Healthcare: ‘Doctor obsession’ to lead to cost blowout
Jonathan Swan — January 2, 2014
Decisions made by Tony Abbott when he was health minister will soon cause a blowout in healthcare costs dwarfing the money saved by introducing a $6 fee for GP visits, a health workforce expert says.
As health minister in the Howard government, Mr Abbott oversaw a massive expansion of new medical schools and student intakes, leading to an oversupply of graduating doctors, said Peter Brooks, former director of the Australian Health Workforce Institute and now a professorial fellow at the University of Melbourne.
Australia is expected to have 2811 superfluous doctors by 2025, based on projections in a March 2012 report by the government body Health Workforce Australia. The figure assumes a modest 5 per cent increase in productivity in the healthcare system.
Health lobby groups often said Australia would be short 2700 doctors by 2025, but the figure was misleading because it assumed no productivity gains would be made, Professor Brooks said.
The boom in medical graduates would ”lead to a blowout in costs” with doctors already giving patients too many unnecessary procedures so they could earn a good living in Australia’s fee-for-service system, Professor Brooks said.
At least $20 billion of ”low value” medical procedures were already being done every year in Australia, he said. If Mr Abbott wanted a ”sustainable” healthcare system, he should address these multibillion dollar structural healthcare problems rather than “fiddling around” with fees for GP visits, Professor Brooks said.
The Medicare controversy kicked off at the weekend with reports of a submission to the government’s commission of audit from Mr Abbott’s former health adviser, Terry Barnes. Mr Barnes said the government would save $750 million over four years by forcing patients who are bulk-billed to pay $6 to visit their GP for each of the first 12 visits a year.
A spokeswoman for Mr Abbott said on Wednesday the Coalition ”won’t be commenting on speculation around what the commission of audit may or may not recommend”. ”Labor spent a lot of money on creating huge health bureaucracies,” she said.
”The Coalition government is committed to directing more of that money back to delivering and improving frontline services for patients.”
The debate over the $6 GP fee – which experts say will harm the poorest and sickest Australians – was obscuring a more important debate over healthcare costs, Professor Brooks said.
Australian governments had become ”doctor obsessed”, ignoring evidence that many of the tasks performed by doctors could be given to other health professionals such as pharmacists, nurse practitioners and physician assistants.
Health Workforce Australia reports that in 2003, 1889 students began medical degrees. By 2012 there were 3686 students starting medicine. Even with international students excluded, the medical education peak body, Medical Deans Australia, said medical graduates more than doubled between 1996 and 2012.
This blog was inspired by a post and follow-up data from Gene Steuerle, and informed by discussions with Tom Getzen. The three of us will be elaborating on this general topic at our Robert Wood Johnson Foundation-funded sustainable health spending symposium on July 30th in Washington DC. Hope to see you there!
The historical growth in health spending as a share of GDP is well-documented and increasingly well-known, having increased from about 6 percent in 1965 to 18 percent in 2012. We know this share will eventually level off – but where? I begin by reviewing the historical trend.
As shown in the first chart, the historical trend since 1965 is roughly on a linear path, increasing by 4 percentage points each 15 years (see, for example, 1975 to 1990 and 1990 to 2005). At this rate, the share would reach 20 percent in 2020, 28 percent in 2050, and 40 percent by 2095. And yes, health spending would reach 100 percent of GDP in about 310 years! OK – we obviously don’t believe this trend will continue for the next 300 years but the chart provides no clue about a leveling-off. What macro variable might we examine for clues as to the longer term path of this line and its possible leveling-off point?
The Health Spending Share of the Growth in GDP
Gene Steuerle has long been a proponent of looking at the per capita growth in health spending as a share of the per capita growth in GDP (a marginal approach). His blogpresents a variety of historical statistics including the chart below. The health share of GDP growth rose during the first three decades beginning in 1960, dropped during the managed care decade of the 1990s, and jumped dramatically during the most recent decade. Between 2000 and 2010, health spending accounted for a whopping 43 percent of total and 87 percent of per capita GDP growth!
Reprinted with permission from Gene Steuerle’s May 2013 blog.
It is difficult to discern any long-term pattern in these shares, particularly with the sharp jump from 2000 to 2010. As Gene notes, this jump is influenced by the recession which affected GDP growth much more than health spending growth.[i] Perhaps we could learn more about the long-term pattern if we eliminated the noise introduced by business cycles, especially the 2007-2009 recession.
Removing the Effects of Business Cycles
The next chart plots the health spending share of real per capita GDP growth for various time periods between 1965 and 2011, after removing the effects of business cycles (the Appendix Chart presents annual data).[ii] I refer to the health spending share of real per capita GDP growth as the “marginal” share. The chart shows that this marginal share increased steadily between 1965 and 1990, from 13 percent for 1965-70 to 29 percent for 1985-90. The 1990-2005 period encompasses the managed care era of very slow health spending growth (roughly 1994-2000), and three years of backlash featuring very high spending growth. Over the total 15-year period, the marginal share is 27 percent. From 2005 through 2011, the marginal share is 31 percent.
Source: Altarum Center for Sustainable Health Spending
Once business cycle effects have been removed, and managed care and its backlash are averaged together, we see a very interesting pattern. The marginal share grows steadily between 1965 and 1990 and then levels off at about 30 percent (a mathematical asymptote). While this may not represent the equivalent of Plank’s constant, it is astounding to find a key macro-level health spending statistic that has been relatively stable for over 20 years! Obviously, there is no guarantee that it will persist long-term, but it is certainly mathematically possible.[iii] It seems unlikely to decrease in the next couple of decades, given our rapidly aging population. But it also seems unlikely to increase, given the unrelenting pressures to control spending.[iv] Thus, 30 percent appears to be a reasonable baseline assumption for longer-term forecasts of health spending growth around which alternative assumptions could be investigated.
What If the 30 Percent Marginal Share Persists?
