Category Archives: policy

facts & data points, healthy habits, nutrition, policy, politics

Future Diets Report

  • with wealth comes an increase in animal products, fat and sugar, but globalisation is not leading to a convergence towards a single international norm with income becoming a weaker determinant of diet over time – this allows scope for public policy to intervene
  • Trajectories are not pre-ordained; there is scope to  influence the evolution of diet to get better outcomes for health and agriculture.
  • This has never been attempted, with the rare exception of the wartime rationing in Britain, which stands out as an unusual natural experiment that  led to better health; but one that the British public were delighted to abandon once supplies had been
    restored after the Second World War.
  • Studies such as that of Cecchini et al. (2010) show large benefits compared to costs from measures to influence people to  adopt healthier diets.
  • A final comment (and paradox): interest in diet has never been stronger in high-income countries as  we obsess about our waistlines, worry about the social impacts of the marketing strategies of (very) large food retail chains, and enthuse over the culinary art and tradition shown in countless television programmes. Scientifically, a plethora of papers have been drafted in the past 10 years that ponder the  rise of obesity worldwide and its implications.
    It seems, then, that it is only a matter of time before people will accept and demand stronger and effective measures to influence diets. When that time comes, we will need the evidence – provided in a very preliminary way by this review – on the main problems of emerging diets, and which policies  (and combinations of policies) will be most effective in addressing the emerging challenges.
  • overweight and obese in developing countries grew from 250M in 1980 to almost a billion (mostly Indians) in 2008
  • consumption of sugar has risen 20% per person between 1961 and 2009
  • 1 in 8 people (852m) in poor countries do not have sufficient access to food
  • 1/3 of infants in the developing world are stunted
  • 2 billion affected by micro-malnutrition
  • this impacts on the number of people developing certain types of cancers, diabetes, strokes and heart attacks
  • politicians are fearful of interfering in the dinner table, combined with powerful lobbying
  • South Korea has seen an increase in fruit and vegetable consumption after publicity, social marketing and an education campaign including large-scale teaching of women in preparing traditional, low-fat, high-vegetable meals

Future Diets Report (PDF):  http://www.odi.org.uk/sites/odi.org.uk/files/odi-assets/publications-opinion-files/8776.pdf

Source: http://www.foodnavigator-asia.com/Markets/Obesity-is-a-weighty-issue-for-almost-1bn-in-developing-world

By RJ Whitehead, 06-Jan-2014

Related topics: Markets, Asian tastes

The number of overweight and obese adults in developing countries has ballooned from some 250m in 1980 to almost a billion today, with Indians forming a huge chunk of this number.

This figure is highlighted in a major new review by the UK’s Overseas Development Institute to expose the global scale and consequences of overweight and obesity, and what it calls governments’ failure to address this growing crisis.

The Future Diets report is an analysis of public data detailing what the world eats. It selected five middle-income countries—India, China, Egypt, Peru and Thailand—as case studies to illustrate changes in dietary trends.

One in three overweight

The results highlight that the number of adults who are obese or overweight in the developing world more than tripled between 1980 and 2008, while in richer countries the figure has risen by over 200 million. One in three of the world’s adults are now overweight or obese, it found.

According to ODI research fellow Steve Wiggins, who authored the report, the growing rate of overweight and obesity in developing countries is alarming.

“On current trends, globally, we will see a huge increase in the number of people suffering certain types of cancer, diabetes, strokes and heart attacks, putting an enormous burden on public healthcare systems,” Wiggins said, warning governments that they are not doing enough to tackle the growing crisis.

The percentage of obese and overweight in India rose from about 9% of the population in 1980 to 11% in 2008.

“India’s consumption of animal products is approaching that of China’s in terms of its contribution to the average plate, but here the increase is almost entirely in milk consumption, with only limited increases for meat,” the report said.

“Many Indians are vegetarian, avoiding beef or pork for cultural and religious reasons. The consumption of pulses remains relatively high in India, although it has been on the decline.”

Politicians fearful of meddling

Wiggins believes that the rise in obesity is partly due to politicians’ reluctance to interfere at the dinner table, along with the powerful influence of farming and food lobbies in the developing world and a large gap in public awareness of what constitutes a healthy diet.

“Governments have focused on public awareness campaigns, but evidence shows this is not enough. The lack of action stands in stark contrast to the concerted public actions taken to limit smoking in developed countries.

“Politicians need to be less shy about trying to influence what food ends up on our plates. The challenge is to make healthy diets viable whilst reducing the appeal of foods which carry a less certain nutritional value.”

However, the report does cite some successful examples of governments’ changing diets for the better. In South Korea, for example, policies that have led to an increase in fruit and vegetable consumption largely thanks to a publicity, social marketing and education campaign, including large-scale training of women in preparing traditional low-fat, high-vegetable meals.

Analysis of existing data shows that, amongst others, since 1980 overweight and obesity rates have almost doubled in China.

One indicator of changing diets is an increase in the consumption of sugar. Sugar and sweetener consumption has risen by over one-fifth per person globally from 1961 to 2009.

Fat consumption is also an issue. Among developing countries the highest consumption of fat is in East Asia, however industrialised countries still have much higher levels of fat consumption—often more than double.

Worryingly, despite a 50 per cent increase in the amount of food sourced from animals and a doubling in the quantity of fruit and vegetables being harvested, the report also notes that one in eight people (852m) in poor countries still do not have enough food to satisfy their basic needs.

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complex adaptive systems, entrepreneurship, policy, politics, research methodology

Gruen: A unified economic theory of privately provided public goods and social capital

Nicholas delivers a terrific presentation (1hr 7mins) to The Australian Centre for Social Innovation about the private provision of public goods and the subsequent generation of social capital.

It is as crisply considered as it is thought provoking:

  • after all this time, I think I finally understand that economists believe themselves to be the purveyors and arbiters of well-being, and ultimately health – no wonder they’re so suspicious of, and have so much trouble relating to medicine and health care
  • it would be interesting to apply this prism to health care – I don’t think it will present favourably

The presentation wraps with a 5 min video of the Family by Family program – a compelling sounding intervention that generates an abundance of social capital by developing and then using resources embedded in the community.

Many references to Adam Smith, Hayek and Robert Putnam.

Great to see something not confined to the sub-20min constraint.

Bravo Nicholas!!


http://clubtroppo.com.au/2013/12/20/public-goods-privately-provided-the-video/

 

 

data saving lives, facts & data points, healthcare, policy

Justin Coleman: The ethical imperative to tackle overdiagnosis and overtreatment

  • Beautifully written, wise piece by a friend and colleague of Gavin Mooney
  • Archie Cochrane humorous anecdote
  • Donald Berwick’s 30% waste JAMA link
  • Futility of spinal fusions
  • Futility of knee arthroscopies
  • Testosterone over-prescribing
  • EBM is a necessary but not sufficient condition for practising good medicine.When my friend Prof Gavin Mooney gave me his book, he explained why he’d called it EBM ‘in its place’.

    He did not want to promote a system of slavish adherence to a deontology. As a leftie health economist—a rare breed indeed—his primary concern was always one of health equity. Not health equality, which is clearly unattainable, but equity, where we strive for equal access to equal care for equal need.

    An equitable health system does not mean trying to give everyone the very best, if by that you mean the most; the most tests, the most expense, the most treatments. Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient.

    Gavin was killed in tragic circumstances last Christmas, and I dedicate this article to his memory.

