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In an earlier post I described the problem of excessive and inappropriate drug prescribing when a patient with multiple chronic illnesses did not have good care coordination by a single primary care physician. In this post I will relate the story of a lady who had an excellent primary care physician but the communication system broke down when she went elsewhere for a single visit. In her case the problem was the recommendation of an inappropriate medical technology for her chronic condition.
Ellen is an elderly lady who had been going to the same primary care physician (PCP) for over twenty years. On nearly every visit she said that she felt “tired.” Repeated history and exam revealed no cause nor did logical tests such as those for anemia or hypothyroidism. She then developed syncopal episodes – times she would black out and fall to the floor, once bruising her head when she fell against the stove, and then waking up in a few minutes. Evaluation showed that she had intermittent episodes of bradycardia, or very slow heart rate, resulting in the drop attacks. In consultation with a cardiologist, it was decided to insert a single lead pacemaker. The pacemaker senses the electrical action in the heart and when the rate drops below a set level, it immediately begins to send out an electrical stimulus – on demand - to the heart muscle so that it will contract at a normal rate. The pacemaker is expensive and the procedure to place it is expensive as well. But it worked perfectly and she no longer had the attacks that were not only scary and medically dangerous but seriously impacting her quality of life. A good return on investment.
A few months later during a visit to her daughter, she went to that daughter’s internist for an unrelated reason; he urged her to see a cardiologist colleague. Both the internist and the new cardiologist heard the usual complaint of “being tired” and assumed it related to her cardiac status. This cardiologist in turn recommended that she needed a “dual lead” pacemaker instead of the single lead one she had. [It has been found that having more than one lead can sometimes improve the heart’s output for very carefully selected patients with heart failure.] When the PCP much later received the cardiologist’s mailed consult report, he disagreed, noting she did not have heart failure, just syncopal attacks – an electrical not a mechanical problem in her heart. Further, the current pacemaker was only needed about 10% of the time meaning that her heart beat at a normal rate at least 90% time, so the pacemaker was not even active most of the day. This lady did not need the proposed new, even more highly expensive pacemaker. No pacemaker, no procedure, no risk of insertion, no risk of post operative infection or bleeding. A lot of money could be saved and the patient could be spared a straight forward yet somewhat risky procedure – which she did not need. The fundamental problem was the lack of care coordination. One would like to believe that had her medical record been easily available digitally, the newly involved internist would have never even suggested the need for a cardiologist opinion and even if sent on, the cardiologist would have rapidly recognized the lack of need for the new device.
The lesson is one doctor needs to be the orchestrator of all of the patient’s care. A good PCP, like this one, coordinates the care of his or her patients with chronic illnesses and in so doing avoids excess referrals, tests, procedures and hospitalizations along with unneeded drugs or devices – all the elements that drive up the total cost of care – and in the process assures quality care, safer care and a close doctor-patient relationship. But sometimes a patient is elsewhere, sees a new physician and the medical history is not readily available. All too often as in this case, the patient ends up getting tests, images or procedures that he or she just does not need.
One of the most effective ways to reduce medical care costs is with good coordination of the care of individuals with chronic illnesses. As the story of Ellen above and of Henry from the earlier post exemplify, there is a strong tendency today for patients with chronic illnesses to either be referred to various specialists or else to go on their own. When this occurs without coordination, the visits add up, the number of tests and images ordered go up, the number of drugs prescribed rises rapidly and the number of procedures and even hospitalizations climb. Unfortunately, many of these are simply not needed – excessive and wasteful, not the best quality and obviously very costly. The value of a good digital medical record in both of these patients is obvious because communication among providers is critical to optimal care.
The primary care physician is in the best position to coordinate care. He or she knows the patient, the patient’s family and socio-economic situation and of course the patient’s various illnesses. Ellen did not need to see a second cardiologist and did not need the dual lead pacemaker. The PCP knew that “tired” was just her normal statement at every visit; not a reason to do more tests, add a drug or do a new procedure. It was unfortunate, indefensible but not at all uncommon that the new cardiologist did not make the effort to call the long time PCP. It would have been quickly determined that Ellen did not need a very expensive new pacemaker.