Let us assume that health spending continues to consume 30 percent of the growth in real per capita GDP. Intuition should tell you that, over time, this will cause the health spending share of GDP to grow from its current 18 percent toward 30 percent. The faster is the growth in real per capita GDP, the faster the growth in the health spending share of GDP toward its upper limit of 30 percent.[v]
The next chart reproduces the historical health spending share of GDP and its linear trend line through 2012 (shown above), and then projects forward to the year 2100 under three alternative growth rates in real per capita GDP. The projections confirm that greater economic growth accelerates the growth in the health spending share of GDP. The middle rate of 1.5 percent is similar to what the Congressional Budget Office (CBO) projected for the latter half of their 10-year forecast. If this rate persists, the health spending share of GDP would reach 20 percent in 2025 and 25 percent in 2070. At the 2 percent growth rate, these milestones would be met sooner (2022 and 2056); while at 1 percent growth they would be met later (2031 and 2100). The projections illustrate how the roughly linear historical trend eventually begins to bend downward toward a long-run upper limit of 30 percent.
Source: Altarum Center for Sustainable Health Spending
Income Elasticity and Excess Growth
The “income elasticity” of health spending and rate of “excess growth” in health spending are statistics of great interest to health economists. The income elasticity refers to the percent increase in real per capita health spending associated with a one percent increase in real per capita GDP, and excess spending refers to health spending growth minus GDP growth. Here are the formulas (via Steuerle) linking these concepts to the marginal share:
Income Elasticity = marginal share / cumulative share
Excess Growth = (Income Elasticity – 1) * GDP growth rate (real per capita)
Under our assumption of a constant 30 percent marginal share, the income elasticity declines steadily over time due to growth in the cumulative share. Consider the 1.5 percent growth projection line from the chart above. In 2013 the cumulative share is 18 percent so the elasticity is 1.7 and excess growth is 1 percent, i.e., we are at GDP+1.[vi] By 2025 the elasticity has fallen to 1.6 and excess growth to 0.8 percent and by 2050 these figures are 1.3 and 0.5 percent respectively. In the long run, the elasticity approaches 1.0 and excess growth approaches 0.0.
As shown in formula (2), excess growth depends upon both the income elasticity andeconomic growth.[vii] Over the past 25 years of a stable marginal share and growing cumulative share, the income elasticity has declined, and this explains part of the decline in excess growth observed over that period. The underlying trend in real per capita GDP growth began dropping in about 2004, resulting in additional reductions to excess growth in recent years and contributing to the pre-recession slowdown.[viii]
Sustainability
Given the focus of the Center for Sustainable Health Spending, I should address the sustainability of a constant 30 percent marginal share. It is certainly sustainable in the sense that it could, mathematically, go on forever. But the more interesting question is whether it is sustainable in terms of federal government financing requirements.[ix]In previous work, we have used 2035 as a target year for a balanced federal budget. Between now and 2035, if the marginal share remains at 30 percent and real per capita GDP growth averages 1.5 percent, excess growth will slow from 1.0 percent to 0.6 percent, averaging about 0.8 percent. According to our Triangle of Painful Choices, tax revenues would have to increase to more than 22 percent of GDP for a balanced budget even if defense and other non-health federal spending (other than social security) were kept to historically low shares of GDP.
If you have managed to follow all of this, you might be thinking we should hope for slower growth in GDP in order to reduce excess growth in health spending. Of course this turns out to be something we should not hope for – but there’s no space to address that here. Come to our symposium where we can delve more deeply into this and other related issues!
APPENDIX CHART
Source: Altarum Center for Sustainable Health Spending
[i] Gene finds a much more stable pattern in recent years by averaging over longer periods, thereby diluting the business cycle effects (see the last chart in his blog).
[ii] I eliminated business cycle effects from GDP using “potential” GDP, and from health spending using a variant of the model described here. More specifically, to purge GDP of business cycles, I began with real potential GDP (PGDP) estimates from the February 2013 Congressional Budget Office (CBO) report. This represents CBO’s estimate of what real GDP would have been each year if the nation was at full employment. Even this series has some significant business cycle-related noise so I used an 11 year centered moving average to provide further smoothing. For health spending, I regressed real per capita health spending on smoothed real per capita PGDP along with a set of business cycle variables (current year and five lagged years) representing the difference between GDP growth and smoothed PGDP growth. I used this model to estimate, for each year, the impact of business cycles on real per capita health spending growth. I then created a health spending series in which these business cycle effects were eliminated. Details are available upon request.
[iii] This mathematical possibility contrasts with the commonly-used statistic – growth in excess of GDP – which cannot remain positive forever.
[iv] Expanded coverage under the Affordable Care Act will almost certainly drive the marginal share well above 30 percent during the years of implementation. But this is a very short-term effect with a minimal impact on the longer-term trend.
[v] The overall share is a mixture of the historical share (18 percent now) and the accumulated future share (30%), with the weights depending upon the cumulative increase in real per capita GDP. Note that if there was no growth in real per capita GDP, the health spending share of GDP would remain constant.
[vi] The elasticity is .30/.18 = 1.7. Excess growth is (1.7 – 1)*1.5 percent = 1 percent.
[vii] We ignore the short-term effects of business cycles; think of real per capita GDP growing along its long term path in this analysis.
[viii] The trend in smoothed real per capita potential GDP averaged 1.9 percent from 1985 through 2004 and 1.3 percent from 2005 through 2011.
[ix] This is the definition of sustainability that our Center has developed.
Some great lines, factoids and observations in this piece:
With half a billion dollars spent by medical lobbyists each year, according to the Washington-based Center for Responsive Politics, our fragmented profit-driven system is effectively insulated from many of the forces that control spending elsewhere. Even Medicare is not allowed to negotiate drug prices for its tens of millions of beneficiaries, and Americans are forbidden by law to re-import medicines made domestically and sold more cheaply abroad.
Many health economists say we must move away from the so-called fee-for-service model, where doctors and hospitals bill every event, every pill, every procedure, even hourly rental of the operating room. Though insurers try to hold down costs by negotiating discounts or limiting reimbursement, this strategy has limited power because armies of consultants now advise hospitals on what is known as “strategic billing”: Losing money from trauma patients? Hospitals can add on a $10,000-plus “trauma activation fee.” Medicare not paying enough for a broken wrist? Add a separate “casting fee” to the bill. “People in fee-for-service are very clever — they stay one step ahead of the formulas to maximize revenue,” said Dr. Steven Schroeder, a professor at the medical school of the University of California, San Francisco.