    His philosophy was that, sometimes, less is more. We must pare things back, strip away excesses and judiciously apply what we know works, rather than enthusiastically embrace what we wish would work.

    As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.

Source: http://blogs.crikey.com.au/croakey/2013/06/23/the-naked-doctor-an-indepth-look-at-the-pitfalls-of-cutting-edge-medicine/

The Naked Doctor: an indepth look at the pitfalls of “cutting edge” medicine

MELISSA SWEET | JUN 23, 2013 5:15PM | EMAIL | PRINT

The Naked Doctor is an ongoing project at Croakey that aims to encourage discussion and awareness of the opportunities to do more for health by doing less.

In this latest edition, Dr Justin Coleman suggests that an equitable health system does not mean trying to give everyone the very best, if that means “the most tests, the most expense, the most treatments”.

“Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient,” he says.

Perhaps one area where more intervention is needed is in tackling overdiagnosis and overtreatment – Dr Coleman suggests that if the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.

He concludes with a powerful call to action:

“As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.”

The article below is based upon his plenary address to the Qld RACGP Annual Clinical Update in Brisbane last month.

It is dedicated to the late Professor Gavin Mooney, whose philosophy was that we must “judiciously apply what we know works, rather than enthusiastically embrace what we wish would work”.

***

The ethical imperative to tackle overdiagnosis and overtreatment

Justin Coleman writes:

Two years ago my good friend Gavin Mooney gave me a signed copy of his latest—and, as it turned out—last book, Evidence-Based Medicine in its Place. 

Professor of Health Economics at Curtin University, Gavin was an irascible Scot, and his book detailed his work with another great Scotsman, Archie Cochrane, who of course pioneered the science of Evidence-Based Medicine.

According to Mooney, after their first meeting, Cochrane informed him that he had revised his opinion of economists.

On the basis of the evidence of an afternoon with Mooney, he now placed them second bottom, with sociologists at the bottom. This merely confirmed for Mooney that there was much on which they agreed.

Mooney told me the story, repeated in his book, of how Archie Cochrane first gained notoriety as a very junior staff member at the massive Department of Health in London.

The young Archie presented slides from an RCT on outcomes after heart attacks following rehabilitation, either while remaining a hospital inpatient or after early discharge home.

London’s ‘Who’s Who’ of learned physicians nodded sagely as Archie showed the crucial slides where the hospital outcomes—represented in red—outdid the blue columns of home-based outcomes across nearly every parameter. A couple of supportive comments, no questions.

Then the young epidemiologist pretended to look flustered. ‘I’m terribly sorry. I seem to have mixed up the red and the blue!’

He had deliberately switched the labels. All the better outcomes were in fact in the home-based, early discharge group.

Needless to say, chaos ensued as suddenly a hundred disgruntled audience members grilled him on every possible dubious aspect of the study design!

Best practice or common practice?

Until that time, there had been no reason for a London physician to doubt that an intensive, expensive, high-tech hospital stay would improve health outcomes.

It made perfect sense, and a whole bunch of highly intelligent, caring physicians had spent their careers ensuring that such a system existed. Where it wasn’t affordable, public and charity funds were sought to ensure more people could get longer hospital stays.

This was best-practice care, in the same way that bed rest for back pain, monthly breast self-examinations, and antibiotics for sore throats have been understood by clever and well-meaning people to be fairly obvious best care. More about Archie—and Gavin—later.

In the brilliant Mitchell and Webb parody of a Homeopathic Emergency Department, Webb attempts to save a trauma victim’s life by drawing on his palm in pen to extend his life line. He justifies it by asking ‘Have you got a better idea?’

Luckily, the answer is ‘yes’.

There are some things that do work better than a pen mark, or a homeopathic vial of water, even a vial where the water molecules somehow retain the memory of a herb they once knew, while conveniently forgetting they were once flushed down a toilet.

And there are some things that do work better than our mainstream medical interventions, even when tens of thousands of medical practitioners believe they are doing the right thing.

This has always been true, and will ever be so. Our mistakes from the past remind us that we are making mistakes right now. Full credit to all those anonymous doctors and researchers who unwrapped these anomalies.

The art of discovering nothing

History rightly lauds those who discovered ‘something’; Alexander Fleming and penicillin.

But I also dips me lid to those who discovered ‘nothing’. Bloodletting doesn’t work. Arsenic doesn’t work. Keeping kids with polio in hospital back straighteners for six months of their lives doesn’t work.

In many cases, our patients would be better off if we chose not to act.

There’s a minimum standard in the medical profession—not the gold standard, but let’s call it the bronze.

The bronze standard is that the patient is no worse off as a result of seeing us. The bronze standard is probably achieved by enthusiasts who light ear candles and discover people’s chakras. Let’s at least stop doing things which fall below the bronze standard.

We must balance the important and exciting work of discovering new stuff with the un-sexy hard-slog science of analysing those times where we have over-reached and over-enthused.

The best of our medical predecessors started this process and we must continue it; this is why we are a science and not merely a tradition.

Two hundred years ago, the French physician Phillipe Pinel cared enough about the damage his colleagues were doing to his psychiatric patients to observe:

“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.”

It took a young epidemiologist Archie Cochrane to highlight the flaws in obstetric practice that should ideally have already been obvious to the world’s leading obstetricians and their institutions.

And these were not minor flaws. Obstetrics units in one part of the world were teaching methods which had already been shown in another part of the world to kill women and babies, and vice versa.

Cochrane didn’t do the research himself; his genius was to inspire others—in this case, Iain Chalmers— to collect, collate and analyse all the available evidence and, importantly, reject the shoddy stuff: the anecdote and the meaningless trial, so that obstetricians and their departments could make informed decisions as to how to get the best outcomes.

Archie never delivered a baby nor managed a single maternal complication, but his legacy would probably have saved more lives than any doctor watching his slide presentation in London.

Somewhere on the spectrum

Let’s look at chronic diseases, and use diabetes as an example.

Insulin’s invention in 1922 was a miracle, which converted the inevitable rapid death sentence of Type 1 diabetes into a chronic disease. Chronic in the best sense of the word, because insulin bought you time; years, decades.

That simple chemical justifiably sits at the high table in the pantheon of superb medical interventions.

But diabetes, like most chronic diseases, has nominal cut-off points which define its existence and degree. Diseases stretch themselves out along a spectrum, blissfully unaware of how we choose to dissect them.

Medical tests and interventions that work brilliantly at the sharp end of the spectrum do not work nearly so well when we slide towards the middle and enter the grey zone.

Any gains to be had here in the land of the long grey cloud are far foggier than anything out at the extreme edge.

Benefits diminish; every diagnostic test becomes less accurate; false positives increase exponentially; patient numbers increase—and with them, costs, pain and inconvenience; health gains are smaller in this less-sick population; and suddenly being diagnosed with a chronic disease such as diabetes or pre-diabetes doesn’t look so good any more.

Instead of being grateful to Chronos, the Greek god of time who grants you each extra year of life, suddenly the old bugger expects you to jab your finger three times a day, jab your stomach three times a day, and to roll a boulder up Sisyphus’s mountain just to have your liver pecked out by Prometheus’s eagle.

There comes a point where ignoring your diabetes educator becomes…to continue the theme…tantalising!

If the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.

