out in slow motion. One imagines viewing ourselves through the medium of time-lapse photography, and suddenly seeing the obvious: We topple into the briny, obesigenic depths of modern culture, and emerge obese. Cause and effect on vivid display, no committees required.

Consider how differently we would feel about junk food if it caused obesity or diabetes immediately, rather than slowly. Imagine if you drank a soda, and your waist circumference instantly increased by two inches. It likely will — it’s just a matter of time.

We generally deal effectively with cause-and-effect catastrophes that have the “advantage” of immediacy. One obvious exception comes to mind: gun violence. If the “pool lobby” were to address drowning the way the gun lobby addresses gun violence, the solution would somehow be more pools, fewer fences, and no lifeguards. But that will have to be a rant for another day, so let’s not go down that rabbit hole.

Instead, let’s flip the comparison for a moment. What if saw beyond our Paleolithic perceptions of temporality, recognized the cause-and-effect of epidemic obesity and chronic disease, and treated the scenario just like drowning?

We would, indeed, rely on parental vigilance and responsibility — but not invoke them as an excuse to neglect the counterparts of fences and lifeguards. We would impede, not encourage, children’s access to potentially harmful foods. We would avoid promoting the most dangerous exposures to the most vulnerable people.

We would recognize that just as swimming must be taught, so must swimming rather than drowning in the modern food supply and sea of technology. We would teach these skills systematically and at every opportunity, and do all we could to safeguard those who lack such skills until they acquire them. Swimming is not a matter of willpower; it’s a matter of skill-power. So, too, is eating well and being active in a world that all too routinely washes away opportunities for both.

Your “eye for resemblances” is likely as good as mine, so I leave a full inventory of all the anti-obesity analogues to defenses against drowning to your imagination. They are, of course, there for us: analogues to lifeguards, fences, swimming lessons, warnings against riptides, beach closures, personal responsibility and vigilance, public policies, regulations and restrictions, and a general pattern of conscientious concern by the body politic for the fate of individual bodies.

The only real distinction between drowning in water and drowning in calories related to causality is time. One hurts us immediately, the other hurts us slowly. The other important distinction is magnitude. People do, of course, drown, and it’s tragic when it happens. But obesity and chronic disease affect orders of magnitude more of us, and our children, and rob from us orders of magnitude more years of life, and life in years.

No one with a modicum of sense or a vestige of decency would stand near a pool, watch children topple in one after another, and wring their hands over the dreadfully complicated problem and the need for innumerable committees to contend with it.

We are drowning in copious quantities of poor-quality (even willfully addictive) calories, and labor-saving technologies all too often invented in the absence of need. We have run out of time to see that this is like the other kind of drowning, a clear-cut case of calamitous cause-and-effect, albeit in slower motion, playing out over an extended timeline.

We could fix obesity. It’s hard, because profit and cultural inertia oppose change. But it’s not complicated. (And maybe it isn’t even as hard as we tend to think.)

As we look out at an expanse of bodies sinking beneath the waves of aggressively-marketed junk and pervasive inactivity, wring our hands and contemplate forming more committees — I can’t help but think we’ve gone right off the deep end.

-fin

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

complex adaptive systems, data saving lives, healthcare, healthy habits, management and leadership, nutrition, policy, rapid learning health systems

Health Care Value

There’s a lot of good buried in this post, but it’s all starting to sounds like the development of a perfect map… not that inspiring.

The data is already there. At a national level, it can be used to inform a national increase in health funding… functioning like a CPI.

——-

Michael Porter defines value as “health outcomes achieved per dollar spent.” … An efficient business gets the most output possible, given current technology, from every dollar spent.

Porter and colleagues adapt microeconomics to health care through their definition of output: patient-centered health outcomes. These are results that individual patients desire: survival, speedy and uncomplicated recovery, and maintenance of well-being over the long term. These are also things that clinicians, payers, and purchasers should seek for their patients, employees, and customers.

The value movement’s definition of outcomes treats the patient as a whole person, insists that measures of outcome transcend disease-specific indicators to account for all of the patient’s conditions, and include data collected over time and space to produce comprehensive measures of patient well-being. Value proponents further insist that inputs be measured comprehensively to include all the costs of producing desired outcomes.

Widely adopted, the concept of value would provide a north star toward which health care providers could navigate.  Its emphasis on the whole patient and comprehensively measured costs would encourage teamwork among clinicians and coordination of care across specialties, clinical units, and health care organizations. The focus on patient-centered outcomes would support increased effort to measure patient-reported outcomes of care, such as their level of function and perceived health status over time.

[…] the lack of data systems to support outcome measurement.  Producing the holistic assessments needed requires the aggregation over time and space of data from multiple clinicians and health care organizations, as well as patients themselves. The health care system’s electronic data systems are just now entering the modern age.