Given that national or even regional rate-setting is out of the question, most health economists argue that the nation needs a new type of payment model, one where doctors and hospitals earn more by keeping patients healthy with preventive care rather than by prescribing expensive tests. Such models exist: A number of hospital and doctors groups engage in so-called capitated care, where they are paid an annual fee by an employer or individual for all patient needs and must work within that budget. The Affordable Care Act promotes a strategy focused on accountable care organizations, in which similar networks can earn financial rewards for figuring out how to save money while meeting standards for good care. But such models are still far from the norm in a country where a majority of physicians are in business for themselves and doctors and hospitals bill separately.
Reference pricing: Pick a rate they think is fair for a procedure — say $32,000 for a knee replacement, all-inclusive. If a patient wants to go to a hospital with higher fees, the difference comes out of his pocket.
Blumenthal on US health reform: “If you put our health care system on an island and floated it out into the Atlantic it would have the fifth-largest G.D.P. in the world. It’s like saying you have to change the economy of France.”
HAVING spent the last year reporting for a series of articles on the high cost of American medicine, I’ve heard it all. There was Fred Abrahams, 77, a skier who had surgery on both ankles for arthritis — one in New York for more than $200,000 and one in New Hampshire for less than $40,000. There was Matthew Landman, 41, billed more than $100,000 for antivenin administered in an E.R. after a small rattlesnake bite. There was Robin Miller, a Florida businessman, who needed to buy an implantable defibrillator for his ill brother, who was uninsured; the machine costs tens of thousands of dollars, but he couldn’t get a price for a make or a model.
Extreme anecdotes, perhaps. But the series has prompted more than 10,000 comments of outrage and frustration — from patients, doctors, politicians, even hospital and insurance executives.
As of Jan. 1, the Affordable Care Act promises for the first time to deliver the possibility of meaningful health insurance to every American. But where does that leave the United States in terms of affordable care?
Even supporters see Obamacare as a first step on a long quest to bring Americans affordable medicine, with further adjustments, interventions and expansions needed.
There are plenty of interesting ideas being floated to help repair the system, many of which are being used in other countries, where health care spending is often about half of that in the United States. For example, we could strictly regulate prices or preset payment levels, as is currently done for hospital stays under Medicare, the national insurance program for people over 65, or at least establish fair price corridors for procedures and drugs. We could require hospitals and doctors to provide price lists and upfront estimates to allow consumers to make better choices. We could stop paying doctors and hospitals for each service they performed and instead compensate them with a fixed monthly fee for taking care of each patient. We could even make medical school free or far cheaper and then require service afterward.
But the nation is fundamentally handicapped in its quest for cheaper health care: All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here. “A lot of the complexity of the Affordable Care Act arises from the political need in the U.S. to rely on the private market to provide health care access,” said Dr. David Blumenthal, a former adviser to President Obama and president of the Commonwealth Fund, a New York-based foundation that focuses on health care.
With that political backdrop, Obamacare deals only indirectly with high prices. By regulating and mandating insurance plans, it seeks to create a better, more competitive market that will make care from doctors and hospitals cheaper. But it primarily relies on a trickle-down theory of cost containment. The Princeton health economist Uwe E. Reinhardt has called it “a somewhat ugly patch” on “a somewhat ugly system.”
With half a billion dollars spent by medical lobbyists each year, according to the Washington-based Center for Responsive Politics, our fragmented profit-driven system is effectively insulated from many of the forces that control spending elsewhere. Even Medicare is not allowed to negotiate drug prices for its tens of millions of beneficiaries, and Americans are forbidden by law to re-import medicines made domestically and sold more cheaply abroad.
And so American patients are stuck with bills and treatment dilemmas that seem increasingly Kafkaesque. The hopeful news is that American health care spending has grown at a slower pace over the past four years. While that is partly because of the recession, economists say, many credit the cost-containing forces unleashed by Obamacare with a significant assist. Even at that rate, many models suggest that nearly 25 percent of gross domestic product will be eaten up by health care in 20 years. That is not sustainable.
“It’s like a diet you can’t just stop, because it’s starting to work,” said Michael Chernew, an economist at Harvard Medical School. “And remember, we haven’t even lost weight yet, we’re just gaining weight more slowly.”
Many health economists say we must move away from the so-called fee-for-service model, where doctors and hospitals bill every event, every pill, every procedure, even hourly rental of the operating room. Though insurers try to hold down costs by negotiating discounts or limiting reimbursement, this strategy has limited power because armies of consultants now advise hospitals on what is known as “strategic billing”: Losing money from trauma patients? Hospitals can add on a $10,000-plus “trauma activation fee.” Medicare not paying enough for a broken wrist? Add a separate “casting fee” to the bill.
“People in fee-for-service are very clever — they stay one step ahead of the formulas to maximize revenue,” said Dr. Steven Schroeder, a professor at the medical school of the University of California, San Francisco.
Given that national or even regional rate-setting is out of the question, most health economists argue that the nation needs a new type of payment model, one where doctors and hospitals earn more by keeping patients healthy with preventive care rather than by prescribing expensive tests.
Such models exist: A number of hospital and doctors groups engage in so-called capitated care, where they are paid an annual fee by an employer or individual for all patient needs and must work within that budget. The Affordable Care Act promotes a strategy focused on accountable care organizations, in which similar networks can earn financial rewards for figuring out how to save money while meeting standards for good care. But such models are still far from the norm in a country where a majority of physicians are in business for themselves and doctors and hospitals bill separately.
The new law includes a number of incentives intended to nudge doctors, hospitals and insurers to join groups and focus more on value, “but we don’t know how well they’re going to work,” said John Holahan, a fellow at the Urban Institute’s Health Policy Center.
For example, the law will tax premiums for the most expensive insurance plans to keep luxury health care spending down. And Medicare, through a value-based purchasing program set up by the law, is providing bonuses to doctors and hospitals for meeting quality-care standards. But those are tentative steps. In fact, recent research published in the journal Health Affairs concluded that the magnitude of bonuses now offered to hospitals was too small to change behavior, noting that even supermarket coupons tended to offer benefits worth well over 10 percent of total value.