Henry suffered because he did not have a PCP. Instead he had four doctors, each one dealing with all of his problems and none communicating with the others. Once he had a single PCP, his prescriptions plummeted from 23 to seven, he felt better, had fewer drug-induced side effects and both he and his insurers were saving a lot of money.
Care coordination is critical; it improves the quality of care; it reduces risk; it reduces the costs of care; and it ultimately improves patient satisfaction. A good PCP (or occasionally a specialist) is needed to the orchestrator of that coordination. The electronic medical record has an integral part to play in robust care coordination.
Why, with all of these attendant advantages, do not all PCPs engage in excellent care coordination? I believe it is twofold – dollars and lack of training.
My new book, “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published in February, 2012 by Potomac Books
Showing posts with label chronic disease. Show all posts
Showing posts with label chronic disease. Show all posts
Thursday, October 13, 2011
Sunday, September 18, 2011
Taking 23 Drugs From 4 Different Doctors – Lousy But Expensive Care
Lack of Care Coordination of Chronic Illnesses Leads to Excess Prescriptions, Suboptimal Care and High Expenses
Henry is a 69-year-old living alone in a small town about 60 miles from the nearest metropolitan area. He has healthcare coverage via Medicare, Medigap, and Medicare Part D. He had recently been discharged from the hospital after an ICU stay for a urinary tract infection and called to ask for some advice. He was taking twenty-three -- yes, 23 -- different prescription drugs; some once, some twice and some three times per day along with one by shot monthly. He was not certain why many of them had been prescribed and stated that despite them he did not feel well. Here is a partial list: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate and one for depression.
I asked him who his primary care physician was and learned that he did not have one but rather went to four different doctors, each of whom treated different issues and none of whom shared all of his information and none of whom used electronic medial records. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage. He told me that when he went to the local drug store and checked his blood pressure, it was always normal.
Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues. The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, one of the doctors had given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result he had developed an infection that had almost killed him. And all these drugs were expensive, both to him and to his Medicare Part D insurance plan.
Heart failure and diabetes together consume more than 50% of our healthcare dollars and here is a person whose care is not being adequately monitored; rather he is getting one drug after another without attention to what else is going on. This lack of care coordination is a prime reason why the costs are so high yet quality so low.
My first suggestion was that Henry needed a primary care physician, one to call his own. He found one who had just started his practice, had the time and inclination to coordinate his care and had installed an electronic medical record system. A few months later Henry called and told me that he was now taking just seven medicines and felt much better!
Henry still has four serious chronic conditions. But with a single physician serving as orchestrator rather than just intervener, one who uses an electronic medical record and who actually pays attention to Henry’s medical plus social and home life, Henry has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap and Medicare Part D’s money. In short good care coordination is a win-win for all concerned.
And yet, care coordination is not appreciated for its importance by most physicians, insurers nor patients. Why is that?
Henry is a 69-year-old living alone in a small town about 60 miles from the nearest metropolitan area. He has healthcare coverage via Medicare, Medigap, and Medicare Part D. He had recently been discharged from the hospital after an ICU stay for a urinary tract infection and called to ask for some advice. He was taking twenty-three -- yes, 23 -- different prescription drugs; some once, some twice and some three times per day along with one by shot monthly. He was not certain why many of them had been prescribed and stated that despite them he did not feel well. Here is a partial list: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate and one for depression.
I asked him who his primary care physician was and learned that he did not have one but rather went to four different doctors, each of whom treated different issues and none of whom shared all of his information and none of whom used electronic medial records. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage. He told me that when he went to the local drug store and checked his blood pressure, it was always normal.
Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues. The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, one of the doctors had given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result he had developed an infection that had almost killed him. And all these drugs were expensive, both to him and to his Medicare Part D insurance plan.
Heart failure and diabetes together consume more than 50% of our healthcare dollars and here is a person whose care is not being adequately monitored; rather he is getting one drug after another without attention to what else is going on. This lack of care coordination is a prime reason why the costs are so high yet quality so low.
My first suggestion was that Henry needed a primary care physician, one to call his own. He found one who had just started his practice, had the time and inclination to coordinate his care and had installed an electronic medical record system. A few months later Henry called and told me that he was now taking just seven medicines and felt much better!