The paradigm promoted by industry, the media and some doctors, particularly the sub-sub-specialists, is that the only important news is a new invention, new drug, robotic surgery, more MRIs.

Is the best doctor always the one at the cutting edge? Is the best endocrinologist for my grandmother the one who has just spent a year in America learning the finer points of subcutaneous insulin infusion pumps?

There exists a cut-off point on every disease spectrum, inevitably ignored by drug companies and often enough by doctors, where medications simply don’t help. At that point, they do nothing. Beyond that point, they actively harm. This is true almost by definition for every medical or surgical intervention.

There is pressure from multiple sources—patient, doctor, pharma, specialist, psychologist, media, disease-awareness campaigns, patient advocacy groups—to nudge this point towards the midline of the spectrum.

This is true for diabetes, but also for depression, ADHD, lipid levels, cardiac stents, and deficiencies of a host of replaceable substances including testosterone, oestrogen, and various vitamins, the trendiest of which is Vitamin D.

If we don’t test early and often for all these problems, we are ignoring our duty of care and if we don’t treat when the test result comes back in red, we are downright obstructive and possibly liable.

Andropause: the new epidemic

Take testosterone. In the past five years we have witnessed a concerted wave of discussion around the andropause. Feature articles have called it the hidden epidemic, hinting at reverse sexism whereby women get their daily oestrogen but our men’s hormones have rights too!

Disease-awareness campaigns, subtle in Australia compared to countries that allow direct-to-patient advertising, ask males if they ever experience tiredness, weakness or low libido. The suggested remedy is to get your levels checked by your friendly local GP. It’s not advertising: it’s just caring.

This tumescent rise in publicity tied in beautifully with the advent of ‘men’s clinics’, whose doctors were the only clinicians with enough spare time to keep up with all the clever new ways of getting the testosterone into your body; oral, patches, gels, suppositories, inhalants; no orifice was left unsullied in the competition to supply Vitamin T.

The result?

PBS expenditure on testosterone has increased 450 % since 2006. Patients at the pointy end of the spectrum—men with testicular cancer and orchidectomies—have been swamped by the enormous market of men who are…wait for it…ageing. A bit like what’s happening to the percentage of cancer-sufferers in the opioid market.

Last year, the departing boss of the US Medicare system, Dr Donald Berwick,estimated that 20-30 per cent of US health spending is ‘waste’—as in; it yields no benefit to patients. That one quarter of the US health budget wasted could power the entire GDP of most countries on the planet.

Berwick listed five reasons for this catastrophic waste, and the first of them was ‘overtreament’. We are not talking a minor problem here.

Why do we overtest and overtreat?

Let’s look at some causes of overtesting and overtreating. Why do we do it?

Some of it is simply because the evidence doesn’t exist yet.

There was no shame in a medical graduate treating headaches with bloodletting a century ago; no-one knew any better. According to the prevailing understanding of the human body, it made sense and it no doubt appeared to work in some people.

But lack of evidence is not the only reason for our actions.

I like the list prepared by Australian surgeon Dr Skeptic (clearly his parents were prescient when naming him) of the reasons why we act even when evidence tells us ‘Don’t just do something, stand there!’

Defensive medicine: If you miss one rarity and thereby harm one person, this is more likely to end you up in court than causing far more harm by routinely overtreating everyone.

It takes an epidemiologist to tell you about the latter, whereas a lawyer will be quite happy to keep you posted about the former.

The language of inaction vs. action: Overinvestigation and overtreatment are very difficult concepts to convey to patients.

If we tell the patient ‘I really don’t know precisely why you have low back pain; would you like me to run a few tests?’ then the answer will be ‘yes’.

Our choice of language suggests that after doing the tests, we will know why they have low back pain. But whether doctor, physiotherapist or chiropractor, ye may ask the gods of radiology but shall not receive an answer.

If we give a glucometer to a person with pre-diabetes, or with diabetes that doesn’t require insulin, we will indeed get an answer as to precisely what their blood sugar is at any given moment, but this knowledge will not actually improve health outcomes.

The answer does not help the patient, therefore we are asking the wrong question.

This flawed logic of Test = Answer = Cure is used by iridologists and scientologists. And doctors.

Influence of recent experience: obstetricians who attend a birth with complications are significantly more likely to recommend a Caesarean section in their next 50 cases, before they settle back into a more sensible, case-by-case evidence-based approach.

The lottery mindset: Few people have a good understanding of risk.

My chances of winning the first division prize in tattslotto this Saturday are the same whether or not I buy a tattslotto ticket. The same. Not absolutely, mathematically, precisely the same, but the same in any meaningful, ordinary sense of the word.

People don’t understand tiny chances. I have more chance of being dead next Saturday than being both alive and collecting my winnings.

Studies consistently show that both doctors and patients, just like gamblers and stockbrokers, overestimate gains and underestimate losses.

People will jump at a whole body CT scan to ‘rule out’ a tiny risk of cancer, and ignore the fact that the radiation from each such scan increases their lifetime cancer risk by about 1%.

The prevailing wisdom: Medical students come out of university knowing thousands of new words and knowing about thousands of new interventions. The consultants taught us all the pharmaceutical and surgical interventions in their own specialised area of expertise.

But it’s not really anyone’s job to teach you about how to avoid patient referrals into the system; how to stop the cascade before it starts.

A recent Australian study showed that half of all IV cannulas inserted in ED are never used. Why does every junior ED doctor put the IVs in? Because everyone else has always put them in.

When ‘more’ is harmful

If a junior doctor is trained in breast surgery outpatients and has met women whose cancer was detected by screening mammogram, it takes some active un-training not to assume that therefore all women are better off having a mammogram.

When I was a student, my consultant orthopod took the time to kindly explain the intricacies of spinal fusion and of arthroscopic debridement for osteoarthritic knees, and I think he probably mentioned that ‘some patients don’t seem to gain as much as others’.

However, this is a starkly different prevailing wisdom from the reviews that have shown that neither spinal fusions nor arthroscopies for osteoarthritic knees differ much from placebo. In the US alone, 650 000 such arthroscopies were performed each per year in the late 1990s.

Ironically, sometimes the richer you are, with more access to the private system and doctors who will cut corners for you, the more intervention you get and the more harm is done.

The extreme of this is the Hollywood celebrity with their own physician on call, who would feel like a fool telling his client that for their thousand-dollar callout fee they get absolutely nothing except ‘watch and wait’.

When Michael Jackson went to his umpteenth plastic surgeon, she didn’t say ‘no’. When he complained he was getting anxious and couldn’t sleep and needed something more than light sleeping tablets, I bet Dr Conrad Murray now wishes he had opted for conservative management.

Making the system work

I believe it is our ethical responsibility to avoid overtreatment at an individual level, and also to support system-wide changes in the way we spend money on health.

I am no slave to evidence-based medicine; not one of those sceptical EBM types who eat gruel for breakfast and secretly believe deep down that nothing works. Although, on a bad day this pessimism reaches its ultimate fruition—absolutely nothing I do works!

EBM is a necessary but not sufficient condition for practising good medicine.

When my friend Prof Gavin Mooney gave me his book, he explained why he’d called it EBM ‘in its place’.

He did not want to promote a system of slavish adherence to a deontology. As a leftie health economist—a rare breed indeed—his primary concern was always one of health equity. Not health equality, which is clearly unattainable, but equity, where we strive for equal access to equal care for equal need.