To turn the promise of value measurement into the reality of better care at lower cost, a few short-term actions seem prudent. First, the nation needs a plan to turn the concept of value into practical indicators. Since government, the private sector, consumers and voters all have a vital stake in health system improvement, they should all participate in a process of perfecting and implementing value measures, preferably under the leadership of a respected, disinterested institution. The Institute of Medicine comes to mind, but others could be imagined.  This process should produce an evolving set of measures that will be imperfect initially but improve over time.

Second, both government and the private sector need to invest in the science and electronic data systems that support value measurement. Investments in systems should focus on speeding the refinement of standards for defining and transporting critical data elements that must be shared by patients, providers, and insurers to create patient-centered outcome measures.

 

 

http://blogs.hbr.org/2013/09/getting-real-about-health-care-value/

via

http://www.commonwealthfund.org/Blog/2013/Sep/Should-Value-Be-the-New-Mantra-in-Health-Care.aspx?omnicid=20

Getting Real About Health Care Value

by David Blumenthal and Kristof Stremikis  |   12:15 PM September 17, 2013

Words can spearhead social transformation.  Let’s hope that’s true for “value” in health care. Where other mantras – such as quality or managed care – have failed to galvanize the system’s diverse stakeholders, value may have a chance.

What seems special about the term is that, seemingly simple, it is actually complex and subtle. Under its umbrella, a wide range of interested parties can find the things they hold most dear, from improved patient outcomes to coordination of care to efficiency to patient-centeredness. And it is intuitively appealing. As Thomas Lee noted in the New England Journal of Medicine, “no one can oppose this goal and expect long-term success.”

The question, of course, is whether the term will help spur the fundamental changes that our health care sector so desperately needs. In this regard, a closer examination of the value concept confirms its appeal but also exposes the daunting challenges facing health system reformers.

Michael Porter has defined value as “health outcomes achieved per dollar spent.” Any survivor of introductory microeconomics will hear echoes in this phrase of one basic measure of economic efficiency: output per unit of input. An efficient business gets the most output possible, given current technology, from every dollar spent.

Porter and colleagues adapt microeconomics to health care through their definition of output: patient-centered health outcomes. These are results that individual patients desire: survival, speedy and uncomplicated recovery, and maintenance of well-being over the long term. These are also things that clinicians, payers, and purchasers should seek for their patients, employees, and customers. The value movement’s definition of outcomes treats the patient as a whole person, insists that measures of outcome transcend disease-specific indicators to account for all of the patient’s conditions, and include data collected over time and space to produce comprehensive measures of patient well-being. Value proponents further insist that inputs be measured comprehensively to include all the costs of producing desired outcomes.

Widely adopted, the concept of value would provide a north star toward which health care providers could navigate.  Its emphasis on the whole patient and comprehensively measured costs would encourage teamwork among clinicians and coordination of care across specialties, clinical units, and health care organizations. The focus on patient-centered outcomes would support increased effort to measure patient-reported outcomes of care, such as their level of function and perceived health status over time.

Promising as it is, the emphasis on value also raises illuminating and challenging questions. The first is: why all the fuss with defining it? In most markets consumers define value by purchasing and using things. In the 1990s, personal computers had considerable value. We know that because consumers bought lots of them. Now, with the arrival of tablets, personal computers seem to be losing value.  And so it goes for untold numbers of goods and services in our market-oriented economy. Eminent professors don’t wrack their brains defining the intrinsic value of electric shavers, overcoats, or roast beef.

We need to define the value of health care, however, for a simple but profound reason explained in 1963 by Nobel-prize-winning economist Kenneth Arrow. Arrow showed that health care markets don’t work as others do, because consumers lack the information to make good purchasing decisions. Health care is simply too complex for most people to understand. And health care decisions can be enormously consequential, with irreversible effects that make them qualitatively different from bad purchases in other markets. Americans are therefore reluctant to let the principle of caveat emptor prevail. One reason to define value carefully and systematically is to enable consumers to understand what they are getting, an essential condition for functioning health care markets.

The compelling need for a good definition of health care value highlights another fundamental challenge. We have not yet developed scientifically sound or accepted approaches to defining or measuring either patient-centered outcomes of care, or – surprisingly – the costs of producing those outcomes. The scientific hurdles to defining patient-centered outcomes are numerous. Outcomes can be subtle and multidimensional, involving not only physiological and functional results, but also patients’ perceptions and valuations of their care and health status.  The ability of health care organizations to measure costs is primitive at best and doesn’t meet the standards used in many other advanced industries. Equally challenging is the lack of data systems to support outcome measurement.  Producing the holistic assessments needed requires the aggregation over time and space of data from multiple clinicians and health care organizations, as well as patients themselves. The health care system’s electronic data systems are just now entering the modern age.

Given the value of measuring value, and the current obstacles to doing so, still another urgent question arises: what should we do now? Despite recent moderation in health care costs, our health care system is burning through the nation’s cash at an extraordinary rate and producing results that, by almost every currently available measure, are disappointing.

