Category Archives: policy

data saving lives, facts & data points, healthy habits, nutrition, policy

The Key to Changing Individual Health Behaviors: Change the Environments That Give Rise to Them

 

http://harvardpublichealthreview.org/the-key-to-changing-individual-health-behaviors-change-the-environments-that-give-rise-to-them/

The Key to Changing Individual Health Behaviors: Change the Environments That Give Rise to Them

PDF: HPHRv2-Stulberg

Over the past four decades, the United States has faced steadily rising rates of obesity and associated chronic conditions. Many of these chronic conditions are rooted in nutrition and physical activity behaviors, and are often referred to as lifestyle diseases. Historically, the prevention of lifestyle diseases has focused on changes in individual behavior and personal choices, and personal responsibilities. However, a growing body of research has demonstrated the strong influence of physical and social surroundings on individuals’ actions. The context in which options are presented can shape the decision-making processes that impact health. Altogether, the research suggests that altering environments may be an effective driver of behavior change. 1Intentionally designing environments to promote healthy behaviors holds promise to reverse the increase of lifestyle diseases.

The emerging field of behavioral science – which gathers insights from disciplines like behavioral economics, cognitive psychology, and social psychology – illustrates that while individuals retain “free choice,” their environment significantly influences the choices they make, and in some instances, may lead them to act in ways that are counter to their true preferences. 2 A few examples:

  • Individual preferences are often inconsistent over time, especially in situations where immediate pleasures carry long term consequences. In a study that asked [hypothetically] if people would prefer fruit or chocolate as a future snack, 74% chose fruit. But, when those same participants were presented with both fruit and chocolate in real-time, 70% selected chocolate. 3
  • A person’s actions can be dramatically influenced by related contextual features. For instance, research shows that kitchenware size significantly influences serving and eating behavior. In a series of studies, individuals who were given larger bowls served themselves between 28-32% more cereal than those given smaller bowls. Studies also report that people tend to eat 90-97% of what is on their plate, irrespective of plate size. 4
  • People tend to consent to the “default option.” This has been observed in numerous situations ranging from deciding whether or not to become an organ donor to making saving allocations for retirement. For example, organ donation rates are 4% in Denmark and 12% in Germany where the default option is “opt-in.” In contrast, the rates are 86% in Sweden and nearly 100% in Austria where the default option is “opt-out.” Cultural differences cannot explain the discrepancy. 5

When these behavioral science insights are applied in the context of health, the growth of lifestyle diseases is not surprising. This expanding body of research sheds light on the difficulties of healthy living when society is dominated by the marketing of unhealthy foods and unduly large portion sizes, and where sedentary behavior is often the default option.

The good news is that the same forces that currently promote unhealthy behaviors can be used to encourage healthy ones. In their bestselling book Nudge, Richard Thaler and Cass Sunstein described “choice architecture,” or the proactive designing of environments that “nudge” people to make healthier selections while still retaining freedom of choice. 6 There are many opportunities to apply this concept to promoting healthy behaviors. In particular, given their resources, broad reach, and financial and social incentives, both governments and employers are in a unique position to promote healthy behaviors in a way that would affect many lives.

Government food programs such as the Supplemental Nutrition Assistance Program (“SNAP”) and the school lunch program could be designed to make healthy selections more accessible, and in some cases, the default options. Those that oppose the trend toward encouraging healthier foods often cite added costs and waste, arguing that children don’t like healthy foods and will throw them away uneaten. But the data tell a different story. A recent study in Childhood Obesity found that a vast majority of middle-school and high-school students like the updated and significantly healthier school lunch that was introduced in 2012. 7

Nonetheless, making the change is not cost-free. A recent meta-analysis found that the healthiest diets cost $1.50 more per-person, per-day, which amounts to $550 per-person, per-year. 8 While this amount is not insignificant, it pales in comparison to the cost of treating most diet-related chronic conditions. Designing government food programs around the “healthiest diets” may yield a positive return on investment.

Even so, many individuals – including those who do qualify for SNAP, as well as those who do not qualify for SNAP (i.e. incomes just about the SNAP cut-off) – may still struggle with affordability and availability of healthy foods. Perhaps the most sustainable and far-reaching approach to making healthy foods more accessible is to change food policies (e.g., subsidies) that currently favor the production and systematic delivery of unhealthy foods to favor healthy ones. This would likely lead to higher volumes, more efficient delivery, and lower costs for nutritious foods.

The government can also promote healthier eating by improving nutrition labeling. While the FDA’s recent proposal to ensure that serving sizes listed on food products reflect actual average consumption (e.g., nutrition specifications would reflect an entire muffin, not one-third of a muffin) is a small step in the right direction, there is potential to go a lot further. Research suggests that catchier and simplified nutrition labels could have a much greater impact on consumer behavior. 9 For example, NuVal, an independently designed system that gives food items a single overall score based on more than 30 nutrient and nutrition factors, could be considered for more widespread adoption. 10 Not only does NuVal make for easier interpretation of a product’s nutrition profile, it also enables comparison shopping between options and encourages people to “trade-up” to healthier options. 11 An additional model to consider is a traffic-light rating system that marks foods with either a green, yellow, or red light. In instances where it has already been implemented (in some private organizations and outside the United States), the traffic-light model has increased consumer awareness of health and leads to healthier purchases. 12

In addition to promoting a healthy diet, government should play an active role in encouraging physical activity through the education system (e.g., ensure the existence of meaningful recess and gym programs), transportation system (e.g., create options for safe pedestrian/bike commuting), and by supporting relevant community resources (e.g., building, maintaining, and ensuring the safety of outdoor parks and recreation centers). When options for physical activity are easily accessible, people tend to be more active. For example, a recent study published in the American Journal of Public Health illustrated that the establishment of traffic-free cycling and walking routes increased overall physical activity among those that lived nearby. 13

Employers may have the ability and incentives to move faster than government in designing health promoting environments. A healthier workforce results in both reduced health care costs and absenteeism, and in increased productivity. Recent data from the Society of Human Resource Management’s annual Employee Benefits Survey shows that employers are taking notice and increasing their investment in workforce wellness programs. While these programs have traditionally focused on offering employees classes, counseling, and incentives for healthy behaviors such as discounts on insurance premiums, subtler tweaks to the workplace itself could prove just as, if not more effective.

An example of these subtler changes is happening at Google. There, company leaders have invested in promoting employee nutrition and health. Instead of relying solely on traditional programs such as nutrition counseling and weight-loss classes, Google redesigned cafeterias to encourage healthier eating. Now, the most nutritious options are positioned at the front of the cafeteria and unhealthy foods are hidden in corners and placed in opaque bowls. Smaller plates are the norm and marked with reminder messages that “bigger dishes prompt people to eat more.” Foods are tagged with either red “warning” stickers, or green stickers signifying healthy foods. Beverage coolers stock water at eye level, and relegate sweetened beverages to the bottom where they are not as easily seen or accessed. These changes – which notably do not restrict options, but simply rearrange the way options are presented – have led to dramatic reductions in candy and sugar-sweetened beverage consumption, and increases in the use of smaller plates. 14 15

To encourage physical activity, employers can adopt similar approaches to workplace design, such as centrally located staircases and ergonomically fit workstations. Further, similar to current LEED certifications for environmentally-friendly buildings, there could also be a meaningful certification for health-promoting buildings. In addition to the design of physical workplaces, the way that work itself is conducted can also be designed to promote health. For example, some employers have made “walking meetings” a cultural norm to build physical activity into otherwise sedentary jobs. 16

 

Other Considerations

While the value of these environmental interventions is promising, there is a need for additional research that focuses on cost effectiveness. This is especially true if we hope to see increased governmental action, where broad policy implementation almost always follows a positive cost/benefit analysis. That said, some of the ideas – such as using smaller plates in government cafeterias or simplifying nutrition labels – come at relatively little additional financial cost, and have already demonstrated health-promoting benefits. These ideas could be fast-tracked for more widespread adoption.