Henry still has four serious chronic conditions. But with a single physician serving as orchestrator rather than just intervener, one who uses an electronic medical record and who actually pays attention to Henry’s medical plus social and home life, Henry has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap and Medicare Part D’s money. In short good care coordination is a win-win for all concerned.
And yet, care coordination is not appreciated for its importance by most physicians, insurers nor patients. Why is that?
Thursday, September 8, 2011
Complex, Chronic Illnesses Last a Lifetime and Consume 70% of the Healthcare Dollar
Medical care is organized to treat acute conditions but the need today is to prevent, diagnose and treat chronic illnesses. Unfortunately, we are sorely lacking in a good chronic care management system. this will be the first in a series of six posts on this issue.
Our medical care system has developed over decades and even centuries around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gives an antibiotic for the pneumonia and the patient gets better. The surgeon cuts out the gall bladder or the appendix and the patient is cured. One patient; one doctor. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that once developed usually remain with the individual for life. These patients with chronic illnesses need a different approach to care. They need long term care, not episodic care. They need a multi-disciplinary, team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers along with all of the tests and procedures to allow for a unified, coordinated care management approach. Not only are these diseases likely to last a lifetime, they are difficult to manage, have an adverse impact of both quality of life and mortality, and they are usually quite expensive to treat. Today 70% of our medical care expenditures go toward their treatment. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs and this will require high quality health information technology.
However, it is valuable to first understand the implications of chronic disease. Most of us are just not aware that their incidence is rising - and rapidly. The Milken Institute (http://bit.ly/lGHFqP ) quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:
• “More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.
• The total impact of these diseases on the economy is $1.3 trillion annually.
• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.
• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.
• $4.2 trillion in treatment costs and lost economic output.
• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.
• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.
• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.”
To me the most telling and important finding is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.” Restated, we as individuals need to take responsibility for our own health. Not every chronic illness is preventable, but most are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps will make a huge difference in our health and our lives. Adding in dental hygiene, avoiding sexually transmitted diseases, using seat belts and not drinking and driving will further prevent many illnesses. Many do not appreciate either that following a more appropriate lifestyle will actually slow the normal aging process that ultimately leads to many of these chronic illnesses.
Meanwhile, when chronic illness does strike, it is imperative to have a single care provider take responsibility for care coordination. Someone to not only recommend tests, procedures, images and specialist visits but who will actively ensure that each provider is properly attuned to the patient’s needs and that all of the information is collected and aggregated in a meaningful manner. When this is done the quality of care rises markedly, many fewer adverse events occur, the patient is more satisfied and the costs of care are dramatically reduced. In most cases, a primary care physician is the appropriate one to coordinate care although sometimes a specialist is better equipped for this role (e.g., a very complex cancer treatment plan). To be effective, the PCP or specialist needs to have not only the willingness and interest but also the time available to actually do the care coordination – time that is not available for most PCPs today. This coupled with limited digitized health information leads to today’s inadequate care of many individuals with chronic illnesses. In future posts I will describe today’s problems with lack of care coordination and how it can be corrected.
I wonder what others think abut why the problem of chronic illnesses and the need for care coordination is just not well recognized?
Our medical care system has developed over decades and even centuries around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gives an antibiotic for the pneumonia and the patient gets better. The surgeon cuts out the gall bladder or the appendix and the patient is cured. One patient; one doctor. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that once developed usually remain with the individual for life. These patients with chronic illnesses need a different approach to care. They need long term care, not episodic care. They need a multi-disciplinary, team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers along with all of the tests and procedures to allow for a unified, coordinated care management approach. Not only are these diseases likely to last a lifetime, they are difficult to manage, have an adverse impact of both quality of life and mortality, and they are usually quite expensive to treat. Today 70% of our medical care expenditures go toward their treatment. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs and this will require high quality health information technology.
However, it is valuable to first understand the implications of chronic disease. Most of us are just not aware that their incidence is rising - and rapidly. The Milken Institute (http://bit.ly/lGHFqP ) quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:
• “More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.
• The total impact of these diseases on the economy is $1.3 trillion annually.
• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.
• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.
• $4.2 trillion in treatment costs and lost economic output.
• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.
• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.
• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.”