To turn the promise of value measurement into the reality of better care at lower cost, a few short-term actions seem prudent. First, the nation needs a plan to turn the concept of value into practical indicators. Since government, the private sector, consumers and voters all have a vital stake in health system improvement, they should all participate in a process of perfecting and implementing value measures, preferably under the leadership of a respected, disinterested institution. The Institute of Medicine comes to mind, but others could be imagined.  This process should produce an evolving set of measures that will be imperfect initially but improve over time.

Second, both government and the private sector need to invest in the science and electronic data systems that support value measurement. Investments in systems should focus on speeding the refinement of standards for defining and transporting critical data elements that must be shared by patients, providers, and insurers to create patient-centered outcome measures.

Third, in consultation with consumers and providers, governments need to develop privacy and security policies that will assure consumers that their health care data will be protected when shared for the purpose of value measurement.

Last, and perhaps most important, the trend toward paying providers on the basis of the best available value measurements needs to continue. These payment policies motivate providers to use value measures to their fullest extent for the purpose of improving processes of care and meeting patients’ needs and expectation.

To some observers putting value at the forefront of health care reform may seem obvious and non-controversial.  As Lee notes, who can be against it?  To use an American cliché, it seems a little like motherhood and apple pie: comfortable and widely endorsed. But the value movement could be much more than that.  When value does become a well-accepted principle, we’ll be much closer to making health care better for everyone.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

data saving lives, entrepreneurship, healthy habits, musings, policy, quantified self, rapid learning health systems, technology

Location-based prevention services

OK, so here’s the idea:

Our physical environment is loaded with cues capable of triggering healthy and unhealthy behaviours…

  • walk past any take-away, and you might succumb to the call of a chicko-roll (or bottle of water)
  • approach the supermarket, and you might feel the urge to purchase a tub of ice cream (or bag of oranges)
  • do you take the escalator (or the stairs)

Rather than leaving it to fate, why not use a location-triggered message to steer away from temptation, and towards a healthy future.

The danger areas can be configured individually, crowd-sourced or pre-loaded, as can the messages.

healthy habits, policy

Health-Wealth effect…

Still, there is copious evidence around the world that obesity is a peculiar condition for poor people in rich countries. Less-developed countries have lower obesity, but in richer countries, there tends to be an inverse relationship between waistlines and bank accounts. It’s what researchers have called the “health-wealth” effect: Wealthier people tend to be healthier people. In the U.S., rich white women and poor black men have the lowest obesity rates (followed by rich white guys). America’s highest obesity rates by far are among poor minority women. A 2008 U.S. Department of Agriculture’s review of the effect of food stamps found obesity didn’t rise among children or men but did increase slightly among women.

 

http://www.theatlantic.com/business/archive/2014/01/where-does-obesity-come-from/283060/

Where Does Obesity Come From?

We think poverty makes people obese and that obesity makes people poor. It’s harder to understand exactly why.
Reuters

A new article by John Cawley in NBER Reporter, “The Economics of Obesity,”poses an interesting question right at the top. Why study obesity like aneconomic problem, anyway?

There are two broad answers. The first is simply methodological. Understanding the causes and consequences of obesity is hard because scientists like randomized experiments—e.g.: give one group drug X, give another group a placebo, and observe the difference. But this is almost impossible to do with weight. It’s unethical to randomly make participants obese just to watch what happens to them. So, it’s useful to study compare data and try to find out how income and obesity are actually related. Essentially: To study weight like an economist.

The second answer is that obesity is an economic problem, plain and simple. Obese Americans costs the U.S. $190 billion in annual medical costs attributable to their weight—or 20 percent of national health-care spending, according to Cawley’s research. That’s a shockingly high figure, and it implies that unpacking the relationship between income and obesity could save America even more money and anxiety than many researchers estimate.

The trouble is that, when it comes to obesity, practically nothing is clear-cut, starting with the word, itself.

Obesity is broadly defined by a body-mass index—a.k.a.: BMI, a ratio of height to weight—over 30. But not all weight is the same. There are variations of fat and muscularity that can make perfectly healthy, muscular men and woman technically obese. If you switch measures to body-fat percentage, the black-white obesity gap among women falls by half. If you switch to skin-fold thickness, scientists can predict obesity decades before your BMI crosses the 30 threshold.

Equally murky is whether being poor leads to obesity. Cawley’s own research didn’t quite find causality (there is “little evidence that income affects weight,” he writes).

Still, there is copious evidence around the world that obesity is a peculiar condition for poor people in rich countries. Less-developed countries have lower obesity, but in richer countries, there tends to be an inverse relationship between waistlines and bank accounts. It’s what researchers have called the “health-wealth” effect: Wealthier people tend to be healthier people. In the U.S., rich white women and poor black men have the lowest obesity rates (followed by rich white guys). America’s highest obesity rates by far are among poor minority women. A 2008 U.S. Department of Agriculture’s review of the effect of food stamps found obesity didn’t rise among children or men but did increase slightly among women.