Another potential barrier that must be overcome is the political power of special interests groups that rely on built-environments conducive to unhealthy behaviors. For example, a large part of the reason that the migration to healthier school lunches has taken so long is because various food interests have launched strong lobbying campaigns against such changes. 17 In order to transition entrenched unhealthy built-environments to healthier ones, policymakers will need to prioritize the demands of public health against the backdrop of influential and longstanding special interests

A broader approach to designing environments that promote healthy behaviors must also account for additional barriers that individuals with lower socioeconomic status commonly face. The government cannot rely solely on the private sector to drive these changes since those who stand to benefit most may be unemployed or not working for progressive employers with the resources to launch effective health campaigns. Thus, focusing on government food programs and community-based approaches that effect a lower-income demographic is critical (e.g., sidewalk coverage and safe streets, eliminating food deserts, maintaining outdoor parks). In addition to these more specific interventions, the clear connection between environment and health should only bolster the case for expanding social service programs more broadly. Realizing and addressing the fact that so many of the outcomes that lie inside of health care are rooted in factors that lie outside of health care is thus critical to improving health.

 

If we want to avert a public health crisis at the hands of chronic lifestyle-driven diseases, we need not only focus on changing individual behaviors, but also on changing the environments that give rise to those behaviors. Governments and employers must recognize the overwhelming influence of context on action, and take advantage of their unique position to intentionally shape environments that promote healthy behaviors.
  1. Kahneman, D. Thinking fast and slow. New York: Farrar, Straus, and Giroux. (2011). ↩
  2. For more on Behavioral Science, see the Behavioral Science and Policy Association and its forthcoming journal Behavioral Science and Policy. ↩
  3. Read, D., & Van Leeuwen, B. Predicting hunger: the effects of appetite and delay on choice. Organizational Behavior and Human Decision Processes. 1998; 76 (2), 189-205. ↩
  4. Van Ittersum, K., & Wansink, B. Plate size and color suggestibility: the delboeuf illusion’s bias on serving and eating behavior. Journal of Consumer Research. 2012; 39 (2), 215-228. ↩
  5. Johnson, E. J., & Goldstein, D. Do defaults save lives? Science. 2003; 302, 1338-1339. ↩
  6. Thaler, R. H., & Sunstein, C. R. Nudge: Improving decisions about health, wealth, and happiness. New York: Penguin Books. (2009). ↩
  7. Turner, L., & Chaloukpa, F. J. Perceived reactions of elementary school students to changes in school lunches after implementation of the United States Department of Agriculture’s new meals standards: minimal backlash, but rural and socioeconomic disparities exist. Childhood Obesity. 2014; 10 (4), 349-356. ↩
  8. Rao, M., Afshin, A., Singh, G., & Mozaffarian D. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open. 2013; 3 (12). doi:10.1136/bmjopen-2013-004277. ↩
  9. Roberto, C. A., & Khandpur, N. Improving the design of nutrition labels to promote healthier food choices and reasonable portion sizes. International Journal of Obesity. 2014; 38, 525-533. ↩
  10. Nuval.com. Accessed August 12, 2014. ↩
  11. Nuval.com: Trading Up Tips. Accessed August 28, 2014. ↩
  12. Sonnenberg, L., Gelsomin, E., Levy, E. D., Riis, D., Barraclough, S., & Thorndike, A., N. A traffic light food labeling intervention increases consumer awareness of health and healthy choices at the point-of-purchase. Preventative Medicine. 2013; 57 (4), 253-257. ↩
  13. Freeland, A. L., Banerjee, S. N., Dannenberg, A., L & Wendel, A. M. Walking associated with public transit: moving toward increased physical activity in the United States. American Journal of Public Health. 2013; 103 (3), 536-542. ↩
  14. Kuang, C. 6 ways Google hacks its cafeterias so Googlers eat healthier. Fast Company. April 2012; (164). ↩
  15. Wacther, Luke. Personal Interview on July 20, 2014. ↩
  16. Walking meetings could make work healthier, happier. CBS News. 07, May 2014. ↩
  17. Nixon, R. Nutrition Group Lobbies Against Healthier School Meals it Sought, Citing Cost. New York Times. 01, July 2014. ↩
cool, healthy habits, nutrition, policy, rapid learning health systems

MIT launches wellness advancing technology program…

Potentially very interesting work…

http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2014/09/media-lab-to-launch-wellness-initiative-with–1-million-grant-fr.html

Media Lab to Launch Wellness Initiative with $1 Million Grant from the Robert Wood Johnson Foundation

New program, Advancing Wellness, combines academics with on-the-ground initiatives to prompt cultural shifts toward better health.

Princeton, N.J.—The MIT Media Lab this week launched a wellness initiative designed to spark innovation in the area of health and wellbeing, and to promote healthier workplace and lifestyle behaviors.

With support from the Robert Wood Johnson Foundation (RWJF), which is providing a $1 million, one-year grant, the new initiative will address the role of technology in shaping our health, and explore new approaches and solutions to wellbeing. The program is built around education and student mentoring; prototyping tools and technologies that support physical, mental, social, and emotional wellbeing; and community initiatives that will originate at the Lab, but be designed to scale.

The program begins with the fall course Tools for Wellbeing, followed by Health Change Lab in the spring. In addition to concept and technology development, these courses will feature seminars by noted experts who will address a wide range of topics related to wellness. These talks will be open to the public, and made available online. Speakers include such experts as Walter Willett, noted nutrition and clinical medicine researcher; Chuck Czeisler, physician and sleep expert; Ben Sawyer, game developer for health applications; Matthew Nock, expert in suicide prevention; Dinesh John, researcher on health sciences and workplace activity; Lisa Mosconi, neuroscientist studying the prevention of Alzheimer’s; and Martin Seligman, one of the founders of the field of positive psychology. More information about the courses, speakers, and presentation topics and dates can be found here.

The RWJF grant will also support five graduate-level Research Fellows from the Program in Media Arts and Sciences, who will be part of a year-long training program. The funding will enable each Fellow to design, build and deploy novel tools to promote wellbeing and health behavior change at the Lab in a living lab environment, and then at scale.

One of the significant ways that this program will impact Media Lab culture is in the review of all thesis proposals submitted by students in the Media Arts and Sciences program. The Media Lab faculty recently added a new requirement that all thesis proposals consider the impact of the proposed thesis work on human wellbeing.

Other Lab-wide aspects of the initiative include:

  • A monthly health challenge that would engage the entire Lab, with review and analysis of each month’s deployment to help inform the next month’s initiative
  • A buddy system to pair students at the Lab with one another—to build an awareness of wellbeing as a social function, and not just a personal one, and to draw on people’s inclination to solve the problems of others differently than we would solve our own.
  • The Media Lab will host a special event on October 23, 2014, when the creators of the X-Prize convene at MIT, presenting on a new X-Prize for Wellbeing.

“Wellbeing is a very hard problem that has yet to be solved by psychologists, psychiatrists, neuroscientists, biologists or other experts in the scientific community,” said Rosalind Picard, professor of Media Arts and Sciences and one of the three principal investigators on the initiative. “It’s time to bring MIT ingenuity to the challenge.”