The Affordable Care Act generally requires patients to be responsible for more of their bills — copays and deductibles — so they will become more price-savvy medical consumers. But the deck is stacked against them in a system where doctors and hospitals are not required or expected to provide upfront pricing. Why not? They should tell and patients should ask. (In France, before a hip replacement on a private patient, doctors must sign a contract that includes a price.)
And policy makers need to address two of the biggest drivers of our inflated national health care bill: the astronomical price of hospitalizations and particularly end-of-life care.
Obamacare plans cap an individual’s annual out-of-pocket spending at $6,350 a year. That (happily) prevents bankruptcy, but it also means that patients will still not be very discerning shoppers when it comes to major hospitalizations, since — in the United States — they’ve quite likely surpassed their out of pocket maximum by the time they’ve been formally admitted.
On the private side, some companies and employee health plans are experimenting with new payment models to limit these large bills. They may follow Medicare, which offers hospitals bundled payments for given procedures, or try a technique known as reference pricing, in which they pick a rate they think is fair for a procedure — say $32,000 for a knee replacement, all-inclusive. If a patient wants to go to a hospital with higher fees, the difference comes out of his pocket.
To rein in price increases, companies and insurers have begun offering patients narrower networks, already a major gripe about many Obamacare plans.
And as choices narrow while prices rise, I sense that many patients are no longer so devoted to a market-based health care system. Barbara Felton, 86, was “shocked” when she saw her $12,000 itemized hospital bill for a recent brief stay to repair a fractured femur in Pocatello, Idaho. “I’ve never been in favor of a single payer before, but now I am,” she said, referring to a government-run health system.
The perfect recipe for containing medical costs remains to be written and must be tweaked thoughtfully. After all, the American health care system is a major part of the economy. As Dr. Blumenthal, the former Obama adviser, put it: “If you put our health care system on an island and floated it out into the Atlantic it would have the fifth-largest G.D.P. in the world. It’s like saying you have to change the economy of France.”
But after a year spent hearing from hundreds of patients like Mr. Abrahams, Mr. Landman and Mr. Miller, I know, too, that reforming the nation’s $2.9 trillion health system is urgent, and will not be accomplished with delicate maneuvers at the margins. There are many further interventions that we know will help contain costs and rein in prices. And we’d better start making choices fast.
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Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, “Paying Till It Hurts.”.
The Swedish Institute for European Policy Studies (SIEPS) has established a discussion around how to develop laws of sufficient impact to make a difference and strength to withstand inevitable industry challenge.
Related topics: Legislation, Nutrition labelling, Sugar, salt and fat reduction, Marketing
Passing EU-wide regulations on the food industry for reducing non-communicable diseases (NCDs) is not a question of ‘whether’ but ‘how’, according to a new report published as part of the Swedish Institute for European Policy Studies (SIEPS) research project, known as Social Europe.
Health researchers and policy makers must engage more thoroughly with the legal issues relevant to regulations that aim to reduce NCDs to ensure that such strategies ‘can withstand industry challenges’, the report says.
The report (found here) examines the development of EU regulation targeting three risk lifestyle factors (tobacco, alcoholic drinks, and unhealthy diets) and analyses the role of law in developing successful transnational NCD control and prevention strategies.
“Our analysis has shown, a broad range of strategies exists to prevent and control NCDs. These different strategies have different natures, involve different actors and vary in scope, yet as they all require some forms of legal intervention, they illustrate how the law may offer opportunities for the prevention and control of NCDs as well as constraints,” reads the report – which is authored by two leading experts in the field; Professor Alberto Alemanno of l’Ecole des Hautes Etudes Commerciales (HEC), and Professor Amandine Garde at the University of Liverpool.
“The question is not so much whetherthe law can play an important role in promoting healthier lifestyles. Rather, the question is how the law can be validly designed to support effective NCD prevention and control policies.”
Writing in the preface of the report, Anna Stellinger, director of SIEPS noted that the laws and regulations surrounding NCDs are a ‘highly sensitive area,’ in which the law needs to be seen not just as a source of opportunity, but also as a potential source of problems.
“The importance of this question cannot be understated: good laws concerning NCDs must be able to withstand legal challenges as much as can possibly be anticipated,” commented Garde and Alemanno.
Indeed, they suggested in turn that the public health community develop the skills it both lacks and urgently needs to oppose the audacious legal arguments industry operators have relied upon to challenge in court the development of NCD agendas at global, regional, national and local levels.
“The more the public health community can deal with the legal constraints that the law imposes on public authorities, the more it can maximize the opportunities that the law offers to the NCD prevention and control agenda.”
Speaking with FoodNavigator, Professor Garde said the report argues that while the European Union has a range of regulatory tools at its disposal to promote healthier lifestyles, it has used much more in relation to tobacco than alcoholic beverages and unhealthy diets, “not least in relation to marketing regulation”.
“We are also calling on the health community to engage more systematically and thoroughly with legal issues relevant to NCD prevention and control to ensure that the strategies they are calling for can withstand industry challenges,” she said.
This hour long presentation covers the key points from Taleb’s Antifragile. It doesn’t matter how often I read or listen to this, it still comes across as massive. Interesting that the UK conservatives are taking it up with vigor, hmm….
In 2006 Nassim Taleb came to prominence with the publication of The Black Swanand the idea that the world is full of highly improbably and unpredictable events. In his latest book Antifragile he explains how to live with, and respond to, these seemingly random and unforeseen black swan events.
The key he says is to create systems that are Antifragile; ones that are not simply robust or resilient but can adapt and improve when subjected to uncertainty, chaos and volatility.
Highlights of Antifragile – RSA (UK) 6th Dec. 2012
Distinguished Professor of Risk Engineering at New York University’s Polytechnic Institute.
Author of ‘Antifragile: how to live in a world we don’t understand’ (Allen Lane, 2012).
Rohan Silva
Senior policy adviser to UK Prime Minister, David Cameron.
rich american’s die earlier than rich people in other countries
Having a sicker population, Woolf points out, means a sicker economy and a sicker future for the U.S.