So poverty might make some people obese, but obesity definitely makes many people poorer, through two broad channels: (a) it reduces take-home pay, particularly for women; and (b) it’s related to health conditions that reduce discretionary income, too.

If there is there is a close relationship between weight and poverty, it is strongest among women, from the peak of the 1 percent to below the poverty line. At the top, corporate boards appear severely biased against larger women in a way they don’t discriminate against larger men. Cawley’s research found that obesity lowers wages for all workers but particularly for white women. Women who are two standard deviations from normal weight (64 pounds for the typical woman) earn 9 percent less, he writes. Obese women are half as likely to attend college, 20 percent less likely to get married, and seven times more likely to experience illness, depression, or death from being overweight.

As Dan Engber wrote, unpacking the direction of causality here amounts to untying a Gordian Knot of interwoven effects:

Sickness, poverty, and obesity are spun together in a dense web of reciprocal causality. Anyone who’s fat is more likely to be poor and sick. Anyone who’s poor is more likely to be fat and sick.  And anyone who’s sick is more likely to be poor and fat.

Just about every easy solution to fighting obesity comes with an asterisk or a frightening medical warning. An extra hour-per-week of physical activity for fifth graders reduced obesity by 5 percent, according to Cawley’s research, but he couldn’t find a similar effect for children of other ages. In another experiment, Cawley introduced a workplace wellness program where colleagues deposited money and stood to receive payments for their weight loss. More than two-thirds of the participants had dropped out within a year, and the results showed practically no positive effect. In fact, the third of those still making deposits at year-end had lost, on average, just two pounds more than the control group. There are pharmaceutical solutions to weight-loss, but they, too, are more full of hope than success: “There is very little, if any, evidence suggesting that [weight-loss] products are effective, and some have potentially fatal side effects,” Cawley sums up.

The fact that obesity resists easy fixes—combined with the fact that it’s associated so strongly with low-income women—suggests that policymakers should perhaps look for solutions to its underlying causes and circumstances, like upscaling food deserts and redistributing income to alleviate poverty, which correlates so highly with obesity both in the U.S. and abroad. The very condition of poverty tends to focus the mind on immediate goals, which makes long-term planning (e.g.: diets) all but impossible.

But then again, one of the confounding aspects of the relationship between low wages and high obesity rates is that researchers like Cawley can’t show quite how one leads to the other. His conclusion is a reminder that for all the words and money spent deconstructing the origins of obesity, we’re still a long way from understanding which factors directly contribute to it—and, therefore, which factors to focus on to fight it. “It may never be possible to affirm with any degree of certainty the percentage of the rise in obesity attributable to specific factors.”

complex adaptive systems, healthcare, healthy habits, musings, nutrition, policy, politics, rapid learning health systems, storytelling

Katz smashes it again… it’s the culture, stupid.

“Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm.”

…but how do we operationalise culture change…. it is massive task, but it needs to happen. Purpose perhaps?

http://www.linkedin.com/today/post/article/20140121144506-23027997-obesity-and-oblivion-or-what-i-ve-learned-under-general-anesthesia

Director, Yale University Prevention Research Center

Obesity and Oblivion- or- What I’ve Learned Under General Anesthesia

David L. Katz, MD, MPH

January 21, 2014  

I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.

I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian– privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.

This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.

And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74 birthday last summer with a hilly, 56-mile bike ride.

By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and productivity. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.

Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.

Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness; oblivion.

And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.

True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.

And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words- as nobody ever does under general anesthesia.

Our society’s tendency to “over-medicalize” has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after – wait for it- 17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.

It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.

With that in mind, I ask my fellow parents reading this column; I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.

Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 lbs, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.

Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.

The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.

Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.

It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves- and perhaps thereby perceive a new world of opportunity.

-fin

Dr. Katz was recently named one of the most influential people in Health and Fitness (#13) byGreatist.com. His new book, DISEASE PROOF, is available in bookstores nationwide and at:

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253
http://twitter.com/DrDavidKatz
http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

data saving lives, facts & data points, healthcare, nutrition, policy, quantified self, rapid learning health systems, research methodology

Institute for Health Metrics and Evaluation (IHME)

Gates Foundation backed Washington University team doing some amazing work on gathering, analysing and presenting global burden of disease metrics for easy browsing.

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

Data Visualizations

IHME strives to make its data freely and easily accessible and to provide innovative ways to visualize complex topics. Our data visualizations allow you to see patterns and follow trends that are not readily apparent in the numbers themselves. Here you can watch how trends in mortality change over time, choose countries to compare progress in a variety of health areas, or see how countries compare against each other on a global map.

Not sure which visualization will provide you with the results you are looking for? Click here for a guide that will help you determine which tool will best address your data needs.

GBD Compare is new to IHME’s lineup of visualizations and has countless options for exploring health data. To help you navigate this new tool, we have a video tutorial that will orient you to its controls and show you how to interact with the data. You can also watch the video of IHME Director Christopher Murray presenting the tools for the first time at the public launch on March 5, 2013.