“RWJF is working to build a culture of health in the U.S., where all people have opportunities to make healthy choices and lead healthy lifestyles. Technology has long shaped the patterns of everyday life and it is these patterns—of how we work, eat, sleep, socialize, recreate and get from place to place—that largely determine our health,” said Stephen Downs, chief techonology and information officer at RWJF. “We’re excited to see the Media Lab turn its creative talents and its significant influence to the challenge of developing technologies that will make these patterns of everyday life more healthy.”

The three principal investigators on the Advancing Wellness initiative are: Rosalind Picard, professor of Media Arts and Sciences; Pattie Maes, the Alex W. Dreyfoos Professor of Media Arts and Sciences; and Kevin Slavin, assistant professor.  PhD candidate Karthik Dinakar, Reid Hoffman Fellow at the Media Lab, will co-teach the two courses with the three principal investigators.  Susan Silbey, Leon and Anne Goldberg Professor of Humanities, Sociology and Anthropology, will also create independent assessments through the year on the impact of this project.

ABOUT THE ROBERT WOOD JOHNSON FOUNDATION

For more than 40 years the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national Culture of Health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

health market quality, healthcare, policy, rapid learning health systems

On medical disinvestment…

Nice and punchy oped on low value care…

https://www.mja.com.au/insight/2014/34/richard-king-what-not-do

Richard King: What not to do

Richard King
Monday, 15 September, 2014

EARLIER this year, articles appeared in the New York Times and the Australian Financial Review on low-value health care and the response from doctors.

These articles reflect to the public the worldwide drive by health care organisations, governments and doctors towards disinvestment in ineffective or inappropriately applied practices in health care. It has been described as a growing priority for health care systems to improve the quality of care and sustainability of resource allocation.

Identification of procedures and practices for disinvestment has increased, particularly in the past 4 years, with the UK National Institute for Health and Care Excellence introducing “do not do” recommendations, followed by the American Board of Internal Medicine’s “Choosing Wisely”campaign.

Choosing Wisely, an initiative that is about to be introduced in Australia, was developed after about 60 medical colleges and societies in the US put together an evidence-based list of five investigations or procedures in each specialty that had little or no value, and that should not be done.

In Australia, a list of 156 practices that had questionable benefit or low value was published in theMJA in 2012.

A second way to identify inappropriate procedures is to find articles in high-impact journals that produce solid evidence showing current procedures should not be done. One team of US researchers identified 146 articles published over a 10-year period to 2010 that reversed established practice.

A third way is to identify the procedures or devices that will be replaced or substituted when a new technology is introduced. Examples of this were identified at the 2013 National Workshop on Disinvestment and outlined in the final report of the Health Policy Advisory Committee on Technology, including endobronchial ultrasound to biopsy and diagnose mediastinal lung tumours, which resulted in significant disinvestment in its pre-existing surgical comparator, mediastinoscopy, saving millions of dollars.

However, implementation of disinvestment in low-value health care is not well developed. We need action at federal, state and hospital levels.

At a federal level, the Medical Services Advisory Committee (MSAC) has the power to review procedures on the Medicare Benefits Schedule (MBS) and recommend their removal if they are not effective. This did happen in 2006 when MSAC recommended the introduction of magnetic resonance cholangiopancreatography and removed the general use of diagnostic endoscopic retrograde cholangiopancreatography. However, there have been no other recommendations since.

The federal Department of Health and Ageing did report at the 2013 Workshop on Disinvestment that it was looking at 20 items on the MBS being considered for removal.

At a state level, the Queensland Health Clinical Senate in 2013 devoted a lot of time to disinvestment, which it regarded as a priority in Queensland.

In Victoria, the Department of Health’s Victorian Policy Advisory Committee on Technology is looking at how a coordinated approach in hospitals might be achieved through cooperation across the sector. This is still in early days.

Monash Health has a disinvestment subcommittee as part of its New Technology Committee which has been active since 2009. It has recommended the cessation of various procedures such as vertebroplasty for osteoporotic vertebral body fractures and stenting of artherosclorotic renal arteries for hypertension, based on a similar method to identifying articles in high-impact journals that show current procedures should not be done.

There are many impediments to stopping existing practices. It has been said that to get a technology onto a schedule such as the MBS requires the same level of evidence as for civil trials — the balance of probabilities.

To take something off a schedule requires the same level of evidences as for a criminal conviction — beyond reasonable doubt.

If our health system is to remain sustainable, disinvestment must become part of the health care process.

As Dr Lowell Shipper, chair of a task force on value in cancer care at the American Society of Clinical Oncology, told the New York Times: “We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room.”

Associate Professor Richard King is the medical director of medicine at Monash Health and chair of the Victorian Policy Advisory Committee on Technology.

health market quality, healthcare, policy

Faux: The pitfalls of outsourcing Medicare

 

http://blogs.crikey.com.au/croakey/2014/09/09/outsourcing-medicare-is-it-as-easy-as-%CF%80/

Outsourcing Medicare: Is it as easy as π?

JENNIFER DOGGETT | SEP 09, 2014 11:29AM | | PRINT

Following on from the range of issues raised by Croakey contributors about the outsourcing of MBS and PBS payments, Margaret Faux discusses the most appropriate role for the private sector in supporting core government functions and the risks involved when private sector interests conflict with the central role of government. She writes:

In a U.S managed care styled initiative, private insurers have been given the right to tender to manage the operation of the government’s new Primary Health Networks, which will soon replace existing Medicare Locals. And recently, the government’s expression of interest from the private sector to provide outsourced claims and payment services for the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Schedule (PBS) was closed.

There’s nothing new or surprising about governments outsourcing service provision to the private sector. Recognising that key policy issues can sometimes be better addressed by tapping into private sector innovation and expertise is an important role of government. But when outsourcing amounts to the abrogation of core functions of the state, the inherent risks can be high.

The commission of audit recommendation to outsource MBS and PBS payment processing suggested that outsourcing these payments was a potentially high risk undertaking and specifically warned against outsourcing the assessment of entitlements. The problem however is that almost all MBS claims require assessment of entitlements. And given that there is not yet one third party payer of medical claims in Australia who has successfully mastered the complexity of this work, the prospect of outsourcing it tocontenders such as banks, Australia Post or even the private health insurers is cause for serious concern.

The business of paying for medical services in Australia – whether related to workers compensation, third party matters, the public or private provision of services, veterans entitlements, consultations at the GP or a specialist, in or out of hospital or anywhere else – takes place across an astonishingly fragmented industry in which each third party payer has its own requirements, rules, procedures and fees. Some private health insurers even pay different rates in different states.

But of all of these payers, the most effective, efficient and accurate in terms of the core business of processing and paying claims, is Medicare. This is a basic and undeniable truth accepted by those who interact daily with all payers in the medical billing industry. So it is interesting that rather than outsourcing areas in which Medicare struggles, such as claim adjustments, complex claim assessments, provider liaison and MBS interpretations, the government has instead chosen to seek expressions of interest in the one area in which Medicare excels.

In 1973 the architects of the original Medibank Scheme, Scotton and Deeble, understood very well the importance of having a separate department to manage the complexities of medical claims processing.

“In the fragile chain of decisions on which the successful implementation of Medibank hung, the decision to establish the Health Insurance Commission must have been one of the most critical.”1

The battle for an independent body of experts to administer the new national insurance scheme was hard fought and finally won when Bill Hayden agreed to the establishment of the Health Insurance Commission (HIC).

And this was long before private health fund schemes accessed the Medicare bucket of tax payer money, when there were approximately 5000 less Medicare services than there are today, well before some modern medical specialties had been thought of, before Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scanning existed and at a time when the concept of Telehealth would have been considered science fiction.

But the HIC was dissolved in 2005 and with it went much needed expertise, and today no-one and no software has been able to conquer what is highly specialised and still largely manual work.