An equitable health system does not mean trying to give everyone the very best, if by that you mean the most; the most tests, the most expense, the most treatments. Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient.

Gavin was killed in tragic circumstances last Christmas, and I dedicate this article to his memory.

His philosophy was that, sometimes, less is more. We must pare things back, strip away excesses and judiciously apply what we know works, rather than enthusiastically embrace what we wish would work.

As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.

• Dr Justin Coleman is a GP at Inala Centre of Excellence in Aboriginal and Torres Strait Islander Health. He is senior lecturer at Griffith University and University of Queensland, and President of the Australasian Medical Writers Association (AMWA). Twitter: @drjustincoleman. Web:http://drjustincoleman.com/

• You can read more about Naked Doctor here and this Croakey page has been established as a memorial to Professor Gavin Mooney.

facts & data points, healthy habits, nutrition, policy, politics

WHO leaks sugar report – industry will be displeased

  • WHO will recommend sugar be limited to 5 teaspoons per day or 5% of total calories (current AU consumption around 35-45 teaspoons)

Source: http://www.raisin-hell.com/2014/01/the-world-health-organisation-has-taken.html

Sunday, January 5, 2014

The World Health Organisation has taken a tough stand on sugar. It’s about time we listened.

Last week the WHO (World Health Organization) leaked a draft report about sugar. The report will tell the world’s health authorities that they should be severely limiting the amount of sugar we all eat. It will recommend that we consume no more than 5 teaspoons of sugar a day. Given the average Australian is putting away somewhere closer to 35-45 teaspoons a day, it’s a very big call indeed.
The WHO is the health policy unit of the United Nations. Its aim is provide evidence based leadership on health research. It is well funded, free from corporate influence and motivated entirely by a desire to ensure that the 92 UN member countries get the best possible, evidence based, health advice. The WHO doesn’t run a Tick program or receive sponsorship from the processed food industry. Indeed it has even recently taken the extraordinary step of banning one ‘research’ group sponsored by industry from participating in its decision making processes.
Shrinath Reddy, a cardiologist and member of the WHO panel of experts, told the Sunday Times the WHO is moving on sugar because “There is overwhelming evidence coming out about sugar-sweetened beverages and other sugar consumption links to obesity, diabetes and even cardiovascular disease.”
The worldwide burden for those diseases is accelerating very quickly. According to a new report out this week the number of overweight and obese in the developing world has quadrupled since 1980.
A billion people in the developing world are now on the chronic disease express. But don’t worry, we still win. Less than a third of the population in China and India is overweight compared to our two thirds or more. They are just starting to get the hang of this Western Diet Thingy, so expect very big rises in the very near future.
The WHO have looked dispassionately at the evidence and have seen the tsunami of human misery caused by sugar coming for more than a decade They publicly warned that sugar was strongly implicated in obesity, type II diabetes, hypertension and heart disease in 2003.
They then took the extraordinary step of telling member governments that they should ensure their populations limited sugar consumption to a maximum of 10% of total calories (around 10 teaspoons of sugar a day – the same amount you would find in a Coke or a large Apple Juice). They did this despite an overt and vicious public campaign conducted by the Food industry.
The US sugar lobby demanded that the US Congress end its $406 million funding of the WHO. This is the same WHO that co-ordinates global action against epidemics like HIV, Bird Flu and SARS. But the US food industry wanted it destroyed because it dared to suggest we eat less sugar.
The lobbying behind the scenes was even more ruthless. Derek Yach, the WHO Executive Director who drove the sugar reduction policy work told a British documentary crew in 2004, that millions were spent trying to torpedo the policy. US Senators wrote directly to the WHO threatening its very existence. They also threatened the Food and Agriculture Organisation (a sister UN department concerned with food production) with a cut in funding.
In the end the food industry campaign paid off. The WHO removed its 10% recommendation from the final text of its recommendation. It was watered down to a suggestion that people ‘cut the amount of sugar in the diet’.
As one of the people involved at the time, Professor Phillip James, Chairman of the International Obesity Taskforce, predicted “we’ll end up with nice little policies telling [us] to have ‘just a bit less sugar and a little more balanced diet’ the nonsense that’s gone on since the Second World War during which time we’ve had this vast epidemic of heart disease, diabetes and obesity.”
Even the briefest glance at the official dietary guidance on sugar in Australia or the UK will tell you Professor James wasn’t too far from the mark with his prediction. Our guidelines are stuffed with words like ‘moderation’ and ‘balanced diet’ when it comes to sugar.
But the thing about evidence is, it doesn’t go away. And in the 10 years since the WHO last tried to save us from sugar, the evidence has become overwhelming (to quote Dr Reddy).
The WHO got a serious kicking when they tried to suggest a 10 teaspoon upper limit on sugar consumption, so you can imagine that the evidence they have reviewed must be truly overpowering to have them step up to the plate again. But this time they want the limit to be 5% (5 teaspoons) or less. I hope they’re wearing their flak jackets because I suspect a whole heap of blood money from the processed food industry is pouring into ‘lobbyists’ pockets as we speak.
The WHO is not running down sugar because it hates sugar farmers. It is not doing it because it likes getting mauled by the US Government (and its sponsors). It’s doing it because we will all suffer immensely if we don’t act on its advice.
I don’t know if the WHO can withstand the punishment they are about to receive. And I have no confidence that their recommended limit will make it through the firestorm of food industry sponsored ‘science’ which will suddenly surface. But I do know that when good people decide the evidence is so powerful that they should say it anyway, then the rest of us better be bloody listening.
facts & data points, healthy habits, policy

RAND: Impact of food environment

  • studies prove that people’s choices are heavily influenced by the setting, context, framing, and characteristics of the environment in which they make food purchasing decisions.
  • In the early 1980s, manufacturers discovered that how their products were marketed in stores was among the most important factors in influencing the buying habits of consumers. That fueled an acceleration in the practice of buying supermarket shelf space, a deal in which retailers give preferred placement to the products of wholesalers who pay for it. The ends of aisles, near the check out lines and stand-alone floor displays are choice product locations. This is how that Santa cutout ends up hawking candy canes in the middle of the produce section. People are very sensitive to such displays. As a consequence, purchases from these locations are between two and five times higher than when the same items are placed elsewhere. The products displayed in this way comprise an estimated 30 percent of all supermarket sales and provide the largest profits for manufacturers.
  • Lame remedies then follow…

‘Tis the Season to Be Wary

Deborah Cohen  December 23, 2013
 

During the holiday season it’s more important than ever that consumers consider the fundamental force driving the obesity epidemic in America: the tsunami of novel strategies used to market food. When shopping for holiday food, keep in mind that the treats being proffered by that smiling, life-sized Santa cutout in the aisle of your favorite supermarket may not be the healthiest gift for you and your waistline.

During the holiday season, a time when overindulgence is a tradition for many, food marketing creates especially serious challenges for people trying to limit their intake and make careful decisions about healthier eating. Walk through any supermarket or big box store this time of year and it’s impossible not to be confronted with promotions for fatty appetizers and snacks, processed cookies and cakes, holiday themed sugary drinks and cereals and super-sized chocolates and candy canes.

To be sure, it is ultimately up to individuals whether to reach for that highly processed treat that is all but devoid of nutritional value. Yet the common belief that everyone has the capacity to consciously and independently control what they buy or how much and what they eat is challenged by studies that have proven that people’s choices are heavily influenced by the setting, context, framing, and characteristics of the environment in which they make these decisions. This is a problem all year, of course, but it becomes even more difficult to resist in-store temptation when it is bathed in images of holiday good cheer.