Tobacco Burden Visualization

This interactive data visualization tool shows modeled trends in tobacco use and estimated cigarette consumption worldwide and by country for the years 1980 to 2012. Data were derived from nationally representative sources that measured tobacco use and reports on manufactured and nonmanufactured tobacco.

US Health Map

With this interactive map, you can explore health trends in the United States at the county level for both sexes in: life expectancy between 1985 and 2010, hypertension in 2001 and 2009, obesity from 2001 to 2011, and physical activity from 2001 to 2011.

GBD Compare

Analyze the world’s health levels and trends in one interactive tool. Use treemaps, maps, and other charts to compare causes within a country, compare countries with regions or the world, and explore patterns and trends by country, age, and gender. Drill from a global view into specific details. Watch how disease patterns have changed over time. See which causes of death and disability are having more impact and which are waning.

Mortality Visualization

How does input data become a GBD estimate? Walk through the estimation process for mortality trends for children and adults for 187 countries. See the source data and then watch as various stages in the estimation process reveal the final mortality estimates from 1970 to 1990.

COD Visualization

Where do we have the best data on the different health conditions? For any age group, see where the various data sources have placed the trends in causes of death over time. You can examine more than 200 causes in both adjusted and pre-adjusted numbers, rates, and percentages for 187 countries.

GBD Insight

What are the health challenges and successes in countries around the world?

GBD Heatmap

How do different health challenges rank across regions?

GBD Arrow Diagram

How has the burden of different diseases, injuries, and risk factors moved up or down over time?

GBD Uncertainty Visualization

Where do we have the best data on the different health conditions?

GBD Cause Patterns

What diseases and injuries cause the most death and disability globally?

 

healthy habits, nutrition, policy, storytelling

DH getting serious on healthy food policy

  •  getting rid of guilt lanes at supermarket checkouts
  • removal of confectionery and soft drinks from gondola ends
  • voluntary code to limit marketing (incl. use of cartoon characters) of HFSS to children
  • Lidl trials of juices and fresh fruit in checkouts attracted 20% higher footfall
  • a new pilot scheme in a Morrisons store in Salford, using cardboardboard cut-outs of local GPs in the fresh produce aisles delivered a 20% rise in the sales of fresh fruit and a 30% uplift for frozen fruit.

Tip: http://www.foodpolitics.com/2014/01/how-to-get-people-to-buy-healthier-food-cardboard-cutouts/

Source: http://www.thegrocer.co.uk/topics/dh-wants-new-deal-to-tackle-unhealthy-food-promotions/353654.article

DH wants new Responsibility Deal measures to tackle unhealthy food promotions

18 Jan 2014 | By Ian Quinn

Health cutout

Cardboard cut-outs of local GPs convinced Salford shoppers to buy 20% more fresh fruit

The government has given retailers and suppliers a “short window of time” to agree a voluntary clampdown on the promotion of foods high in fat, salt or sugar as it prepares to launch a new strategy to fight childhood obesity in the spring.

The DH claims supermarkets and suppliers can supply the final piece in the jigsaw in its Responsibility Deal if they support a raft of proposals, including getting rid of “guilt lanes” at checkouts and the removal of sweets and sugary fizzy drinks from gondola ends. It is also planning a new voluntary code to limit the marketing of HFSS products to children. Talks before Christmas between health secretary Jeremy Hunt, health minister Jane Ellison and CEOs of suppliers and all the major supermarkets focused on protecting children from obesity and Ellison said she was “hopeful” they would result in a “package of measures”. Dr Susan Jebb, chair of the Responsibility Deal food network, who was central to the talks, said: “We’ve challenged them to think what they might do from a long and wide-ranging list of ideas. We’re giving the industry a short window of time to come back with a response.” She said pressure was growing on the government to regulate if companies failed to respond to the calls. With pressure on the DH reaching fever pitch in the wake of this week’s alarmist reports, it wants a commitment to guarantee a minimum level of price and loyalty promotions for healthier options, the banning of cartoon characters on packaging of HFSS foods and restrictions on online promotions. This week, discounter Lidl promised to roll out its ‘Healthy Checkouts’ concept – an initiative first trialled last year – replacing unhealthy items with fresh fruit and juices at tills, claiming the trial stores attracted a 20% higher footfall. “I think it’s a bold move,” said Jebb. “What I find very encouraging is that they’ve done it in response to what their customers want and I think it sends a powerful message to other retailers.” “This is a huge opportunity for the industry to show that a voluntary strategy is the way to deal with the obesity crisis,” she added. “We’re tackling satfats, calories and salt, and the thing that would wrap it all up is something around promotions.” Meanwhile it was revealed this week that a new pilot scheme in aMorrisons store in Salford, using cardboardboard cut-outs of local GPs in the fresh produce aisles delivered a 20% rise in the sales of fresh fruit and a 30% uplift for frozen fruit.

healthcare, healthy habits, policy, politics, quotes & aphorisms

2014 AMA Health Priorities

Steve Hambleton
– population health
– reduce unwarranted clinical variation

Chris Baggoley
– dementia

Lesley Russell
– value-based payment

 

The five most pressing health priorities in 2014

21/01/2014

Trying to identify just five top priorities in an area as complex and ethically fraught as health care is a tough challenge, but that was the task Australian Medicine set for seven of the nation’s leading health advocates and thinkers, including AMA President Dr Steve Hambleton, the nation’s Chief Medical Officer Professor Chris Baggoley, health policy expert Dr Lesley Russell and World Medical Association Council chair Dr Mukesh Haikerwal. Here they provide their thought-provoking and insightful responses.