In order to consider the possible outcome of any future outsourcing of Medicare payments let us look at a frontline experience of the recent outsourcing of medical claims, which was undertaken by the Department of Defence. In 2012 government processing of Australian Defence Force (ADF) medical claims was outsourced to the private sector. In a four year $1.4 billion deal, a contract was awarded toGarrison Health Services (a business arm of Medibank Health Solutions) to provide a national, integrated solution which included the processing of ADF personnel medical claims.

Conceptualising the process was easy, however the execution was not.

Midway through 2013 many billers noticed that ADF claims, which had previously been processed without too much fuss, were not being paid. The 90 day arrears on these claims had reached unacceptable levels as had practitioner complaints. Numerous calls and enquiries later, one medical billing company had almost $100,000 worth of ADF claims returned indicating there was a new arrangement and advising that the claims should be redirected to Medibank Private as part of a new government outsource initiative.

But after redirecting the claims as instructed, they were again returned as no-one at Medibank knew anything about them. Some months later, advice was received indicating that a new branch within Medibank had taken over the role, but that before any claims could be paid, every doctor first had to register, by signing a new form. Hundreds of signed forms later the claims were rejected again, this time because the amounts were considered incorrect. ADF claims had always been paid at the AMA rates (for as many years as memory serves) but apparently a unilateral decision had been made to instead apply Medibank’s no-gap rates, which are significantly lower. It was then of course only a matter of time before the medical profession would protest against the resultant 27% reduction in remuneration, which had been imposed without consultation.

After reprocessing hundreds of claims for the third time, the first payments started to trickle in, though the anticipated calls from doctors enquiring as to why the fees they were receiving were below the AMA rates were not far behind. Within weeks a full blown dispute had erupted between the payer and one group of doctors, while others had started requiring ADF personnel to pay their medical bills at the point of service, informing them that they should sort out their reimbursements themselves. The official letters came next, in which doctors were reminded of the legal barrier which prevented them from requiring ADF personnel to pay for medical services. It fell on deaf ears.

In subsequent advice it appeared that Garrison had changed its process yet again by adopting its own new fee schedule and that no further accounts would be paid without the correct new fees, as well as the inclusion of the defence approval number (DAN), to which the EP ID number (an unexplained extra piece of data) was later added – two additional pieces of data for the one soldier were considered better than one. Many DAN inclusive but EP exclusive rejected claims later, it was discovered that the mysterious EP was apparently unknown to anyone – neither clinicians nor hospital account administrators. But with a steely resolve and tenacious spirit EPs were finally tracked down and claims could be submitted again. However one must note here that it takes on average an hour on the phone to obtain the DAN and EP for each ADF claim.

As at today, ADF claims continue to be a significant cause of patient and doctor complaints, which has escalated to a point where some doctors are considering whether they may exclude ADF personnel from their practices altogether – patients always come off worse in these scenarios. The process is manual, labour intensive, slow and from the point of view of integration and efficiency, an abject failure.  It was far simpler and much more efficient before it was outsourced.

Because profit will often usurp clinical outcomes as the main priority in private sector participation in health, the potential risks of the proposed outsourcing of management of the new Primary Health Networks is also apparent. In fact corporate involvement in general practice has long been identified as an area of concern, and one which has contributed to increased health spending, for which individual doctors are sometimes blamed.

Since 2006 the Professional Services Review Scheme (PSR), whose objective is to protect the public interest in the standard of MBS and PBS services, has commented that the corporatisation of medical practices is a contributor to inappropriate and excessive MBS claiming by doctors. Having signed contracts binding them to daily, weekly and monthly targets (both in terms of the number of patients seen and the types of services provided) doctors have reported feeling pressured to reconcile targets with real patients. It is not uncommon for doctors working in these corporate practices to end up in front of the PSR where their MBS claiming behaviour comes under review. And due to regulatory limitations, the corporation itself will rarely be held to account.

Our current workers compensation system (which is managed care by another name) provides another example, as well as important evidence, of the potential poor health outcomes and increased costs that can result when care is managed outside of the doctor patient relationship, and is driven by private sector profits.

Outsourcing works best when the private sector is used to support core government activity. But when it is the core government activity that is outsourced, the private sector will inevitably find itself conflicted between profit and service.

While Aristotle might have outsourced the preparation of his meals by hiring a cook, he would never have outsourced geometry.  He would rather have eaten an outsourced pie than outsource the discovery of π itself.

1. The Making of Medibank, RB Scotton and CR Macdonald, Australian Studies in Health Service Administration, No 76

complex adaptive systems, data saving lives, facts & data points, health market quality, healthcare, policy, rapid learning health systems

The “pay less, get more” era of health care

Excellent summary of current US funding situation…

http://www.vox.com/2014/9/10/6121631/the-pay-less-get-more-era-of-health-care

The “pay less, get more” era of health care

Updated by on September 10, 2014, 1:00 p.m. ET

Health care spending has, for decades, followed a consistent pattern. America pays more and more for health care — and gets less and less.

Between 1990 and 2012, the insured rate in the United States fell two percentage points, from 86.6 to 84.6 percent. If the insured rate had just held steady, six million more people would have been covered in 2012.

While we were covering less people, we kept spending more on health care. National health spending, over that time period, rose from 12 percent of the economy in 1990 to 17.2 percent in 2012. Adjusted for inflation, health-care spending rose from $1.1 trillion to $2.8 trillion over those 22 years.

health spend more get less

That’s been the typical story of American health care: a lousy deal where we get less and spend more.

But there’s a growing body of evidence that this trend is changing; that we’re starting to get a shockingly better deal in a way that has giant consequences for how America spends money. Call it the “get more, pay less” era.

The “get more, pay less” era of health care spending

There are two big trends that, taken together, suggest we may be fundamentally different era of health care spending.

The first is lots more people getting coverage. This is mostly Obamacare: the health care law is expected to expand insurance coverage to 26 million people by 2024. In 2014 alone, most estimates suggest about 5 million people have gained health coverage through the law. The recovering economy is likely playing a supporting role, too, with those gaining jobs also gaining access to employer-sponsored coverage.

The second big trend is in what we spend: actuaries expect that health care costs will grow slower over the next decade than they did in the 1990s and 2000s.

More specifically: health care costs grew, on average, 2 percent faster than the economy between 1990 and 2008. Health spending took over an ever-growing share of the economy. Workers barely got raises; skyrocketing premiums ate up most of their additional wages.

The next decade is now expected to be different. Actuaries at the Center for Medicare and Medicaid Services project health care costs to grow 1 percent faster than the rest of the economy between 2013 and 2023.

“We are seeing historic moderation in costs now over a considerable period of time,” Kaiser Family Foundation president Drew Altman says. HIs group recently released data showing slow growth of employer-sponsored coverage. “It’s absolutely true we’re seeing that and any expert will tell you that.”

This is startling: over the next decade, forecasters think our health spending will grow at a slower rate, even as millions and millions of Americans gain access to health insurance. After two decades of spending more and getting less, we’re entering an era of spending less and getting more. It’s bizarro health spending world.

There are signs of this throughout the health care system

One thing that’s so striking about the “get more, pay less” trend is that it isn’t limited to one particular insurance plan or program. It’s starting to crop up in lots of new health care data, suggesting this change has become pervasive in the health care industry.

Start with private health insurance: the Kaiser Family Foundation recently published research finding the average price of Obamacare’s benchmark will fall slightly in 2015. As my colleague Ezra Klein wrote recently, this just about unprecedented. “Falling is not a word that people associate with health-insurance premiums,” he writes .”They tend to rise as regularly as the morning sun.”

Lower premiums make health care dollars stretch further: Obamacare shoppers will be able to buy the coverage they had last year at a slightly lower price. That’s a big deal when you’re talking about paying for a health insurance program meant to cover tens of millions of Americans.