“Anyone that lives on mac and cheese, a lot of this packaged food, probably will grow up in one way or another addicted to this type of food. It’s well-known that there is very clear evidence that packaged foods are designed to be addictive,” he says. “Do you know anyone who is addicted to chicken or fish or celery? That doesn’t exist.”
We were standing at Target in an aisle we’d never walked down before, looking at things we didn’t understand. Pill splitters, multivitamins, supplements, and the thing we were here to buy: a long blue pill box—the kind with seven little doors labeled “S M T W T F S “ for each day of the week, the kind that old people cram their pills into when they have too many to remember what they’ve already taken.
My husband, Joe Preston, shook his head. “Do I really need this?”
I grabbed it off the shelf and threw it in our basket. And when we got home, Joe—then a fit and fairly spry 30-year-old man with a boss-level beard—stood at the kitchen counter, dropping each of his prescriptions with a plink into the container.
I guess it’s true that life is full of surprises, but for the three years since Joe’s crippling pain was diagnosed as the result of an autoimmune disease called Ankylosing Spondylitis, our life has been full of surprises like this one. Pill boxes, trips to the emergency room, early returns from vacation. Terms like “flare-up” have dropped into our vocabulary. We’ve sat in waiting rooms where Joe was the only person without a walker or a cane. Most of our tears have been over the fact that these aren’t the kind of surprises either of us thought we’d be encountering at such a young age.
But here’s the thing: We recently realized we weren’t alone. Almost all of our friends are sick, too. When we met our friend Missy Narrance, Joe found solace in talking to her about his health. She’s 29 and has been battling lupus and fibromyalgia for the past 10 years. She’s been through chemotherapy twice, and her daily symptoms are so extreme that she was granted federal disability status when she was just 23 years old. In our close group of friends—who range from 25 to 35 years old—we know people with everything from tumors to chronic pain. Sometimes our conversations over beers on a Friday night turn to discussions of long-term care and miscommunication between doctors.
I thought this would be the time when we’d be preparing for the rest of our lives: earning money, going on fun vacations, having families, building our careers. And we are, but at the same time, we’re doing it while we’re trying to manage pain symptoms, chase down prescriptions, and secure stable health insurance. When I was in college, I remember being prepared to survive in the workforce, but I don’t remember a class that told me how to do that if half of your household is in so much pain on some days that they can’t get to work. I’m barely over 30. I thought I had so much more time before I had to think about this stuff.
I wondered if this was normal. Do we know so many people who are dealing with pain because people are just getting sicker in general?
I found out that they kind of are. It turns out that chronic conditions like what Joe and my friends are dealing with are one of America’s biggest health emergencies. And it’s one that many people say we’re not prepared to deal with.
Not surprisingly, the CDC says cancer is still the second leading cause of death for Americans. But not only do chronic conditions—a category that includes everything from autoimmune diseases like arthritis and lupus, to obesity, heart disease, and diabetes—claim the number one spot, they’re compromising Americans’ quality of life and disabling people for long periods of time. Take arthritis for example: Right now, the CDC says it affects 1 in 5 adults, and is the most common cause of disability in America. “As the U.S. population ages, the number of adults with doctor-diagnosed arthritis is projected to increase from 46 million to 67 million by 2030, and 25 million of these individuals will have limited activity as a result,” the CDC report reads.
But it’s not just that Americans are getting sicker—it’s that young Americans are getting sicker. A 2013 report by the National Research Council and Institute of Medicine (NAC/IOM) echoes the shock of that fact. “The panel was struck by the gravity of its findings,” it reads. “For many years, Americans have been dying at younger ages than people in almost all other high income countries.”
Steven Woolf, director of the Center on Society and Health at Virginia Commonwealth University, helped prepare the NAC/IOM report and brought the findings before the U.S. Senate last month during a discussion on what is ailing Americans. In particular, Woolf points at how data is painting a bleak future for American women.
“Women are less likely to live to age 50 if they’re born in the United States than other high income countries,” he says. “I have a chart where we show this pattern going back to 1980. Back then if you looked at the survival of women to age 50, the U.S. was in the middle of the pack. Over time, not only has the U.S. fallen down in the ranking, they’ve fallen off the chart. That’s something we’re trying to understand.”
And don’t be mistaken, Woolf says: The United States’ outlook isn’t skewed from other countries’ because of its diverse people and massive disparities in socioeconomic status. “We analyzed the data by a variety of social classes and have found that the problem is pervasive. Rich Americans die earlier than rich people in other countries. College-educated people die earlier than college-educated people in other countries,” he says. “It’s misguided for people who are better off and doing well to think that this is someone else’s problem.”
“It’s very concerning,” Woolf says. “We are living shorter lives than people in other countries. We’re sicker than people in other countries.”
In fact, a recent report by the University of Washington’s Institute for Health Metrics and Evaluation, says that “in some U.S. counties… life expectancies are on par with countries in North Africa and Southeast Asia.”
Having a sicker population, Woolf points out, means a sicker economy and a sicker future for the U.S.
“In terms of the economy… this means that American businesses are at a competitive disadvantage with other countries because their workforce is sicker. This doesn’t bode well [for] the next generation’s well-being in terms of health and life expectancy.”
It’s noon on a Thursday, and my friend Missy is sitting in her pajamas. For the past six years since she was put on disability, this is what her day-to-day life has looked like. She draws and paints compulsively, holed up in the tiny room she shares with her boyfriend in a house with four other people. She watches a lot of documentaries, and she sleeps constantly.
For her, discovering she had lupus and fibromyalgia was a weight lifted off her shoulders. Ever since she was in junior high and discovered swollen lymph nodes under her arms, she ping-ponged between doctors and different diagnoses. Being sick meant that she missed her last semester in high school. She watched her friends fall away as they worried about prom, and she worried about chemotherapy. She told any guy that wanted to date her that if they wanted to leave because she was sick, she understood.
She grappled with constant guilt, thinking that maybe she wasn’t really sick—that she could bite the bullet and be a productive member of society if she tried hard enough. So when she found out that her condition had a name, it was a relief.