AMA President Dr Steve Hambleton

1.  Make population health a cross-portfolio priority for all levels of government
Population health is not just about treating illness. It’s also about keeping people well, and all portfolios (Agriculture, Defence, Education, Employment, Environment, Finance, Foreign Affairs and Trade, Health, Immigration and Border Protection, Industry, Infrastructure and Regional Development, Social Services, Treasury etc) need to do their part to fight the threat of non-communicable diseases which stem from tobacco, alcohol, over-nutrition and under- exercise.

2. Continue the investment in closing the life expectancy gap between Aboriginal and Torres Strait Islander peoples and all Australians
All governments need to keep up the investment, but not just in the health portfolio. There is stark evidence that investing in the social determinants of health and a good education, starting at birth, are major predictors of health outcomes.

3. Fix e-health and the PCEHR
We must be able to talk to each other in the same language -general practice, hospitals (public and private), public outpatients, private specialists, aged and community care. Too often the right message just does not get through. Let’s get the (e) rail gauge right and use it.

4. Reduce unwarranted clinical variation
The fastest way to save health dollars and achieve better outcomes is to (as Professor Lord Ari Darzi advised at the 2012 AMA National Conference) “close the gap between what we know and what we do”.  We know we are doing a good job and are very cost effective. If we embrace the move of learned colleges toward clinical audit and self-reflection we can make best practice even better.

5. Invest in research
The human papillomavirus vaccine will save millions of lives. Research delivered and refined the place of statins, also saving millions of lives. We need new ways of treating infections, perhaps more antibiotics or better ways to use the ones we already have.

Professor Chris Baggoley, Australian Government Chief Medical Officer

It is not easy to nominate five priority areas for action, given that there are so many deserving areas that require our ongoing attention. Of course, in my role there are a number of areas where my direct involvement is needed to help made a difference.
Understanding that this list excludes other equally deserving priority areas, my list is:
1. Antimicrobial Resistance, where concerns we are facing a post antibiotic era are widely shared across the globe. Australia is taking a leading role: we have adopted a One Health approach, a safety and quality approach (via the National Standards), and we are increasing our surveillance of resistant microbes and antimicrobial usage.

2. Emerging Infectious Diseases. The appearance of avian influenza H7N9 in China in 2013, and the Middle East Respiratory Syndrome Coronavirus in 2012-13, has redoubled the focus of all areas of the health system to prepare to manage emerging infectious diseases, and this must remain a focus for 2014.

3. Immunisation coverage. Public interest in the benefits of high levels of childhood immunisation was a particular feature of 2013, especially following the National Health Performance Authority report breaking coverage down to Medicare Local and postcode areas. Vaccine-preventable diseases should be prevented, and our attention to this aspect of health care in all areas must remain a priority.

4. Dementia. While the first three areas are part of my daily work, this is not the case for dementia. Nonetheless, the case for research into the causes and prevention of dementia is apparent to all of us.

5. Improving the nation’s mental health. Much work is underway to improve our mental health. Improved community and professional understanding and reduction in stigma will assist sufferers of mental health illness to seek help, and assist their recovery.

Dr Lesley Russell, Visiting Fellow, Australian Primary Health Care Research Institute, Australian National University

National

1. Addressing health disparities

Prime among these is the need to Close the Gap on health disparities for Indigenous Australians, but we should not forget the disparities suffered by people with mental illness, people with disabilities, the homeless, and those who are isolated, both geographically and socially. These gaps will only be closed by a broader focus on the social determinants of health through a whole-of-government approach.

2. Changing the way we pay for healthcare services

It’s time to move away from fee-for-service to a financing system that is (1) focused on value rather than volume; (2) rewards improved health outcomes and cognitive services as much as procedures; (3) encourages effective teamwork and collaboration; and (4) recognises time dedicated to education, mentoring, research, essential paperwork and communication.

3. Reworking the healthcare workforce

If we are to address the health and healthcare needs of the 21st century in a country as large and diverse as Australia, then we need an appropriate workforce and a system that enables every healthcare profession to work to full scope of practice. That means widening who can prescribe and who can work independently. The new workforce must include more Aboriginal and Community Health Workers to assist with outreach, education, care coordination and cultural sensitivity.