Increasingly narrow health insurance networks are another sign of “get more, pay less” era. Over the past few years — and especially under Obamacare —insurers have gravitated towards cheaper premium plans to offer access to a smaller number of doctors.

narrow network graph

These plans’ more limited doctor choice can have a big impact on spending. Research from economists Jon Gruber and Robin McKnight found that, in one example, switching enrollees to these plans cut overall spending by one third. And while patients had access to fewer hospitals, the hospitals that were in network were of equally good quality.

Then there’s the Medicare side of the equation, where there has been a unprecedented decline in per person spending. Margot Sanger-Katz at the Upshot has had two fantastic posts on Medicare’s cost slowdown. One of them points out the fact that, since 2010, per patient spending has grown slower than the rest of the economy. You can see that in this graph, which charts “excess cost growth” in Medicare (health wonk speak for cost growth above and beyond inflation). For the past few years, excess growth has been replaced by slower-than-the-economy growth.

medicare excess cost growth

(The New York Times)

As Sanger-Katz points out, there are two trends at play in Medicare. One is that younger baby boomers keep aging onto the program. They’re younger than Medicare’s really old patients, and typically less expensive to care for. That drives down per person spending for the whole population.

But there’s something else going on that looks to be a more permanent trend: Medicare patients are using less expensive care. They go to the doctor more, and the hospital less. You can see this in new data from the Medicare Trustees’ report, which shows per person spending on Medicare Part A (the program that covers inpatient care) falling over the past few years.

medicare

Because of this shift away from hospital care, Medicare Part A now spends less money to cover more people. It paid $266.8 billion covering 50.3 million people in 2012. In 2013, the the same program spent $266.2 billion to cover 51.9 million people.

Will “pay less, get more” health care stick?

We have had periods of relatively slow health care growth before. In the mid-1990s, for example, there was a stretch of time when health spending grew at the same rate as the rest of the economy. You can see that in this graph.

health spending growth

Most health economists attribute that to the rise of health maintenance organizations, or HMOs, that sharply limited access to specialists. Patients, unsurprisingly, didn’t like those limitations and there was a backlash. HMOs declined and health spending rose again.

But some health economists say that this time feels different. For one, the changes are happening in private insurance and Medicare, suggesting there’s no single — and thus easily reversible — force driving the change.

And while there are more patients in narrow network products, something akin to HMOs, consumers are often choosing to be there. These are shoppers on the Obamacare exchanges who have decided to make a trade off: they’re take lower premiums for less choice of doctor.

“In the 1990s, people were essentially stuck in HMOs,” M.I.T economist Gruber says. “This time, people are given an option and make a choice. That’s why I’m more confident this slower growth will stick.”

Medicare actuaries are not fortune tellers; they do not have a crystal ball that conjures up the future of health care with perfect clarity. But at least at this particular moment, there are lots of signs cropping up to suggest something very important in health care is changing, and it’s for the better.

CARD 3 OF 15LAUNCH CARDS

How does American health-care spending compare to other countries?

The United States has higher per-person health-care spending than all other industrialized nations. The most recent international data from the OECD estimates that the United States puts 17.7 percent of its economy towards health care (slightly higher than CMS’s estimate of 17.2 percent). The OECD average is 9.3 percent.

Health_care_oecd

Much of the difference between health care spending abroad and in the United States has to do with prices. Americans don’t actually go to the doctor a lot more than people in other countries. But when we do, our medical care costs more. Specific services, like MRIs and knee replacements, have significantly higher price tags when delivered in the United States than elsewhere.

Health-care spending15 CARDS / EDITED BY SARAH KLIFF UPDATED APR 30 2014, 9:43A
data saving lives, entrepreneurship, health market quality, healthcare, healthy habits, nutrition, policy, quantified self, rapid learning health systems

Bloomberg: Big Data Knows You’ve Got Diabetes Before You Do

 

http://www.bloomberg.com/news/2014-09-11/how-big-data-peers-inside-your-medicine-chest.html

Did You Know You Had Diabetes? It’s All Over the Internet

By Shannon Pettypiece and Jordan Robertson Sep 12, 2014 6:07 AM ET

Photographer: Rick McFarland/Bloomberg

The headquarters of Acxiom Corp. in Little Rock, Arkansas. The Acxiom list was compiled by various sources, including… Read More

Photographer: Joshua Roberts/Bloomberg

An electronic medical records system.

Photographer: Joe Raedle/Getty Images

An elderly man reached for medication in Florida.

Photographer: Joe Raedle/Getty Images

An elderly woman with her medication in Maine.

The 42-year-old information technology worker’s name recently showed up in a database of millions of people with “diabetes interest” sold by Acxiom Corp. (ACXM), one of the world’s biggest data brokers. One buyer, data reseller Exact Data, posted Abate’s name and address online, along with 100 others, under the header Sample Diabetes Mailing List. It’s just one of hundreds of medical databases up for sale to marketers.

In a year when former National Security Agency contractor Edward Snowden’s revelations about the collection of U.S. phone data have sparked privacy fears, data miners have been quietly using their tools to peek into America’s medicine cabinets. Tapping social media, health-related phone apps and medical websites, data aggregators are scooping up bits and pieces of tens of millions of Americans’ medical histories. Even a purchase at the pharmacy can land a shopper on a health list.

“People would be shocked if they knew they were on some of these lists,” said Pam Dixon, president of the non-profit advocacy group World Privacy Forum, who has testified before Congress on the data broker industry. “Yet millions are.”

They’re showing up in directories with names like “Suffering Seniors” or “Aching and Ailing,” according to a Bloomberg review of this little-known corner of the data mining industry. Other lists are categorized by diagnosis, including groupings of 2.3 million cancer patients, 14 million depression sufferers and 600,000 homes where a child or other member of the household has autism or attention deficit disorder.

The lists typically sell for about 15 cents per name and can be broken down into sub-categories, like ethnicity, income level and geography for a few pennies more.

Diaper Coupons

Some consumers may benefit, like those who find out about a new drug or service that could improve their health. And Americans are already used to being sliced and diced along demographic lines. Lawn-care ads for new homeowners and diaper coupons for expecting moms are as predictable as the arrival of the AARP magazine on the doorsteps of the just-turned 50 set. Yet collecting massive quantities of intimate health data is new territory and many privacy experts say it has gone too far.

“It is outrageous and unfair to consumers that companies profiting off the collection and sale of individuals’ health information operate behind a veil of secrecy,” said U.S. Senator Jay Rockefeller, a West Virginia Democrat. “Consumers deserve to know who is profiting.”

Senators’ Attention

Rockefeller and U.S. Senator Edward Markey, a Democrat from Massachusetts, introducedlegislation in February that would allow consumers to see what information has been collected on them and make it easier to opt out of being included on such lists. In May, the Federal Trade Commission recommended Congress put more protections around the collection of health and other sensitive information to ensure consumers know how the details they are sharing are going to be used.

The companies selling the data say it’s secure and contains only information from consumers who want it shared with marketers so they can learn more about their condition. The data broker trade group, the Direct Marketing Association, said it has its own set of mandatory guidelines to ensure the data is ethically collected and used. It also has a website to allow consumers to opt out of receiving marketing material.

“We have very strong self regulation, we have for more than 40 years,” said Rachel Nyswander Thomas, vice president for government affairs for the DMA. “Regardless of how the practices are evolving, the self-regulation is as strong as ever.”

Yet the ease with which data is discoverable in a simple Google search along with Bloomberg interviews with people who showed up in one such database suggest the process isn’t always secure or transparent.