Food purchasing environments are controlled by the food industry, whose goal, like all other businesses, is to increase profits. And the food industry is free to craft a seasonal marketing environment that portrays poor nutritional choices as cherished holiday traditions without regard for the consequences on consumers’ health.

In the early 1980s, manufacturers discovered that how their products were marketed in stores was among the most important factors in influencing the buying habits of consumers. That fueled an acceleration in the practice of buying supermarket shelf space, a deal in which retailers give preferred placement to the products of wholesalers who pay for it. The ends of aisles, near the check out lines and stand-alone floor displays are choice product locations. This is how that Santa cutout ends up hawking candy canes in the middle of the produce section.

People are very sensitive to such displays. As a consequence, purchases from these locations are between two and five times higher than when the same items are placed elsewhere. The products displayed in this way comprise an estimated 30 percent of all supermarket sales and provide the largest profits for manufacturers. They also disproportionately feature highly processed, low-nutrient, “value added” products — the worst for your health. People typically do not recognize that placement figures in their selection of such products, and instead, tend to blame themselves when their holiday shopping trip yields enough fat and sugar to swell even Santa’s ample waistline.

With increasing demand from manufacturers for this premium shelf space, supermarkets have grown larger and larger. The growing variety of products, especially when the holidays are here, can lead people to resort to a type of cognitive processing that relies on mental shortcuts instead of thoughtful decisions. This can lead to impulsive, poor choices based upon superficial characteristics like appearance, pricing, and salience. Thus, the modern supermarket is an environment that increases the risk of chronic diseases all year, but especially now.

Unless we grow our own food, we humans have a limited capacity to avoid exposure to these risk factors. The burden on individuals to keep up their guard, to be wary, and to actively resist an overwhelming food environment has become more than most of us can bear. If we really want to help consumers achieve their long-term goals of controlling their weight and eating a diet that won’t lead to heart disease or diabetes, we need solutions that won’t force people to work so hard.

So how do we make it easier? We need very specific consumer research on how to place products in stores so they don’t overwhelm consumers. Maybe we should segregate all the foods known to increase the risk of chronic diseases from the foods that don’t. Then people who want to limit their exposure can do so, and those who don’t will still be able to choose what they want. Maybe we should set limits on which products can be placed in salient promotional displays. Would consumers feel that their rights had been abridged if they had to travel to the back of the store to get candy and soda, but could find skim milk right up front?

Ordinarily our society does not tolerate flawed designs or business practices that increase the risk of illness or injury. We should no longer accept food marketing practices that undermine our health. As the most important consumer season gets underway, we need to start mitigating these factors if we want better health in 2014.

Deborah A. Cohen, M.D., is a senior natural scientist at the RAND Corporation and the author of the forthcoming book, A Big Fat Crisis: The Hidden Influences Behind the Obesity Epidemic — and How We Can End It.

This commentary appeared on The RAND Blog on December 23, 2013.

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FDA rearguard frame…

It’s all happening anyway. Eventually, the tide will surge and the wall will burst.

Already, an explosion of monitoring, testing, and sensing devices are coming on the market, providing consumers with instant analysis of their fitness, blood chemistry, sleep patterns and food intake. It’s only a matter of time before regulators feel compelled by consumer demand to find a way to accommodate better and cheaper innovations, and for slowly changing industries to dramatically restructure themselves in the face of overwhelming new opportunities. The long-term potential of vast databases of genomic data to improve health outcomes, reduce costs, and reorient the debate on medical priorities is too valuable to be held back for long — and arguably the biggest transformation for the healthcare industry since the discovery of antibiotics in the early 20th century.

http://www.wired.com/opinion/2014/01/the-fda-may-win-the-battle-this-holiday-season-but-23andme-will-win-the-war/

Regulating 23andMe to Death Won’t Stop the New Age of Genetic Testing

  • BY LARRY DOWNES AND PAUL NUNES
  • 01.01.14
  • 6:30 AM

 

Image: ynse/Flickr

 

Market disruptions often occur — or not — as the direct result of unintended collisions between breakthrough technologies and their more incremental regulators. In the latest dust-up, the U.S. Food and Drug Administration (FDA) last month ordered startup 23andMe to stop marketing its $99 genetic analysis kit, just before the Christmas shopping season kicked into high gear.

To date, over half a million customers have taken the swab in return for detailed ancestry data and personalized information on 248 genetic traits and health conditions. The company, which launched in 2007 with substantial backing from Google, has been working closely — albeit more slowly than the FDA would have liked — with the FDA to ensure it complies with federal health and safety regulations. But the agency concluded in its recent warning letter that 23andMe was marketing a “device” that was “intended for use in the diagnosis of diseases or other conditions,” and as such, its marketing materials required pre-approval from the FDA, which includes extensive research studies.

23andMe is an example of what we call a “Big Bang Disruption” — a product or service innovation that undermines existing markets and industries seemingly overnight by being simultaneously better andcheaper than the competition. What’s happening in genomic testing (and healthcare in general) is consistent with our research in over 30 different industry segments, from manufacturing to financial services to consumer products.

When technologies improve exponentially, many industry incumbents — and the regulators who oversee them — are kept constantly off-balance. That’s because incumbents have been indoctrinated by a generation of academic literature and MBA training to ignore disruptive products until they had a chance to mature in the market, assuming they would first appear as cheaper but inferior substitutes that would only appeal to niche market segments.

Doctors — who are also incumbents in this situation — are struggling to respond to disruptive medical technologies that change the power dynamic in the patient relationship. Several 23andMe users have reported taking the FDA’s advice of reviewing their genetic results with their physicians, only to find the doctors unprepared, unwilling, or downright hostile to helping interpret the data.

Often, incumbents’ only competitive response — or the only one they can think of — is to run to the regulators. That’s what’s has been happening to car-sharing services such as Uber, Lyft, and Sidecar; to private drone makers; and casual accommodation services such as Airbnb, to name just a few examples. And now it’s happening to 23andMe, one of hundreds of new startups aimed at giving healthcare consumers more and better information about their own bodies — information that has long been under the exclusive and increasingly expensive control of medical professionals.

Absent any real law on the subject, the agency has strained credulity to categorize 23andMe’s product as a diagnostic “device” — making it subject to its most stringent oversight. The FDA’s letter focuses intently on the potential that consumers will both under- and over-react to the genetic information revealed. The agency fears that users will pressure their doctors for potentially unnecessary surgery or medication to treat conditions for which they are genetically pre-disposed, for example. And it assumes that the costs of such information abuse outweigh any benefits — none of which are mentioned in the agency’s analysis.

The company, of course, has agreed to comply with the FDA’s stern warning, and has ceased providing its customers with anything other than hereditary data. For now. Perhaps it will reach some accommodation with the agency, or perhaps the FDA’s ire will prove untamable, an end to the innovative startup and whatever value its technology might have delivered.

But as with every Big Bang Disruptor in our study, winning the battle and winning the war are two very different things.