“That’s the thing that a lot of people with chronic illness go through. When they finally are diagnosed … it is so relieving,” she says. “Because you have likely been questioned by people about your health and about your symptoms, therefore you’ve questioned yourself about your symptoms and [felt] some sense of guilt. Or [thought], ‘Maybe I’m wrong. Maybe I’m not really experiencing what I’m experiencing.’”
“And so when someone else finally comes in, who knows what they’re talking about, and is like ‘You’ve had these illnesses and you’ve been dealing with these symptoms,’ it’s so relieving. It’s like, ‘God. Thank you. Finally. Thank you.’”
Dr. Enrique Jacoby, regional advisor for healthy eating and active living for the World Health Organization (WHO), says people like Missy and my husband Joe might just be victims of the American lifestyle.
“We’re sicker for a number of reasons. Not one single factor is to be blamed for the problem,” Jacoby says. “One of the reasons is we are eating bad. We are being excessively exposed to junk food… We have more pollution because of biofuels that are really, really bad for you.”
He points to the way American cities have grown so large that people are almost required to drive everywhere instead of walking, which means most people aren’t getting anywhere near the right amount of exercise. Jacoby says that 100 years ago the most popular public spaces were parks and plazas—places that encouraged exercise and social interaction. Today, they’re roadways.
I ask Jacoby: Are my friends sick, by chance, because they grew up eating Spaghetti-O’s and Kraft macaroni and cheese like every other kid in the 1980s? Are they victims of an era driven by convenience foods and sugary drinks? (Joe’s father was a Pepsi salesman.)
“Anyone that lives on mac and cheese, a lot of this packaged food, probably will grow up in one way or another addicted to this type of food. It’s well-known that there is very clear evidence that packaged foods are designed to be addictive,” he says. “Do you know anyone who is addicted to chicken or fish or celery? That doesn’t exist.”
While Missy and Joe both possess certain genes that allow them to have these diseases, Jacoby says dependence on processed food as children might have been what brought them to the surface. And it might be the story behind what’s happening to so many Americans.
So, according to this theory, our genes aren’t really changing, but they’re confused. “It’s not going to be an immediate genetic change in society, but what we’re experiencing is that our genes’ expression is being, in a way, modified,” Jacoby says.
It might be that our lifestyle is why Americans are so sick. Another theory, according to Dr. Frederick Miller of the National Institute of Environmental Health Sciences, might be that humans are being weeded out in different ways than in the past, as more communicable diseases have been eliminated.
“If you do away with the infectious disease risks that perhaps killed off a number of individuals early in life [in the past], people who may have altered immune systems, who perhaps couldn’t have handled [those infections, then] go on in adulthood to develop these diseases,” he says.
He points to the “hygiene hypothesis”: As humans have eliminated infections and led cleaner early lives, allergies and autoimmune disease incidences have increased because of our underdeveloped immune systems. “It’s not completely proven, it’s a hypothesis,” Miller says, “But it is consistent with some of the data out there.”
“There may not be too many free rides in this world,” he says. “As we move away from one disease, we may be moving toward other diseases.”
My husband says he’s lucky. Not because he’s sick, but because it could be so much worse. Joe still holds down a full-time job as a creative director at an advertising agency. He’s still able to play drums in his band.
And, in some ways, he’s just started dealing with his disease. For a long time, he didn’t even want to go to do the doctor to see if something was wrong with him. He’d been diagnosed with Juvenile Rheumatoid Arthritis when he was in elementary school, but that went away when he got older. He figured this pain might just be a new version of that.
“But then at some point I complained enough when I wasn’t paying attention,” he said to me one night as we sat on our couch with a tape recorder rolling. “I complained enough times, [then] you said something enough times, to where I finally decided to go back.”
He says he remembers thinking “if I go and it does turn out to be something, then it’s something I have to deal with.” He was young, after all. Could there really be a problem?
Since he’s been diagnosed, he says he’s done a lot of thinking about how he never expected he’d be dealing with a disease at this point in his life, and how that’s become a polarizing factor with other people our age that aren’t sick.
“It’s, like, I’m still only 33. I probably am still considered in a lot of people’s eyes [to be] youthful enough that I shouldn’t have to deal with thinking about this kind of stuff,” he says. “I feel like my parents were still partying and drinking beers [at 33]. This is the age my Dad was when they had me. I don’t think [he] was worrying about what fucking pills he was going to take or not take, you know what I mean? They were like ‘We’re out of Budweiser.’”
Miller says that when young people are dealing with chronic conditions, it can have a huge impact on the economy, health care system, and the formation of future generations.
“One of the unique things about autoimmune diseases, as opposed to cancer, is that these are more likely to be long-term,” he says. “You’re not just dealing with the immediate problems, but the entire lifelong implications of that.”
It’s a fact that the Institute for Health Metrics and Evaluation noted in its report: “Diseases of poverty, such as communicable, maternal, nutritional and newborn causes, have decreased universally while non-communicable conditions traditionally associated with wealthier countries have risen,” it reads. “As people live longer and die at lower rates, the number of years spent living with disability… has increased.”
Woolf says there is still much research to be done into what’s causing Americans to be so sick. But he says this future we’re headed toward is preventable.
“We’ve known for many years what needs to be done about this,” he says. “The problem is not a lack of knowledge about what to do, but a lack of resolve and resources for how to do it… For each [issue], there are major blue ribbon reports that have outlined precisely what needs to be done about it.”
So why hasn’t it happened?
Woolf says that legislation to create a healthier America—from improved nutritional quality of food to taxes on soda—is seen as an affront to personal liberty. “A willingness to implement public policies … often involves higher taxes that American taxpayers don’t want to spend, or a willingness to change personal freedoms.”
“We can still have a free society but accept some limits on what we do to try to promote good health,” he continues. “There’s such a visceral reaction to what is perceived as a nanny state … or what people think of socialized welfare states, that any semblance of that tends to get rejected.”
Right now, he says that so much research about American health—particularly women’s health—is very new.
“I just think it’s something that hasn’t been widely disseminated,” he says, pointing to the NRC/IOM report “Shorter Lives, Poorer Health.” “The general media … haven’t been briefed about this sufficiently.”
And because of that, people aren’t ready to make healthy, infrastructural changes.