Open Access

Dan Abate said he never agreed to be included in any list related to diabetes. Two other people on the same mailing list said they didn’t have diabetes either and weren’t aware of consenting to offer their information.

In Abate’s case, neither he nor anyone in his family or household has diabetes and the only connection he can think of for landing on the list are a few cycling events he participated in for a group that raises money for the disease.

“I could understand if I was voluntarily putting this medical information out there,” Abate said. “But I don’t have diabetes, and I don’t want my information out there to be sold.”

Bloomberg found the diabetes mailing list on the website of Exact Data in a section for sample lists that included dozens of other categories, like gamblers and pregnant women. The diabetes list contained 100 names, addresses and e-mails. Bloomberg sent e-mails to all of them, and three consented to interviews. There were no restrictions on who could access the list, available on search engines like Google.

Online Surveys

Exact Data’s Chief Executive Officer Larry Organ said the list posted on its website shouldn’t have included last names and street addresses, and the company has since deleted any identifiable information. He said the data came from Acxiom and Exact Data was reselling it.

The Acxiom list was compiled by various sources, including surveys, registrations, or summaries of retail purchases that indicated someone in the household has an interest in diabetes, said Ines Gutzmer, a spokeswoman for the Little Rock, Arkansas-based company. While Gutzmer said consumers can visit the Acxiom website to see some of the information that has been collected on them, she declined to comment about how any one individual was placed on the list.

Acxiom shares rose less than 1 percent, to $18.66 at the close of New York trading. The company has lost 29 percent of its value in the past 12 months.

Sharing Information

One of the more common ways to end up on a health list is by sharing health information on a mail or online survey, according to interviews with data brokers and the review of dozens of health-related lists. In some cases the surveys are tied to discounts or sweepstakes. Others are sent by a company seeking customer feedback after a purchase. The information is then sold to data brokers who repackage and resell it.

Epsilon, which has data on 54 million households based on information gathered from its Shopper’s Voice survey, has lists containing information on 447,000 households in which someone has Alzheimer’s, 146,000 with Parkinson’s disease, and 41,000 with Lou Gehrig’s disease. The Irving, Texas-based company provides survey respondents with coupons and a chance to win $10,000 in exchange for information on their household’s spending habits and health.

The company will share with individual consumers specific information it has gathered, said Jeanette Fitzgerald, Epsilon’s chief privacy officer.

Suffering Seniors

KBM Group, one of the largest collectors of consumer health data based in Richardson, Texas, has health information on at least 82 million consumers categorized by more than 100 medical conditions obtained from surveys conducted by third-party contractors. The company declined to provide an example of the surveys. KBM uses the information for its own marketing clients, and sells it to other data brokers, said Gary Laben, chief executive officer of KBM.

“None of our clients wants to engage with consumers or businesses who don’t want to engage with them,” he said. “Our business is about creating mutual value and if there is none, the process doesn’t work.”

Data repackaging is extensive and pervasive. The Suffering Seniors Mailing List help marketers push everything from lawn care to financial products. It consists of the names, addresses, and health information of 4.7 million “suffering seniors,” according to promotional material for the list. Beach List Direct Inc. sells the information for 15 cents a name. Marketed as “the perfect list for mailers targeting the ailing elderly,” it contains a breakdown of those with diseases like depression, cancer and Alzheimer’s, according to its seller’s website.

Clay Beach, the contact on Beach List’s website, did not return calls and e-mails over the past month.

‘Confidential’ Clients

Little is known about who buys medical lists since data brokers say their clients are confidential, Rockefeller said at a hearing on the issue in December.

Promotional material for the Suffering Seniors data found by Bloomberg on Beach List’s website initially included a list of users. The names of those users have since been removed.

One customer was magazine publisher Meredith Corp. (MDP), which used the list in a test for a subscription offer for Diabetic Living magazine, said Jenny McCoy, a spokeswoman. Other users have included the American Diabetes Association, which said a small portion of names from the list was given to one of its local chapters, and Remedy Health Media, a publisher of medical websites.

Magazine Advertising

Remedy Health may have used the list to advertise one of its magazines, which has been defunct for several years, said David Lee, the company’s executive vice president of publishing.

A growing source of data fodder are website registration forms that ask for health information in order for a user to access the site or receive an e-mail newsletter.

One such site is Primehealthsolutions.com, which provides basic health information on a variety of conditions. It makes money by collecting data on diseases its users have been diagnosed with and medications they are taking, which people disclose when signing up for the site’s e-mail newsletter.

The site has more than three dozen lists for sale, including a tally of 2.2 million people with depression, 267,000 with Alzheimer’s, 553,000 with impotence, and 2.1 million women going through menopause.

Jason Rines, a co-owner of Prime Health Solutions, said he will share the lists only with those marketing health-related products, like pharmaceutical or medical device makers.

Purchasing Trail

Acxiom said it uses retail purchase history or magazine subscriptions to make assessments about whether someone has a particular disease interest.

Health data collection is troubling to people like Rebecca Price, who has early-stage Alzheimer’s disease. While she now makes no secret of her disease and serves as a member of the Alzheimer’s Association’s early stage advisory group, that wasn’t always the case. Price, a 62-year-old former doctor, said she initially didn’t even tell her husband of her condition for fear word would get out and harm her personally and financially.

“It is a very, very personal diagnosis,” Price said.

Social media is another potential way information can be collected on patients, said Dixon, of the World Privacy Forum, who warns patients to be more careful about what they share on sites like Facebook.

“Don’t ‘like’ the hospital website or comment ‘thank you for the great breast cancer screening you gave me,’” she said. “Under the Facebook policy that is public information and it is in the wild and if someone goes to that site and pulls it off, it is totally public.”

Facebook Policy

While it would be possible for data miners to scrape ‘likes’ and public comments from Facebook Inc. (FB)’s social network, the company said such practice is against company policy and, if discovered, would be blocked.

“We don’t allow third-party data providers to scrape or collect information without our permission,” said Facebook spokeswoman Elisabeth Diana. “Third-party data providers that work with Facebook don’t collect personally identifiable information and are subject to our policies.”

For consumers who want to know what list they may be on, there are limited options. KBM for example doesn’t have the technological capabilities to look up an individual by name and tell them what lists they are on, though they can purge a name from all their lists if requested to do so, said CEO Laben.

Acxiom started a website last year that allows people to view some of the information it has on them. Those who choose to can correct or remove their data.

Epsilon’s Fitzgerald says the best way for consumers to protect themselves is to be more aware of where they are sharing their information and pay more attention to website privacy policies.

“If people are concerned, don’t put the information out there,” Fitzgerald said. “Consumers would be better served if they were educated more on what is going on on the web.”

(A previous version of the story mistated the name of the Direct Marketing Association and corrected the spelling of Facebook spokeswoman Elisabeth Diana.)

To contact the reporters on this story: Shannon Pettypiece in New York atspettypiece@bloomberg.net; Jordan Robertson in San Francisco atjrobertson40@bloomberg.net

To contact the editors responsible for this story: Rick Schine at eschine@bloomberg.net Drew Armstrong

health market quality, healthcare, policy, politics

Terry Barnes: Doctors have a fat co-payment scheme of their own

Another cracking, clean head shot from Terry… totally concur with this one!

http://www.afr.com/p/business/healthcare2-0/doctors_have_fat_co_payment_scheme_g9tVCa7kjp7RkGhXIHh3tN

TERRY BARNES

Doctors have a fat co-payment scheme of their own

PUBLISHED: 13 AUG 2014 00:05:00 | UPDATED: 20 AUG 2014 11:53:54

Doctors have a fat co-payment scheme of their own

Even if Medicare rebates don’t cover the full cost of medical services plus a reasonable margin, their subsidies make costly specialist services accessible and affordable to most Australians on low to middle incomes. Photo: Glenn Hunt

TERRY BARNES

While relentlessly attacking the federal budget’s $7 co-payment on bulk-billed GP services measure as unfair, neurosurgeon and Australian Medical Association president Brian Owler asserts doctors’ rights to charge co-payments generally. His specialist members certainly do with gusto, and presumably he does too.