To me the most telling and important finding is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.” Restated, we as individuals need to take responsibility for our own health. Not every chronic illness is preventable, but most are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps will make a huge difference in our health and our lives. Adding in dental hygiene, avoiding sexually transmitted diseases, using seat belts and not drinking and driving will further prevent many illnesses. Many do not appreciate either that following a more appropriate lifestyle will actually slow the normal aging process that ultimately leads to many of these chronic illnesses.
Meanwhile, when chronic illness does strike, it is imperative to have a single care provider take responsibility for care coordination. Someone to not only recommend tests, procedures, images and specialist visits but who will actively ensure that each provider is properly attuned to the patient’s needs and that all of the information is collected and aggregated in a meaningful manner. When this is done the quality of care rises markedly, many fewer adverse events occur, the patient is more satisfied and the costs of care are dramatically reduced. In most cases, a primary care physician is the appropriate one to coordinate care although sometimes a specialist is better equipped for this role (e.g., a very complex cancer treatment plan). To be effective, the PCP or specialist needs to have not only the willingness and interest but also the time available to actually do the care coordination – time that is not available for most PCPs today. This coupled with limited digitized health information leads to today’s inadequate care of many individuals with chronic illnesses. In future posts I will describe today’s problems with lack of care coordination and how it can be corrected.
I wonder what others think abut why the problem of chronic illnesses and the need for care coordination is just not well recognized?
Monday, April 18, 2011
Ultraprocessed Foods Lead to Chronic Illnesses
Much of today’s foods are “ultraprocessed,” lead to obesity and its ultimate diseases such as diabetes, coronary artery disease, hypertension, many cancers and worsening of diseases such as osteoarthritis.
Ultraprocessed foods originate from just a few grains, namely corn, wheat and soy but these then undergo extensive chemical and mechanical manipulation resulting in compounds that humans have never eaten before. Just look at the ingredients list on many store products and notice first how many ingredients are listed and second how few of them you recognize. Further they are concentrated as to sugars, salt and calories while deficient or totally lacking in the fiber, micronutrients and phytochemicals found in fresh or frozen grains, vegetables fruits and unadulterated meats and fish.
David Ludwig MD, PhD of Boston Children’s Hospital wrote a cogent article on ultraprocessed foods in the April 6, 2011 edition of the Journal of the American Medical Association and upon which the proceeding was based. He explains that there have been three major breakthroughs in food technology. The first came perhaps 2 million years ago with the development of stone tools and the use of fire for cooking. This allowed the human who did not have the running speed of large carnivores nor the digestive tract attributes of herbivores like cattle and sheep to expand his diet. The second big technology breakthrough was domestication of grains – agriculture. This led to civilization in the sense of larger more stable communities because domesticated grains such as wheat and corn greatly increased calories available and no longer required migration to hunt or gather. He makes the interesting observation that human stature dropped a few inches with this change because grains carry fewer micronutrients and protein per gram than do animal meats and nuts.
The industrial Revolution was the third breakthrough technology which led to refined flours and concentrated sugars along with grain-fed rather than grass fed cattle, sheep and hogs. Such animals are heavy with saturated fats although their protein content and ready availability has resulted in a return of greater stature in recent generations. More recently have come ultraprocessed foods.
These ultraprocessed foods are high in calories from sugars and fats – often hydrogenated and trans fats – yet low in micronutrients. They are found in supermarkets’ “middle aisles” as processed foods such as cereal with added sugar, cheese “spreads”, “macaroni and cheese,” soups high in salts and calories, “sticky buns,” and of course sugared sodas. And ultraprocessed foods are readily available in many fast food outlets where a muffin may have 400 calories with high contents of sugars and saturated fats. A bacon cheeseburger, large fries and large soda can contain well more than one half of a day’s caloric needs yet be deficient in nutrients.
Ludwig concludes with “the problem is the creation of a dietary pattern based on factory-made, durable, hyper-palatable, aggressively marketed, ready-to-eat or heat foodstuffs composed of inexpensive, highly processed ingredients and additives. Reducing the burden of obesity-related chronic disease requires a more appropriate use of technology that is guided by public health rather than short-term economic benefit.”