“It might be that we as a society make an informed decision that, yeah, we may pay the price for it in terms of poor health, but we get to live our lives the way we want to,” he says. “I feel that that’s okay, as long as we are making that choice as informed citizens. The problem is that I don’t think that the American public knows that that’s happening, or that American parents know that their kids will live shorter lives than in other countries.”
Jacoby, of the WHO, agrees, saying chronic conditions have become a top priority for his organization. “Chronic conditions are really, really stealing lives.”
Back at our house, Joe and I have been talking for hours about his condition and how it affects his daily life. I’ve been crying for most of the conversation, especially when we talk about the future. We talk about how our friend, Missy, can’t leave her house much. Catching someone’s cold could sideline her for weeks. Even fluorescent lights in grocery stores start to make her sick to her stomach.
We talk about how we hope that Joe never has to stop doing the things he loves because of his condition.
“I’m just sad for other people that they can’t do more. That would be the tougher thing. At least, I have very little that I can complain about,” he says. “But in the same breath, the thing that worries me about it, is that it would be one thing if I was 50 or 60. But I’ve got a long time to get worse. Time can be a friend and an enemy, I suppose. That’s just life, I guess.”
Artificial sweeteners are safe and effective tools for weight management, says obesity specialist
By Elaine WATSON, 26-Nov-2013
Related topics: Sweeteners (intense, bulk, polyols), R&D, Food safety, The obesity problem, Health & Wellness, Beverage, Healthy Foods
While consumer concerns over artificial sweeteners have been blamed – in part – for the funk the diet soda market currently finds itself in (click here ), the fact remains that they are safe and effective tools for weight management, according to one obesity specialist.
Suzanne Phelan, PhD, associate professor in the kinesiology department at California Polytechnic State University and adjunct associate professor in the department of psychiatry, Brown Medical School, is an expert in the application of behavioral methods to prevent and treat obesity.
She is also co-principal investigator of the National Weight Control Registry, an ongoing longitudinal study evaluating 5,000+ successful weight losers.
People trying to manage their weight need to spend their calories wisely
Speaking to FoodNavigator-USA after contributing to a myth-busting session on low- and no-calorie sweeteners at the recent ObesityWeek conference in Atlanta, Georgia, Dr Phelan said that in an ideal world, we’d all just drink water to stay hydrated.
However, if people want something sweet, beverages using high intensity sweeteners can quench thirst without adding empty calories, she said, noting that people that successfully lose weight – and keep it off – are less likely to consume sugar sweetened beverages.
Long term successful weight losers consume smaller proportions of sugary drinks
No one food is to blame for obesity, and soft drinks companies are right that balancing calories consumed with calories expended is a key factor in weight management, she said.
However, achieving this balance is a lot harder if you regularly consume large amounts of empty calories from sugar sweetened beverages, she added.
On the firm’s latest earnings call, PepsiCo CEO Indra Nooyi said: “In the last 6-9 months, there has been an accelerated decline in diet drinks as people say they don’t want artificial sweeteners, they want more natural sweeteners, they don’t mind some calories. We are seeing a fundamental shift in consumer habits and behaviors.”
“People trying to manage their weight need to spend their calories wisely andif you want to save calories, cutting out sugar-sweetened beverages and replacing them with water or beverages sweetened with low or no calorie sweeteners is a good way to do this.
“If you look at long term successful weight losers, they are consuming smaller proportions of sugary drinks – they are minimizing their consumption of sugary drinks and juices.”
(Click here to read about a recent Harvard meta-analysis showing that sugar-sweetened beverage consumption promotes weight gain in children and adults.)
No evidence that diet sodas make people crave sweeter foods or serve as an appetite stimulant
Asked if she thought former NYC mayor Michael Bloomberg’s attempts to cap sizes of sugary drinks sold in certain outlets at 16oz were helpful, she said: “We should give initiatives like this a try. I’m in favor of government efforts to make it easier for people to consume fewer calories.”
As for the oft-quoted hypothesis that diet soda and other artificially sweetened products make people crave sweeter foods or serve as an appetite stimulant, there is “no evidence” to support this claim, she said.
(Click here to read a 2010 review in the British Journal of Nutrition which found that “there is no consistent evidence that low-energy sweeteners increase appetite or subsequent food intake, cause insulin release or affect blood pressure in normal subjects”. A more recent study –click here – published in the American Journal of Clinical Nutrition in Feb 2013 came to the same conclusion.)
Correlation, not causation
Meanwhile, a 2012 study also published in the American Journal of Clinical Nutrition (click here ) showed that replacing caloric beverages with non-caloric beverages was an effective weight-loss strategy, while a 2009 study co-authored by Dr Phelan in 2009 and published in the International Journal of Obesity (click here ) showed that those who have lost weight and successfully kept it off adopt a number of strategies, including drinking more artificially sweetened beverages, she said.
Dr Suzanne Phelan: People trying to manage their weight need to spend their calories wisely
So why do some commentators still insist that diet soda is responsible for all manner of problems?
For example, a recent opinion article published in the journal Trends in Endocrinology and Metabolism by behavioral neuroscientist Dr Susan Swithers alleged that regular consumption of diet sodas induced “metabolic derangements”putting users at “increased risk of excessive weight gain, metabolic syndrome, type 2 diabetes, and cardiovascular disease.”.
In the literature, there are some large scale epidemiological studies showing a correlation between consumption of low and no calorie sweeteners and increased risk of some of these health problems, said Dr Phelan, “so that has created a natural state of confusion.”
But this is correlation not causation, she said, and randomized controlled trials do not show similar results.
Meanwhile, a study by Harvard researchers published in the journal Circulation in 2012 (click here ) analyzing the Health Professionals Follow-Up Study, a prospective cohort study including 42,883 men, found that artificially sweetened beverage intake was not associated with increased risk of coronary heart disease risk.
The authors also said their results “highlight the need for cautious interpretation of studies reporting positive associations between diet drinks and cardiometabolic and cardiovascular outcomes”.