The FDA is applying a least common denominator standard to 23andMe, and applying it arbitrarily. Already, an explosion of monitoring, testing, and sensing devices are coming on the market, providing consumers with instant analysis of their fitness, blood chemistry, sleep patterns and food intake. It’s only a matter of time before regulators feel compelled by consumer demand to find a way to accommodate better and cheaper innovations, and for slowly changing industries to dramatically restructure themselves in the face of overwhelming new opportunities. The long-term potential of vast databases of genomic data to improve health outcomes, reduce costs, and reorient the debate on medical priorities is too valuable to be held back for long — and arguably the biggest transformation for the healthcare industry since the discovery of antibiotics in the early 20th century.

The information flood is coming. If not this Christmas season, then one in the near future. Before long, $100 will get you sequencing of not just the million genes 23andMe currently examines, but all of them. Regulators and medical practitioners must focus their attention not on raising temporary obstacles, but on figuring out how they can make the best use of this inevitable tidal wave of information.

Whatever the outcome for 23andMe, this is a losing battle for industry incumbents who believe they can hold back the future forever.

 

Larry Downes & Paul Nunes

Larry Downes and Paul Nunes are co-authors of Big Bang Disruption: Strategy in the Age of Devastating Innovation (Penguin Portfolio 2014). Downes is Research Fellow with the Accenture Institute for High Performance, where Nunes serves as its Global Managing Director of Research. Their book has been selected as a 2014 book of the year by the Consumer Electronics Association.

business, cool, data saving lives, healthy habits, policy

A behavioural vaccine

  • the marshmallow experiment gone wild >> a behavioural vaccine
  • paying tobacconists for cigarettes they refuse to sell to kids
  • paying smoking mothers to quit

 

Listen to the story: 

Good Behavior’ More Than A Game To Health Care Plan

by KRISTIAN FODEN-VENCIL

Danebo Elementary in Eugene, Ore., is one of 50 schools receiving money to teach classes while integrating something called the “Good Behavior Game.” Teacher Cami Railey sits at a small table, surrounded by four kids. She’s about to teach them the “s” sound and the “a” sound. But first, as she does every day, she goes over the rules.

“You’re going to earn your stars today by sitting in the learning position,” she says. “That means your bottom is on your seat, backs on the back of your seat. Excellent job, just like that.”

For good learning behavior, like sitting quietly, keeping their eyes on the teacher and working hard, kids get a star and some stickers.

Railey says the game keeps the kids plugged in and therefore learning more. That in turn makes them better educated teens and adults who’re less likely to pick up a dangerous habit, like smoking.

The Washington, D.C., nonprofit Coalition for Evidence Based Policy says it works. It did a studythat found that by age 13, the game had reduced the number of kids who had started to smoke by 26 percent — and reduced the number of kids who had started to take hard drugs by more than half.

The fact that a teacher is playing the Good Behavior Game isn’t unusual. What is unusual is that Trillium is paying for it. Part of the Affordable Care Act involves the federal government giving money to states to figure out new ways to prevent people from getting sick in the first place.

So Trillium is setting aside nearly $900,000 a year for disease prevention strategies, like this one. Jennifer Webster is the disease prevention coordinator for Trillium Community Health, and she thinks it’s a good investment.

“The Good Behavior Game is more than just a game that you play in the classroom. It’s actually been called a behavioral vaccine,” she says. “This is really what needs to be done. What we really need to focus on is prevention.”

Trillium is paying the poorer schools of Eugene’s Bethel School District to adopt the strategy in 50 classrooms.

Trillium CEO Terry Coplin says changes to Oregon and federal law mean that instead of paying for each Medicaid recipient to get treatment, Trillium gets a fixed amount of money for each of its 56,000 Medicaid recipients. That way Trillium can pay for disease prevention efforts that benefit the whole Medicaid population, not just person by person as they need it.

“I think the return on investment for the Good Behavior Game is going to be somewhere in the neighborhood of 10 to one,” Coplin says.

So, for each dollar spent on playing the game, the health agency expects to save $10 by not having to pay to treat these kids later in life for lung cancer because they took up smoking.

Coplin concedes that some of Trillium’s Medicaid recipients will leave the system each year. But he says prevention still makes medical and financial sense.

“All the incentives are really aligned in the right direction. The healthier that we can make the population, the bigger the financial reward,” he says.

The Oregon Health Authority estimates that each pack of cigarettes smoked costs Oregonians about $13 in medical expenses and productivity losses.

Not all the money Trillium is spending goes for the Good Behavior Game. Some of it is earmarked to pay pregnant smokers cold, hard cash to give up the habit. There’s also a plan to have kids try to buy cigarettes at local stores, then give money to store owners who refuse to sell.

This story is part of a reporting partnership with NPR, Oregon Public Broadcasting and Kaiser Health News.

healthy habits, policy, politics

Multinational businesses harming health

Strong article. Nothing new. Keeping the message out there.

Source: http://www.theage.com.au/comment/unhealthy-big-business-spreading-great-harm-20140105-30bnk.html

Unhealthy big business spreading great harm

January 6, 2014

Rob Moodie

If our negotiators buckle under the pressure applied by third parties, the price of a new trade agreement will be very high.

Illustration: Jim Pavlidis.Illustration: Jim Pavlidis.

Two-thirds of Indonesian men smoke and more than half of Chinese men smoke. Even more disturbing is that 40 per cent of 13-15-year-old Indonesian boys smoke. How have these levels been reached while the world has known for more than 50 years that tobacco is such a deadly habit?

In China, it is now estimated that 114 million people have diabetes. South Africa has one of the highest per capita alcohol consumption rates in the world, with more than 30 per cent of the population struggling with an alcohol problem or on the verge of having one.

Tobacco, alcohol, and diabetes related to overweight and obesity all have one feature in common. They are each largely driven, and in the case of tobacco completely caused, by powerful commercial interests in the form of transnational corporations. It has been said that China’s booming economy has brought with it a medical problem that could bankrupt the health system.

We now face a major dilemma: unrestrained commercial development is pitted against the health and wellbeing of populations. This dilemma is not new – opponents of the abolition of slavery complained it would ruin the economy – but it is manifesting in more obvious ways in the 21st century.

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The tobacco, alcohol and ultra-processed (”junk”) food and drink industries have been rapidly expanding in low and middle-income countries. In the past decade, tobacco retail sales growth in these countries was 20 times that of the developed world. For alcohol consumption it was three times; sugar-sweetened beverages it was twice. But it isn’t only Indonesia, China and South Africa where we find this dilemma; it is alive and well in Australia.

For years we have known that the tobacco industry promotes and funds biased research findings, co-opts policy makers and health professionals, lobbies politicians and officials to oppose public regulation, and influences voters to oppose public health measures through expensive public relations campaigns. This success has been noticed and over the past decade alcohol and ultra-processed food and drink companies have been emulating these very same tactics.

This is of little surprise given the flow of people, funds and activities across the industries. For example Philip Morris owned both Kraft and Miller Brewing; the board of SAB Miller (the second largest alcohol manufacturer) includes at least five past or present tobacco company executives and board members; and the Diageo executive director responsible for public affairs spent 17 years in a similar role at Philip Morris.

Economic development plays an important role in the health and wellbeing of populations. Income, employment and education levels are all major determinants of good health. Businesses create wealth, provide jobs and pay taxes (but as we have seen, not all of them). One of the best ways to protect and promote health is to ensure people have safe, meaningful jobs. The more evenly wealth and opportunity are distributed, the better the overall health and wellbeing of a population.