International

4. Antibiotic resistance

The growing threat of multiple resistance requires a major international effort involving the agriculture, food and health sectors and an increased focus on research to deliver solutions and new antibiotics.

5. Climate change

Everyone’s way of life and even national security is under threat from climate change. Developed nations like Australia must show leadership in tackling both the causes and the impacts. In the absence of government action, communities must step in to lead the way.

Professor Stephen Leeder, Professor of Public Health and Community Medicine, University of Sydney

1. National data collection and evaluation – the collection of national hospital safety and quality data is critical to monitoring the use of drugs and controlling the rise of drug-resistant infections. Information is also needed to track progress in preventive health, such as in addressing obesity. Repeated surveys, done by the same people using the same survey instruments, are needed to judge our progress.

2. We need to tell the story of what we are achieving in health care for the tens of billions we invest in it. The community who pays deserves to hear. Health Ministers need to enunciate what the goal of providing health care is, backed by stories that illustrate what is achieved every day in caring for people. These stories are needed to keep compassion alive in our democracy.  “Look where my Medicare tax dollar goes!” would be a great thing to boast about, and would enable ordinary taxpayers to see that their tax contributes to something of immense social value.

3. Fixing IT. We are 20 years behind best practice. We can see what it looks like in the US. It requires a huge investment, but the pay-off in quality is immense.

Martin Laverty, Chief Executive Officer, Catholic Health Australia

1. Causes of ill health need to constantly inform both health policy and practice. Two-thirds of Australians are overweight, 16 per cent of Australians smoke, and 13 per cent drink at levels of risk. Implementing Senate recommendations on social determinants of health would revive efforts to prevent Australians, particularly the most disadvantaged, from suffering avoidable chronic illness.

2. Coordination of health services around a person’s unique needs must become more of a priority, to improve patient outcomes and reduce waisted expenditure. Ideally, any person with an ongoing health complaint would have a health plan worked out and appropriately managed to focus on right treatment in the right place, ongoing medication management, avoidance of duplicated service, and prevention of further disease.

3. Health workforce constraints and industrial barriers still haven’t been resolved to ensure Australia will have enough medical, nursing, and allied health staff to meet Australia’s growing and ageing population. Role redesign of who does what in the health system remains essential, but as a nation we’re no closer to being able to solve workforce constraints because of entrenched industrial perspectives.

4. Consumer choice underpins the new National Disability Insurance Scheme, and is being introduced into home care for the aged. Better choice in health and aged care also needs attention, so that competition and contestability can drive improvements in financial and clinical outcomes.

5. End of life care needs the entire community’s attention. Health professionals and health consumers need to give new consideration to talking about, determining, and then implementing future care plans. Pastoral care for those in the final stages of life, indeed for any person dealing with significant illness, needs elevation as a priority for health and aged care providers.

Dr Mukesh Haikerwal, Chair of Council, World Medical Association, former AMA President

With a new federal administration in place, a fiscal Armageddon heralded and the health settings for Australia being less favourable, the usual troupe of kite-fliers have been showing their wares in the ‘silly season’. What I think we need is to secure the fundamentals and enhance and support sensible collaborative work practices.

1. Support more care out of hospital – don’t penalise quality holistic care in general practice.

Embed the notion of general practice as the bedrock, not only of primary health care and all out of hospital care, but also for health care delivery across the nation. The costs of the same care out of hospital, when appropriate, are a fraction of the cost in hospital.

2. Enhance hospitals and support the care provided there, and stop perverse penalties.

Support the existing hospital infrastructure that is struggling with the burden of increased demand and expectation from patients and from governments, which absurdly see them penalised for trying their hardest to cope with this. There needs to be a move from blame to re-setting costs and targets based on realistic care need evaluations, allowing for inevitable variation.

3. Embolden and formalise clinical leadership in health in a meaningful way.

Use clinical Senates – groups of cognisant, focussed individuals suggesting and supporting innovation in health care delivery. Enhance their work by trialling and evaluating changing concepts before whole-of-system adjustments, so that unforeseen consequences are outed and adjusted for in real situations with real doctors treating real patients.

4. Use e-health and telehealth logically in clinically safe and acceptable forms over and above the PCEHR, especially secure messaging delivery and web-based videoconferencing.  

Use innovative technologies in health (e-health and telemedicine) for clinical purposes, with clinical needs and drivers at the forefront. We do have potential technology to support and enhance (but not replace) trusted, proven good clinical methods. This is over and above, but could include, the PCEHR. Secure email to connect information is the key element.

5. Innovate with translational research in real clinical situations, proving concepts before rolling them out.

In care settings, sequential work across disciplines and health care establishments, with clinical participants nutting out how to best to innovate. Use just one set of agreed best practice guidelines that promote translational research that have been promulgated to, and agreed by, relevant medical groups. Make sure the economics and medicine are understood: it may cost more to implement in the beginning, but it will save on costs down the track.