What can we do? We need to cut back on the ingestion of these ultraprocessed foods. But this will not be easy. For this to work I believe we need incentives. After all, that bacon cheese burger tastes good – sugar and fat are pleasing in our mouths. So we need more than just knowledge that we are eating well and thereby preventing future disease while improving our health. Knowledge is important because most people just do not realize the extent of the harm that comes from over consumption of ultraprocessed foods. With knowledge we can follow the advice of Pollan in his “In Defense of Food” to never buy a product that has more than five ingredients or has ingredients that we have never heard of or cannot pronounce. But knowledge alone is just not incentive enough to overcome the temptations.
Some thoughts: Government can help with how it subsidizes agriculture, incenting the growth of a broader array of crops and not marking the fattest meat as “prime.” And it can continue to insist that restaurants, especially fast food outlets, display calorie counts. Business can help with wellness programs that reduce the employee share of health insurance premiums in return for weight reduction or exercise programs. Insurance can offer incentives as well. Schools can offer only quality foods – good in itself but also a lesson in good dietary habits for our children in their formative years. And we each need to create our own incentives – as I typed this I also ate a chocolate chip cookie. I enjoyed it but have set myself a limit of one per day. My treat for finishing this blog post.
Ultraprocessed foods originate from just a few grains, namely corn, wheat and soy but these then undergo extensive chemical and mechanical manipulation resulting in compounds that humans have never eaten before. Just look at the ingredients list on many store products and notice first how many ingredients are listed and second how few of them you recognize. Further they are concentrated as to sugars, salt and calories while deficient or totally lacking in the fiber, micronutrients and phytochemicals found in fresh or frozen grains, vegetables fruits and unadulterated meats and fish.
David Ludwig MD, PhD of Boston Children’s Hospital wrote a cogent article on ultraprocessed foods in the April 6, 2011 edition of the Journal of the American Medical Association and upon which the proceeding was based. He explains that there have been three major breakthroughs in food technology. The first came perhaps 2 million years ago with the development of stone tools and the use of fire for cooking. This allowed the human who did not have the running speed of large carnivores nor the digestive tract attributes of herbivores like cattle and sheep to expand his diet. The second big technology breakthrough was domestication of grains – agriculture. This led to civilization in the sense of larger more stable communities because domesticated grains such as wheat and corn greatly increased calories available and no longer required migration to hunt or gather. He makes the interesting observation that human stature dropped a few inches with this change because grains carry fewer micronutrients and protein per gram than do animal meats and nuts.
The industrial Revolution was the third breakthrough technology which led to refined flours and concentrated sugars along with grain-fed rather than grass fed cattle, sheep and hogs. Such animals are heavy with saturated fats although their protein content and ready availability has resulted in a return of greater stature in recent generations. More recently have come ultraprocessed foods.
These ultraprocessed foods are high in calories from sugars and fats – often hydrogenated and trans fats – yet low in micronutrients. They are found in supermarkets’ “middle aisles” as processed foods such as cereal with added sugar, cheese “spreads”, “macaroni and cheese,” soups high in salts and calories, “sticky buns,” and of course sugared sodas. And ultraprocessed foods are readily available in many fast food outlets where a muffin may have 400 calories with high contents of sugars and saturated fats. A bacon cheeseburger, large fries and large soda can contain well more than one half of a day’s caloric needs yet be deficient in nutrients.
Ludwig concludes with “the problem is the creation of a dietary pattern based on factory-made, durable, hyper-palatable, aggressively marketed, ready-to-eat or heat foodstuffs composed of inexpensive, highly processed ingredients and additives. Reducing the burden of obesity-related chronic disease requires a more appropriate use of technology that is guided by public health rather than short-term economic benefit.”
What can we do? We need to cut back on the ingestion of these ultraprocessed foods. But this will not be easy. For this to work I believe we need incentives. After all, that bacon cheese burger tastes good – sugar and fat are pleasing in our mouths. So we need more than just knowledge that we are eating well and thereby preventing future disease while improving our health. Knowledge is important because most people just do not realize the extent of the harm that comes from over consumption of ultraprocessed foods. With knowledge we can follow the advice of Pollan in his “In Defense of Food” to never buy a product that has more than five ingredients or has ingredients that we have never heard of or cannot pronounce. But knowledge alone is just not incentive enough to overcome the temptations.