If he but realises it, Health Minister Peter Dutton is ideally placed to drive a hard bargain with the AMA on containing excessive out-of-pockets, especially given the doctors’ trade union is pressuring the government to dump the $5 cut to Medicare rebates intended to drive GPs to charge the co-payment.

The ace up Dutton’s sleeve is that doctors, particularly surgeons and specialists, depend on Medicare income like a smoker depends on his nicotine fix. Even if Medicare rebates don’t cover the full cost of medical services plus a reasonable margin, their subsidies make costly specialist services accessible and affordable to most Australians on low to middle incomes, especially the pensioners and fixed-income retirees who dominate the demand for medical services.

Given this financial reality, the government should use its domination of purchasing by Medicare on behalf of patients to bring the AMA to heel on excessive specialist charging. Doctors are entitled to a fair and reasonable fee above the Medicare schedule fee, and there’s no cap on what doctors can charge, but too many specialists have assumed this is carte blanche to gouge poor paying punters.

To end specialist billing rorts, the government can and should impose out-of-pocket capping that is simple, elegant, and transparent, using the AMA’s own benchmarks against it.

The AMA has its own private fee schedule, in which it determines what it considers appropriate prices for specific Medicare service items. AMA fees have long been an unofficial benchmark for doctors, the association stressing that it is staying on the right side of competition law by offering general advice to its members rather than giving them direction. The government’s published Medicare schedule fee observance and out-of-pocket data indicate that a great many doctors, notably GPs, apply the AMA recommended fee when they don’t bulk bill.

‘FAIR AND REASONABLE’

 

What’s more, specialist association submissions to the current Senate inquiry into patient out-of-pocket expenses repeatedly cite AMA recommended fees as being fair and reasonable, especially when compared with what they depict as woefully inadequate Medicare rebates.

With this in mind, the government should take doctors at their word and insist, as a condition of specialists’ access to Medicare, that patient contributions for any billed service that exceed AMA recommended fees will be prohibited. If doctors exceeds this cap, they could be fined have their Medicare billing rights suspended or cancelled, and be required to refund gouged patients their contributions plus credit care-level interest. The current but secret AMA recommended fee schedule would be published as a baseline, and subsequently indexed annually under a formula agreed by the government and the profession.

Recommended fees for future new items would be set by the AMA and relevant specialist colleges in consultation with the government.

Should a doctor want to be more competitive on price, there would be no prohibition on their charging a fee lower than the AMA’s recommendation.

But they would not be permitted to exceed it if they bill Medicare as their patients would expect.

Further, private health insurers should be permitted to cover the gap between specialist Medicare rebates and AMA recommended fees. This would be fairer to patients than current arrangements in which insurers have no gap, or no known gap deals with some specialists but not with others. It would also tackle those GPs and specialists, most notoriously anaesthetists, who blatantly ignore their patients’ rights to be informed of and consent to fees before a service is provided.

Private insurers also should be able to advise their members on the comparative performance of doctors, especially in relation to price. In a market for health services bedevilled by information asymmetry, insurers have a wealth of consumer knowledge that can be shared without compromising the privity of the doctor-patient relationship. Let them share it. For too long, medical specialists have got away with ripping off patients through excessive charging practices. Dutton, therefore, should use his negotiations with the AMA to take a stand for patients, call Owler’s bluff, and wield his own market power to bring the AMA to heel over specialists’ stubborn, arrogant and contemptuous disregard for their patients as customers. If the minister does take on the AMA over blatant fee-gouging, he’d be onto a political winner.

Terry Barnes authored the Australian Centre for Health Research’s $7 GP co-payment proposal.

The Australian Financial Review

facts & data points, health market quality, healthcare, healthy habits, policy, politics

Nearly half of all Americans will get type 2 diabetes

 

http://www.theguardian.com/society/the-shape-we-are-in-blog/2014/aug/13/diabetes-usdomesticpolicy

Nearly half of all Americans will get type 2 diabetes, says study

Type 2 diabetes, linked in 90% of cases to overweight and obesity, is soaring. New research shows 40% of Americans and 50% of Hispanics and non-Hispanic black women will get the disease at some point in their life and the numbers are unlikely to be much different elsewhere in the developed world

A patient undergoes a blood test for diabetes

A patient undergoes a blood test for diabetes, a condition which brings icnreased risk of stroke and heart failure. Photograph: Hugo Philpott/PA

How much worse can the type 2 diabetes epidemic get? Shockingly, a new study published by a leading medical journal says that 40% of the adult population of the USA is expected to be diagnosed with the disease at some point in their lifetime. And among Hispanic men and women and non-Hispanic black women, the chances are even higher – one in two appear to be destined to get type 2 diabetes.

As Public Health England spelled out in a recent report urging local authorities to take action, 90% of people with type 2 diabetes are overweight or obese. There is no mystery behind the rise in diagnoses – they match the soaring weight of the population. The climb dates back to the 1980s and is associated with our more sedentary lifestyles and changing eating habits – more food, containing more calories, more often. It is those things that will have to be tackled if the epidemic is to be contained.

The new study in The Lancet Diabetes & Endocrinology journal, from a team of researchers from the Centers for Disease Control and Prevention in Atlanta, shows that the risk of developing type 2 diabetes for the average 20 year-old American rose from 20% for men and 27% for women in 1985–1989, to 40% for men and 39% for women in 2000–2011. The study was big – involving data including interviews and death certificates from 600,000 Americans.

Americans are generally living longer, which is a factor in their increased lifetime chance of developing type 2 diabetes. They are also not dying in the same proportions that they were, because of better treatment. However, that means they are going to spend far more years of their lives suffering from type 2 diabetes, which can lead to blindness and foot amputations as well as heart problems.

This is very bad news for the US healthcare system, says Dr Edward Gregg, study leader and chief of the epidemiology and statistics branch of the Division of Diabetes Translation at CDC:

As the number of diabetes cases continue to increase and patients live longer there will be a growing demand for health services and extensive costs. More effective lifestyle interventions are urgently needed to reduce the number of new cases in the USA and other developed nations.

Both he and Canada-based Dr Lorraine Lipscombe, who has written a commentary on the study, point out that the situation in the US is unlikely to be much different from that elsewhere in the developed world. Dr Lipscombe, from Women’s College Hospital and the University of Toronto, writes:

The trends reported by Gregg and colleagues are probably similar across the developed world, where large increases in diabetes prevalence in the past two decades have been reported.

Primary prevention strategies are urgently needed. Excellent evidence has shown that diabetes can be prevented with lifestyle changes. However, provision of these interventions on an individual basis might not be sustainable.

Only a population-based approach to prevention can address a problem of this magnitude. Prevention strategies should include optimisation of urban planning, food-marketing policies, and work and school environments that enable individuals to make healthier lifestyle choices. With an increased focus on interventions aimed at children and their families, there might still be time to change the fate of our future generations by lowering their risk of type 2 diabetes.

cool, healthcare, management and leadership, policy, politics, quotes & aphorisms, storytelling

Eisenhower’s Farewell Address – The Military-Industrial Complex

President Dwight Eisenhower’s Farewell Address to the nation January 17, 1961

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted only an alert and knowledgeable citizenry can compel the proper meshing of huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together.

….

The prospect of domination of the nation’s scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded.

Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.

It is the task of statesmanship to mold, to balance, and to integrate these and other forces, new and old, within the principles of our democratic system-ever aiming toward the supreme goals of our free society.

 

Transcript of President Dwight D. Eisenhower’s Farewell Address (1961)

My fellow Americans:

Three days from now, after half a century in the service of our country, I shall lay down the responsibilities of office as, in traditional and solemn ceremony, the authority of the Presidency is vested in my successor.

This evening I come to you with a message of leave-taking and farewell, and to share a few final thoughts with you, my countrymen.

Like every other citizen, I wish the new President, and all who will labor with him, Godspeed. I pray that the coming years will be blessed with peace and prosperity for all.

Our people expect their President and the Congress to find essential agreement on issues of great moment, the wise resolution of which will better shape the future of the Nation.

My own relations with the Congress, which began on a remote and tenuous basis when, long ago, a member of the Senate appointed me to West Point, have since ranged to the intimate during the war and immediate post-war period, and, finally, to the mutually interdependent during these past eight years.

In this final relationship, the Congress and the Administration have, on most vital issues, cooperated well, to serve the national good rather than mere partisanship, and so have assured that the business of the Nation should go forward. So, my official relationship with the Congress ends in a feeling, on my part, of gratitude that we have been able to do so much together.

II

We now stand ten years past the midpoint of a century that has witnessed four major wars among great nations. Three of these involved our own country. Despite these holocausts America is today the strongest, the most influential and most productive nation in the world. Understandably proud of this pre-eminence, we yet realize that America’s leadership and prestige depend, not merely upon our unmatched material progress, riches and military strength, but on how we use our power in the interests of world peace and human betterment.

III

Throughout America’s adventure in free government, our basic purposes have been to keep the peace; to foster progress in human achievement, and to enhance liberty, dignity and integrity among people and among nations. To strive for less would be unworthy of a free and religious people. Any failure traceable to arrogance, or our lack of comprehension or readiness to sacrifice would inflict upon us grievous hurt both at home and abroad.

Progress toward these noble goals is persistently threatened by the conflict now engulfing the world. It commands our whole attention, absorbs our very beings. We face a hostile ideology-global in scope, atheistic in character, ruthless in purpose, and insidious in method. Unhappily the danger it poses promises to be of indefinite duration. To meet it successfully, there is called for, not so much the emotional and transitory sacrifices of crisis, but rather those which enable us to carry forward steadily, surely, and without complaint the burdens of a prolonged and complex struggle-with liberty at stake. Only thus shall we remain, despite every provocation, on our charted course toward permanent peace and human betterment.

Crises there will continue to be. In meeting them, whether foreign or domestic, great or small,there is a recurring temptation to feel that some spectacular and costly action could become the miraculous solution to all current difficulties. A huge increase in newer elements of our defense; development of unrealistic programs to cure every ill in agriculture; a dramatic expansion in basic and applied research-these and many other possibilities, each possibly promising in itself, may be suggested as the only way to the road we which to travel.

But each proposal must be weighed in the light of a broader consideration: the need to maintain balance in and among national programs-balance between the private and the public economy, balance between cost and hoped for advantage-balance between the clearly necessary and the comfortably desirable; balance between our essential requirements as a nation and the duties imposed by the nation upon the individual; balance between action of the moment and the national welfare of the future. Good judgment seeks balance and progress; lack of it eventually finds imbalance and frustration.

The record of many decades stands as proof that our people and their government have, in the main, understood these truths and have responded to them well, in the face of stress and threat. But threats, new in kind or degree, constantly arise. I mention two only.

IV

A vital element in keeping the peace is our military establishment. Our arms must be mighty, ready for instant action, so that no potential aggressor may be tempted to risk his own destruction.

Our military organization today bears little relation to that known by any of my predecessors in peace time, or indeed by the fighting men of World War II or Korea.

Until the latest of our world conflicts, the United States had no armaments industry. American makers of plowshares could, with time and as required, make swords as well. But now we can no longer risk emergency improvisation of national defense; we have been compelled to create a permanent armaments industry of vast proportions. Added to this, three and a half million men and women are directly engaged in the defense establishment. We annually spend on military security more than the net income of all United State corporations.

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence-economic, political, even spiritual-is felt in every city, every state house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted only an alert and knowledgeable citizenry can compel the proper meshing of huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together.

Akin to, and largely responsible for the sweeping changes in our industrial-military posture, has been the technological revolution during recent decades.

In this revolution, research has become central; it also becomes more formalized, complex, and costly. A steadily increasing share is conducted for, by, or at the direction of, the Federal government.

Today, the solitary inventor, tinkering in his shop, has been over shadowed by task forces of scientists in laboratories and testing fields. In the same fashion, the free university, historically the fountainhead of free ideas and scientific discovery, has experienced a revolution in the conduct of research. Partly because of the huge costs involved, a government contract becomes virtually a substitute for intellectual curiosity. For every old blackboard there are now hundreds of new electronic computers.

The prospect of domination of the nation’s scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded.

Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.

It is the task of statesmanship to mold, to balance, and to integrate these and other forces, new and old, within the principles of our democratic system-ever aiming toward the supreme goals of our free society.

V

Another factor in maintaining balance involves the element of time. As we peer into society’s future, we-you and I, and our government-must avoid the impulse to live only for today, plundering, for our own ease and convenience, the precious resources of tomorrow. We cannot mortgage the material assets of our grandchildren without risking the loss also of their political and spiritual heritage. We want democracy to survive for all generations to come, not to become the insolvent phantom of tomorrow.

VI

Down the long lane of the history yet to be written America knows that this world of ours, ever growing smaller, must avoid becoming a community of dreadful fear and hate, and be, instead, a proud confederation of mutual trust and respect.

Such a confederation must be one of equals. The weakest must come to the conference table with the same confidence as do we, protected as we are by our moral, economic, and military strength. That table, though scarred by many past frustrations, cannot be abandoned for the certain agony of the battlefield.

Disarmament, with mutual honor and confidence, is a continuing imperative. Together we must learn how to compose difference, not with arms, but with intellect and decent purpose. Because this need is so sharp and apparent I confess that I lay down my official responsibilities in this field with a definite sense of disappointment. As one who has witnessed the horror and the lingering sadness of war-as one who knows that another war could utterly destroy this civilization which has been so slowly and painfully built over thousands of years-I wish I could say tonight that a lasting peace is in sight.

Happily, I can say that war has been avoided. Steady progress toward our ultimate goal has been made. But, so much remains to be done. As a private citizen, I shall never cease to do what little I can to help the world advance along that road.

VII

So-in this my last good night to you as your President-I thank you for the many opportunities you have given me for public service in war and peace. I trust that in that service you find somethings worthy; as for the rest of it, I know you will find ways to improve performance in the future.

You and I-my fellow citizens-need to be strong in our faith that all nations, under God, will reach the goal of peace with justice. May we be ever unswerving in devotion to principle, confident but humble with power, diligent in pursuit of the Nation’s great goals.

To all the peoples of the world, I once more give expression to America’s prayerful and continuing inspiration:

We pray that peoples of all faiths, all races, all nations, may have their great human needs satisfied; that those now denied opportunity shall come to enjoy it to the full; that all who yearn for freedom may experience its spiritual blessings; that those who have freedom will understand, also, its heavy responsibilities; that all who are insensitive to the needs of others will learn charity; that the scourges of poverty, disease and ignorance will be made to disappear from the earth, and that, in the goodness of time, all peoples will come to live together in a peace guaranteed by the binding force of mutual respect and love.

Transcription courtesy of the Dwight D. Eisenhower Presidential Library and Museum.