But clearly not all businesses are good or healthy – yet we see some of them expanding their markets and influence across the globe – seemingly with no capacity to diminish or mitigate the harm they do. It is astonishing that an industry such as tobacco, which is so harmful to human health, can wield so much power. In Indonesia, Philip Morris and its affiliate, Sampoerna, will invest $US174 million to improve production capacities so, as Sampoerna’s president has said, ”Indonesia would be the centre of the Marlboro brand production to cater [for] demands in the Asia-Pacific region”.

Why do they need to expand their activities? Aren’t the existing 700 million smokers in the region enough? Especially when we know that more than half of them will die prematurely, losing about 20 years of life to tobacco.

The major tobacco, food, and alcohol companies have assets that are greater than many countries and can wield this power in parliament, law courts and the media, against the interests of the public’s health.

A new battlefront in this power play is the Trans Pacific Partnership Agreement (TPP). This trade agreement among 12 countries (including Australia, Japan and the US) represents about 40 per cent of the global economy.

The Australian government aims to ”pursue a TPP outcome that eliminates, or at least substantially reduces, barriers to trade and investment” and that will ”also deal with behind-the-border impediments to trade and investment”.

It is highly complex, has 29 chapters, is being negotiated in secret and is provoking considerable criticism on the basis that it could greatly strengthen the hand of some industries to sue national governments for their domestic policies and also greatly weaken the capacity of governments to buy cheaper generic drugs. The Nobel prize-winning humanitarian group Medicins sans Frontieres says the TPP ”could restrict access to generic medicines, making life-saving treatments unaffordable to millions”.

If our trade negotiators buckle under the pressure from other governments, which are, in turn, highly influenced by transnational companies, then Australia will have to confront some major problems. These include delayed availability of cheaper generic drugs and increased cost of medicines; interference with our Pharmaceutical Benefits Scheme; enshrining of rights to foreign corporations, such as tobacco companies, to sue our government; interference with our capacity to introduce health warnings on alcohol packaging, and the limiting of future options for food labelling.

Surely we must find a balance between unrestrained commercialism and maximising health and wellbeing. We need business for our individual and collective wellbeing. However, the benefits unhealthy businesses bring are outweighed by the costs – in terms of premature death, chronic illness, limited healthcare finances, overcrowding of hospitals and loss of productivity from unhealthy employees.

This is why we have governments – to ensure a balance among the rights of individuals, consumers, businesses and society as a whole. If, as Prime Minister Abbott has said, Australia is open for business, then we need to make sure it’s open for good business. If we can’t control the vested interests of unhealthy industries in trade agreements or in our domestic regulations, unhealthy business will come back to bite us all.

Rob Moodie is professor of public health at the University of Melbourne

Read more: http://www.theage.com.au/comment/unhealthy-big-business-spreading-great-harm-20140105-30bnk.html#ixzz2pbgfIvAZ

business, complex adaptive systems, facts & data points, healthcare, policy, politics, quantified self, rapid learning health systems

Dave Chase – How healthcare’s disruption will play out…

 

PDF Report: Volume_to_Value_Revolution

Healthcare’s Trillion-Dollar Disruption

As a healthtech startup, you can’t help but get excited when Bob Kocher (Venrock) or Esther Dyson speak about the opportunities in healthcare given their impressive track records. Both spoke during this past week’s StartUpHealth Summit.

One of Bob’s main points was that the opportunity in healthcare is so big that most startups are thinking too small and his firm is putting their money where his mouth is (e.g. Castlight). Esther has proven time and again to be very prescient — just go back and watch her old interviews on Charlie Rose over the years to see how accurately she predicts the future. She interrupted attending the JP Morgan presentations to visit with the StartUp Health Summit. Paraphrasing, she said companies like those in StartUp Health are the future. Rather than trying to steal share from the companies presenting at JP Morgan, startups should focus on creating the new market space, and the market will move to them…not the other way around.

Transformers vs. Preservatives

While the opportunities are massive, what’s the biggest obstacle to healthcare transformers? It’s the “preservatives” — the incumbent healthcare players. That is, the preservatives are trying to protect the status quo, rather than focusing on how to sincerely address the Triple Aim (improve outcomes, reduce cost, improve patient experience). In every healthcare organization I’ve talked with, whether they are a provider, pharma, or health plan, there are transformers internally who know what to do but are stymied by preservatives.

The same is true politically. There are those who call themselves “progressive” or “conservative.” Unfortunately, it seems that 80 percent of politicos are actually preservatives just doing the bidding of lobbyists trying to protect the status quo. The preservatives are costing thousands of lives and hundreds of billions of unnecessary wasted dollars. The real leaders in healthcare will see through them and get them out of the way of progress.

One of the transformative organizations pushing for change is Oliver Wyman. Oliver Wyman is a leading consultancy that has setup a Health Innovation Center that recently published a paper entitled The Volume-to-Value Revolution (PDF) with the input of an advisory board (PDF) of CEOs ranging from large public companies to emerging companies (disclosure: I’m on the Health Innovation Center Advisory Board). In that paper, authors Tom Main and Adrian Slywotzky make the case that new patient-centered population health models will cause more than $1 trillion of value to rotate from the old models to the new and create more than a dozen new $10 billion high-growth markets (see also Patients Are More Than A Vessel For Billing Codes). Each of these markets creates large opportunities for healthtech startups. Naturally, legacy vendors are optimized for the old models (see Why It’s Good News HealthIT is So Bad) while startups optimize for the new models.

Most industries compete on value. U.S. healthcare does not. But that is about to change.

Healthcare innovators are already redefining healthcare value, putting patients first and inventing with little regard for current constraints. They have ignited a powerful, self-funding upward spiral by focusing first on healthcare’s big opportunities, transforming the value equation, generating large savings, and fueling smart reinvestment in the next wave of innovation. [Introduction, “The Volume-to-Value Revolution”]

In addition, the necessity for change and the accompanying opportunities are causing many healthcare incumbents to establish venture arms. See Strategic Healthcare Investors’ Investment Thesis for more.

Industry Boundaries Rapidly Crumbling

Everyone is getting into each other’s and new businesses. Industry incumbents would be well advised to learn from the mistakes of incumbents in other disrupted sectors. As I observed earlier, providers are making newspaper industry mistakes.

The changes the industry faces will be neither smooth nor linear. A period of intense turbulence will produce more losers and winners than any industry transformation in recent memory. Cross-industry competition (healthcare versus retail versus technology versus others) will erase traditional boundaries and generate exciting new value propositions for patients, payers, and physicians.

For example, just this past week, Walgreen‘s has made it clear they’ll compete with healthcare providers and insurance companies. Competition, as newspapers learned, doesn’t come from obvious places.

Consumerization Of Healthcare

The consumer empowerment taken for granted from everything from buying cars to planning travel is finally arriving in healthcare nearly 15 years later than most industries.

Consumers, long passive, will have a new role. Employer incentives, retail access, and new technology options will encourage them to engage, demand information, and push for value. Baby boomers reaching the age of peak healthcare need will kindle the fire and Millennials focused on nutrition and fitness will keep it burning. The industry’s metamorphosis from a supply-driven market to a more dynamic one driven by demand will happen more quickly and erratically than we expect. Inevitably, mental models will lag behind market reality, and conventional organizations will fight a rearguard battle, hampered by collapsing margins and eroding market share.  [Introduction, “The Volume-to-Value Revolution”]

Walmart recently validated the domestic medical tourism I wrote about awhile back. Their Centers of Excellence program encourages their insured employees to go to the top facilities in the country for free (including travel expenses). The employees have to pay if they choose to go with organizations that haven’t demonstrated a willingness to have a fixed price while producing some of the best outcomes in the world. Love them or hate them, Walmart has a huge ripple effect. Overnight, every facility in America that does cardiac, spinal, or transplant procedures is now competing with Mayo, Cleveland Clinic and other top providers. Sticking to old models and tools endangers the traditional healthcare player.