Some thoughts: Government can help with how it subsidizes agriculture, incenting the growth of a broader array of crops and not marking the fattest meat as “prime.” And it can continue to insist that restaurants, especially fast food outlets, display calorie counts. Business can help with wellness programs that reduce the employee share of health insurance premiums in return for weight reduction or exercise programs. Insurance can offer incentives as well. Schools can offer only quality foods – good in itself but also a lesson in good dietary habits for our children in their formative years. And we each need to create our own incentives – as I typed this I also ate a chocolate chip cookie. I enjoyed it but have set myself a limit of one per day. My treat for finishing this blog post.
Monday, April 11, 2011
Surprise – Adolescent Obesity Leads To Later Heart Disease and Diabetes
Well, probably not a surprise at all. The seeds of coronary artery disease (CAD) are laid down early and over long periods. But given our current pandemic of obesity beginning in childhood, should we worry about an epidemic of chronic disease like diabetes and CAD in the years to come? The clear answer is a resounding “Yes.”
There has been a long term study of military men in the Israeli Defense Force. An article in the New England Journal of Medicine, April 7, 2011 reports on what happened over an average follow-up of 17 years after army induction at age 17 for those who chose to remain in the military after the required three years. This amounted to 37,674 healthy men followed for about 650,000 person years. Among them, 1173 developed diabetes type 2 over time and 327 developed angiography-proven CAD. All by the age of 45.
Here is the baseline data:
Blood pressure, resting heart rate, fasting blood sugar, and low density lipoprotein (LDL – the “bad stuff”) and smoking incidence progressively increased with increasing BMI (BMI, a calculated ratio of weight and height) among the 17 year old inductees. High density lipoproteins (HDL – or the “good stuff”) declined as did the amount of weekly exercise with increasing BMI.
Here is the follow-up data:
Since this was a study of men beginning at age 17 and lasting an average of 17 years, it follows that the 327 cases of CAD and 1173 of diabetes were among relatively young men – aged 25-45 years old. When the investigators adjusted for age, family history of CAD, blood pressure, smoking status, LDL, HDL and triglycerides they found that an elevated BMI at age 17 was a significant independent risk factor for CAD. Indeed the risk increased by 12% for each increment of 1 unit of BMI. They also noted that CAD occurred even in those with BMIs that are generally considered within the acceptable range today.
BMI at age 17 also predicted for the later development of diabetes mellitus type 2 (DM) with risk increasing about 10% for each additional 1 unit of BMI. But with diabetes, it was the adult level (age 25 and beyond) that was associated with a greater increase in diabetes relative risk. Said differently, higher levels of BMI at age 17 correlate with higher risk of CAD and diabetes in early adulthood. Persistent elevations of BMI increase that risk. Elevation in early adulthood increases the risk of DM during early adulthood whether or not the person had a higher BMI at age 17.
My takeaway:
It is imperative to intervene now in the growing pandemic of childhood and adolescent obesity. Even modest increases BMI can predispose to later CAD and DM. Once developed, these are chronic illnesses that persist for life, are challenging to manage, are expensive to treat and have a high impact on both quality of life and longevity. Our children are our future; it is our obligation to protect them. And if that is not reason enough, then think of your wallet. The high costs of their care will have a very significant impact on each of us in our taxes and our insurance premiums.
There has been a long term study of military men in the Israeli Defense Force. An article in the New England Journal of Medicine, April 7, 2011 reports on what happened over an average follow-up of 17 years after army induction at age 17 for those who chose to remain in the military after the required three years. This amounted to 37,674 healthy men followed for about 650,000 person years. Among them, 1173 developed diabetes type 2 over time and 327 developed angiography-proven CAD. All by the age of 45.
Here is the baseline data:
Blood pressure, resting heart rate, fasting blood sugar, and low density lipoprotein (LDL – the “bad stuff”) and smoking incidence progressively increased with increasing BMI (BMI, a calculated ratio of weight and height) among the 17 year old inductees. High density lipoproteins (HDL – or the “good stuff”) declined as did the amount of weekly exercise with increasing BMI.
Here is the follow-up data:
Since this was a study of men beginning at age 17 and lasting an average of 17 years, it follows that the 327 cases of CAD and 1173 of diabetes were among relatively young men – aged 25-45 years old. When the investigators adjusted for age, family history of CAD, blood pressure, smoking status, LDL, HDL and triglycerides they found that an elevated BMI at age 17 was a significant independent risk factor for CAD. Indeed the risk increased by 12% for each increment of 1 unit of BMI. They also noted that CAD occurred even in those with BMIs that are generally considered within the acceptable range today.