Artificial sweeteners and safety
As for safety, aspartame and sucralose are among the most thoroughly tested ingredients in the food supply and have been deemed safe by all major scientific and regulatory bodies from Health Canada to the FDA, the Joint Expert Committee on Food Additives (JECFA) of the World Health Organization (WHO) and Food and Agriculture Organization (FAO); and the European Food Safety Authority, added Dr Phelan.
The Ministry of Health New Zealand uses big data analytics to accurately determine current and predict future diabetic population to improve diabetes policy planning.
In collaboration with experts from the New Zealand Society for the Study of Diabetes (NZSSD), the ministry created a Virtual Diabetes Register (VDR) that pulls and filters health data from six major databases.
The six data sources were: hospital admissions coded for diabetes, outpatient attendees for diabetes and diabetes retinal screening, prescriptions of specific antidiabetic therapies, laboratory orders for measuring diabetes management and primary health (general practitioner) enrollments.
According to Emmanuel Jo, Principal Technical Specialist at Health Workforce New Zealand, Ministry of Health, the previous way of measuring diabetes using national surveys was inefficient, expensive and had a high error rate.
The new analytical model, using SAS software, significantly improved the accuracy and robustness of the system, combining several data sources to generate greater insights.
Interestingly, analytics showed that Indian and Pacific people have the highest diabetes prevalence rate, said Dr. Paul Drury, Clinical Director of the Diabetes Auckland Centre and Medical Director of NZSSD. Health policies can therefore be focused on this group.
“We have 20 different District Health Boards, and the data can show them how many diabetic people are in their area,” Drury said.
“GPs should know already how many they have, but the VDR is also able to help them predict who may be at risk so they can be prepared. By knowing the populations where diabetes is more prevalent, more resources can be directed at them to provide clinical quality improvements,” he added
Patient privacy is protected by regulating access to data in the VDR.
Exercise could be as effective as some of the best drugs which protect against major diseases, research has found.
A study of more than 300 trials has found that physical activity was better than medication in helping patients recovering from strokes – and just as good as drugs in protecting against diabetes and in stopping heart disease worsening.
The research, published in the British Medical Journal, analysed data about studies on 340,000 patients diagnosed with one of four diseases: heart disease, chronic heart failure, stroke or diabetes.
Researchers said the findings suggested that regular exercise could be “quite potent” in improving survival chances, but said that until more studies are done, patients should not stop taking their tablets without taking medical advice.
The landmark research compared the mortality rates of those prescribed medication for common serious health conditions, with those who were instead enrolled on exercise programmes.
Most of the 305 studies examined involved patients had been given drugs to treat their condition. But 57 of the trials – involving 15,000 volunteers – examined the impact of exercise as a treatment.
The research found that while medication worked best for those who had suffered heart failure, in all the other groups of patients, exercise was at least as effective as the drugs which are normally prescribed.
People with heart disease who exercised but did not use commonly prescribed medications, including statins, and drugs given to reduce blood clots had the same risk of dying as patients taking the medication.
Similarly, people with borderline diabetes who exercised had the same survival chances as those taking the most commonly prescribed drugs.
Drugs compared with exercise included statins, which are given to around five million patients suffering from heart disease, or an increased risk of the condition.
The study was carried out by researcher Huseyin Naci of LSE Health, London School of Economics and Political Science and Harvard Medical School, with US colleagues at Stanford University School of Medicine.
He said prescription drug rates are soaring but activity levels are falling, with only 14 per cent of British adults exercising regularly.
In 2010 an average of 17.7 prescriptions was issued for every person in England, compared with 11.2 in 2000.
Mr Naci said: “Exercise should be considered as a viable alternative to, or alongside, drug therapy.”
Dr John Ioannidis, the director of the Stanford Prevention Research Center at the Stanford University School of Medicine, said: “Our results suggest that exercise can be quite potent.”
Other medications compared with exercise included blood-clotting medicines given to patients recovering from stroke, and alpha-glucosidase inhibitors given to patients on the cusp of developing diabetes.
Only the patients who were recovering from heart failure fared best when prescribed drugs, where anti-diuretic medication was most effective.
However, they said their analysis found far more trials examining drugs, than those which measured the impact of exercise.
They said there was a need for more research into the benefits of exercise for those suffering from serious health problems.
Researchers stressed that they were not suggesting that anyone should stop taking medications they had been prescribed, but suggested patients should think “long and hard” about their lifestyles, and talk to their doctors about incorporating more exercise into their daily routines.
@22mins: moving from guideline care to personalised care
@26mins: Bureaucracy is important and necessary, but should stick to what it’s good at doing:
The fair and open employment and promotion of people
The un-corrupt management of money
!! Not the curing of disease or delivery of health care – populations defined by need, not jurisdiction
@32mins: law of diminishing returns – benefits plateau as invested resources rise
@33mins: Harmful effects of healthcare increase in direct proportion to the resources invested
@34mins: combine the 2 curves – get a j-shaped curve with a point of optimality – the point of investment after which, the health gain may start to decline
@35mins: as the rate of intervention in the population increases, the balance of benefit and harm also changes for the individual patient
20th Century Care >> 21st Century Care
Doctor >> Patient
Bureaucracy >> Network
Institutions >> Systems
@42mins: clinicians responsible for whole populations, not just the patients in front of them
@45mins: How to start a revolution
– change the culture – destabilise and constrain; control language
– engage patients and citizens, and the future leaders of 2033
– structure doesn’t matter (5%)
– systems (40%)
– culture or mindset (50%)
@46mins: Culture – the shared tacit assumptions of a group that it has learned in coping with external threats and dealing with internal relationships” Schein (1999) The Corporate Culture Survival Guide
@47mins50s: data doesn’t change the world, emotion changes the world
– atlases written for OMG effect
– programme budgeting
destabilise then constrain then change the language
@49mins: MUDA means waste — resource consumption that doesn’t contribute to the outcome. motonai – the feeling of regret that resources are being wasted. ban old language.
@51mins: mandatory training in new thinking
The Third Healthcare Revolution is already underway
1. PHONE
2. CITIZENS
3. KNOWLEDGE
The third healthcare revolution will come out of the barrel of a smartphone
@56mins: Healthcare is too complex to be run by bureaucracies or markets. Work like an ant colony – neither markets nor bureaucracies can solve the challenges of complexity.