By 2014, as many as 85 million consumers with $600 billion in purchasing power may be shopping for their own healthcare on public and private exchanges. Many will be making their own decisions about coverage for the first time. Consumers will shop not just for insurance, but also for their preferred population-health manager and standalone services, such as basic procedures and retail clinics. [pg. 18, “The Volume-to-Value Revolution”]

New Models Jeopardize Hospitals

Many are predicting half of hospitals will close by 2020. In Denmark, nearly 70 percent of hospitals closed as they made the shift from a reactive, sick-care model to proactive care model. More clinicians than ever will be needed. They’ll simply have a mainframe-to-smartphone like shift as outlined inhealthcare’s age of agility. Unfortunately, the average hospital is one of the most dangerous places with over 100,000 hospital-acquired infections causing death every year. Hospitals are almost always the most expensive place to deliver care so smart health systems are developing new models with a fresh start — what I call the Xboxification of Healthcare.

One of the reasons providers are choosing cloud-based systems over on-premise software is the resource-intensive deployments required with legacy systems. We’ve seen a small clinic get their cloud-based system fully setup and ready to use in 30 minutes without any onsite people. In contrast,  in that same amount of time, one might be able to order the server that gets shipped to that clinic. They will then require onsite installers, trainers, etc. and have a dramatically higher cost base to run that system.

For entirely rational reasons, those older systems were optimized for internal workflows and maximizing billing since that is what has been rewarded historically. To think that those traditional systems will then work perfectly well in the ascending “No Outcome, No Income” era borders on delusional. The reality is hitting right away. A recent article in a HIMSS publication quoted a leading thinker in healthIT, Shahid Shah, outlining 9 major gaps in existing EHRs. He listed “sophisticated patient relationship management (PRM)” as the first major gap. It’s my opinion that as integral as EHRs have been to fee-for-service, PRM will be to fee-for-value. The old model relegated patient portal functionality to be little more than a marketing checkbox. In the new model, PRM functionality becomes a linchpin. In other words, patient portals have been like pre-Google web search (low value afterthoughts on web portals). As Google demonstrated, with the right circumstances, there was huge value ignored by the established players. Likewise, if PRM is viewed as an afterthought, that will increase the risk to providers during this transformative period. Being flat-footed in a time of great change is extremely risky.

The New York Times reported this past week that the public hospitals are already changing the way they compensate their doctors. The first performance measure they listed was how well patients say their doctors communicate with them. These doctors are used to easy communication in the rest of their life with email, text, Facebook, etc.  Suddenly, the hospital IT departments are going to start hearing from doctors asking why they can’t have tools that are as easy to communicate with their patients in the other areas of their life. It’s a rare occurrence to hear a doctor say how user-friendly and patient-focused their EHR is. Of course, it’s about more than just technology. The technology simply enables new models. Despite many doctors’ fears, often the changes are for the better as was mentioned by Dr. Bob Margolis, founder and CEO of HealthCare Partners, and one of the physician leaders who has demonstrated extraordinary outcomes:

You get to the tipping point, where the physicians go, ‘Wow, life is a whole lot better.’ You know, I only have to see 20 patients a day and I go home at night and I feel like I really helped them’—as opposed to, ‘I saw 45 patients, worked until 10 o’clock because I had to then do all my paperwork, I’m tired and I can barely pay the bills because Medicare and the commercial insurers are cutting back on my reimbursement.’

Oliver Wyman’s report projects that patient-centered care and the shift to value will eliminate $500 billion in low-value-add activities. One has to be in major denial as a healthcare leader to think that we aren’t entering a deflationary era in healthcare. Just watch Bill Gates’ TED Talk on state budgets if you have any doubts. This is exactly the reason the state of New York has moved aggressively to change care and payment models. While doing that, they recognized new models require new technology and didn’t expect they’d get it from legacy providers. This is why the New York Digital Health Accelerator was established. The good news for proactive health systems is that one can thrive in a deflationary period if they shed old assumptions.

A leader at Virginia Mason in Seattle shared how Starbuck’s pushback on costs caused them to look at their entire care proces:

 “90 percent of what the hospital was doing was of no value.” As it turns out, the best way to treat most back pain is with physical therapy. That insight led to new processes, including same-day visits (as opposed to 31-day waits), reduced use of imaging tests and prescription drugs, and the addition of psychological support. Within three months, 94 percent of Starbucks employees with back-pain complaints were back at work within a day.

Even today, many EMR vendors will justify the price tags that reach into the hundreds of millions of dollars on the basis of increased billings. That game is nearly over and those hospitals will be saddled with systems optimized for the old models. This past week there were articles in the New York Times and Washington Post stating that EHRs have “failed”. I’d dispute that. EHRs have done exactly as they were designed — maximize billings. That’s how they are pitched so it should be no surprise that costs haven’t been lowered.

It has been said that “when the rate of change outside exceeds the rate of change inside, the end is in sight.”

Three Waves Of Disruption

Below, I have excerpted and paraphrased some more of Oliver Wyman’s insights from the Volume-to-Value paper illustrating how each of the three anticipated waves of disruption will shift hundreds of billions of revenue from one set of players to another:

Wave 1: Patient-Centered Care (2010-2016). “If we simply mainstreamed today’s best-in-class models of patient-centered, population-health management, the U.S. health system would eliminate nearly $350 billion of low-value-add activity and shift another $600 billion from provider-centered care models to patient-centered care models.” […] ”Five percent of Americans account for 45 percent of healthcare spending—$1.2 trillion. These 15 million unhealthy Americans at the top of the healthcare pyramid are at the heart of the near-term healthcare affordability crisis and the unfortunate victims of our fragmented, illness- focused healthcare system.” [pages 5 and 7, “The Volume-to-Value Revolution”]

 

Cost & population pyramid

Wave 2: Consumer Engagement (2014-2020). In Wave 2, another $150 billion in low-value-add activities is squeezed out, while $400 billion of additional value will rotate to the new retail value chain.

Oliver Wyman transition


Wave 3: The Science Of Prevention (2018-2025). Wave 2 will help Wave 1’s great population managers become even more effective and will devastate provider-centric players who have lagged the market. Wave 3 will make the most highly evolved and adaptive population health managers more powerful and will significantly constrict the Wave 1 players who don’t continue to accelerate innovation.

Big Opportunities Require Big Brains

I once heard someone say, “There’s a lot of big brains working on small problems.” They were commenting on the brainpower working on the 8,000th social media app versus where they should be applying their brains. That is, there are three areas that demand as many big brains as possible — healthcare, education, and energy. As a skier, I often say that healthtech startups are the double black diamond in whiteout conditions of startups: super challenging and exhilarating but not for the faint of heart.

I believe the trick is to understand the idiosyncrasies of healthcare without being shackled by them. If you want to make a difference, there’s no better place than healthcare. Healthcare needs all the engineering talent possible that is often wasted on low-impact areas of the tech industry.

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