Dr Brian Morton, Chair, AMA Council of General Practice

1. End of life care – There is an expectation that modern medical technology and care will extend life, but at what cost to the quality of life? The preparation of an Advanced Care Directive when competent will bridge this gap.

2. Lifestyle health issues – The genesis of many health issues are related to poor lifestyle choices which then require medical solutions. We need brave governments to implement public health interventions to de-medicalise preventive management.

3. Obesity – a whole-of-community response is required to manage the obesity “epidemic”, including responsible marketing and labelling of foods, appropriate food helping sizes, ready access to exercise programs, dietetic advice and legislative recognition that obesity is a risk factor for multiple chronic diseases.

4. Prostate cancer – A rational evidence-based and consensus approach is needed regarding screening and management.

5. Alcohol – A multifactorial societal approach is fundamental to alcohol management.

healthcare, policy, politics

PHI GP cover threatens budget and universality

“Aside from equity issues and potential distortions in the allocation and delivery of health services*, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.”

*HAH!!!

https://ama.com.au/ausmed/medibanks-gp-cover-threatens-universal-health

Medibank’s GP cover threatens universal health

21/01/2014

A Medibank Private scheme to give members privileged access to a range of GP services threatens to create a two-tier health system and could fracture the relationship patients have with their family doctor, the AMA has warned.

As the Federal Government proceeds with preparations for the sale of Medibank Private, it has been revealed by The Australian that in November the insurer commenced a trial with medical centre operator IPN in which its members are bulk-billed for GP consultations and get access to several service “enhancements”, including guaranteed appointments within 24 hours and after-hours home visits.

The arrangement is so far being trialled at six IPN clinics in south-east Queensland (including one at which AMA President Dr Steve Hambleton practises), and it circumvents a Private Health Insurance Act prohibition on insurers paying for services that are eligible for Medicare rebates by limiting Medibank Private funding to assistance with covering the administrative and management costs of the trial.

But AMA Council of General Practice Chair Dr Brian Morton said the scheme violated the spirit of the law, and corroded basic principles regarding equity of access to care.

Dr Morton said that although the AMA wanted to see health insurers more involved in primary health care, the approach being trialled by Medibank Private was flawed.

“We do want to involve private health insurers in general practice, but we don’t really see this as the best way of doing it,” Dr Morton told The Australian, adding that any provision to allowed funds to cover primary health services should be open to all patients and GPs.

Anticipating that private funds might seek to give their members privileged access to GP services, the AMA in 2006 released a Private Health Insurance and Primary Care Services Position Statement(https://ama.com.au/position-statement/private-health-insurance-and-primary-care-services-2006) setting out the parameters for the expansion of health fund into primary health care and the dangers that needed to be avoided.

In its Statement, the AMA said that a “limited” expansion of private insurers into primary care may be of some benefit, but only where it provides or pays for services not covered by Medicare.

“There are inherent risks in supporting an expansion of health insurance fund services into primary care,” the Position Statement said, noting especially that “limiting certain services to those who can afford private health insurance, particularly those related to preventive health measures, represents the establishment of a two-tiered system.”

Other concerns identified by the AMA included the potential for the focus of health services to shift from quality and continuity to cost cutting; for insurers to develop models for rationing care; for the development of imprecise patient selection techniques; for a shift away from the provision to patients of information and education “related to their health needs”; and for patients being encouraged to visit participating GPs, who may or may not be their regular family doctor.

In its Position Statement, the AMA warned that any scheme or arrangement that created such risks or undermined the universality and equity of Medicare “will be rejected by the medical profession”.

But so far the Federal Government has adopted a hands-off approach to the Medibank trial.

Health Minister Peter Dutton told The Age that he saw no evidence that the arrangement contravened the legislation, and appeared to give some encouragement to the initiative in a statement to The Australian Financial Review.

“I want every Australian to have a good relationship with their GP, so I wouldn’t rule out any changes,” Mr Dutton said. “Like the Australian Medical Association, I am open to greater involvement of the insurers, who cover 11 million Australians, to keep those people healthy and getting more regular access to primary care.”

Aside from equity issues and potential distortions in the allocation and delivery of health services, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In a note obtained by The Australian Financial Review, the Health Department in 2008 estimated the scheme would spur a 5 per cent increase in demand for GP services and GPs would increase their fees, adding a massive $3.4 billion to the Government’s Medicare rebate bill over five years.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.

The nation’s second largest health fund, Bupa, has joined the criticism, warning that although insurance cover for GPs charges would likely be a boon for providers, it would drive up the Government’s health bill.

The trial arrangement, and a suggestion that Medibank could assume responsibility for helping to administer the National Disability Insurance Scheme, has prompted speculation the Government is trying to boost the interest of investors in the purchase of the health fund, whose possible privatisation is currently the subject of a scoping study.

The pilot of private health cover for GP services has also come as the National Commission of Audit ponders a proposal for a $6 charge for GP visits [see also, $6 co-payment an illusory health saving].

Adrian Rollins