BMI at age 17 also predicted for the later development of diabetes mellitus type 2 (DM) with risk increasing about 10% for each additional 1 unit of BMI. But with diabetes, it was the adult level (age 25 and beyond) that was associated with a greater increase in diabetes relative risk. Said differently, higher levels of BMI at age 17 correlate with higher risk of CAD and diabetes in early adulthood. Persistent elevations of BMI increase that risk. Elevation in early adulthood increases the risk of DM during early adulthood whether or not the person had a higher BMI at age 17.
My takeaway:
It is imperative to intervene now in the growing pandemic of childhood and adolescent obesity. Even modest increases BMI can predispose to later CAD and DM. Once developed, these are chronic illnesses that persist for life, are challenging to manage, are expensive to treat and have a high impact on both quality of life and longevity. Our children are our future; it is our obligation to protect them. And if that is not reason enough, then think of your wallet. The high costs of their care will have a very significant impact on each of us in our taxes and our insurance premiums.
Saturday, March 26, 2011
Bringing Down the Costs of Medical Care
It is currently popular for government officials to single out the insurance companies for the rising cost of healthcare. Not that the insurers are without fault but the real reasons for cost increases are rarely addressed and therefore not appreciated. We are a country with an aging population (“old parts wear out”) and of many adverse behaviors (e.g., overweight, sedentary lifestyle, stress and 20% still smoke.) Combined, these are driving a rapid increase in chronic diseases such as diabetes type 2, cardiovascular disease including heart attacks, heart failure and strokes, high blood pressure, and cancer.
These are illnesses that, once developed, are usually with the individual for life, have a major impact on quality of life and are inherently expensive to treat. The Milken Institute did a comprehensive study of chronic diseases. Among their findings: 109 million Americans have a chronic illness now [that’s about one third of us!] and many have more than one for a total of 162 million. The costs of care today are about $275 million and the total economic costs are well over a trillion dollars per year in lost productivity, etc. They estimate that we are on a track for a 42% increase in these chronic diseases by 2023 (as a result of aging and behaviors,) not that long from now. And if we do nothing to change the way we care for these patients, the costs of medical care will be $790 billion and the total economic costs will be over 4 trillion dollars.
There are two things to do to reverse this trend. These are illnesses that by and large are caused by our behaviors or are the result of aging. We can’t stop aging. So, the first step is to have an active program in behavior modification. Easier said than done, of course but here are some principles. We need to individually accept responsibility for our own health. But we need to understand what we are doing and how it impacts us over the long term. Government can help here with educational programs, rules about school lunches, requiring restaurants to post calorie and fat contents, labeling food packages with a more realistic total calorie assumption (today packages imply that the average person needs a 2000 calorie diet) and other steps. Incentives, primarily monetary ones, can have a big impact. Incentives need to be large enough to be useful yet focused enough to drive toward the desired end. Our employer can help with wellness programs to assist us to stop smoking, loose weight, improve our nutrition or deal with stress more effectively. The incentive here can be asking the employee who is successful to pay a lower portion of their health insurance premium. Insurers can create incentives directly for following a healthier lifestyle by lowering premiums for those who don’t smoke or are at a reasonable weight.
The second major step is to ensure that those who do have a chronic illness get very good care coordination. Unfortunately, this is just not the case for most patients today. They end up with multiple doctors, each doing their own thing, excess specialist consultations, too many medications, unnecessary tests and procedures and sometimes even unneeded hospitalizations. This drives up the cost of care dramatically. When one has a primary care physician that takes the time to fully coordinate all the elements of care, the use of specialists declines as do tests, procedures and hospitalizations and drug therapy is well managed.
Unfortunately, most primary care physicians have too many patients under their care to allow adequate time for prevention sessions or the time needed for care coordination. They need to care for fewer patients meaning they will need to receive a higher fee for each visit and this must include a reasonable payment for preventive activities and coordination efforts. Added to this they need to be paid to take the time to respond to emails and to use other technologies that can keep the patient out of the office unless really necessary. Some docs are doing just this by limiting their practice to about 500 patients (rather than the usual 1200-1400) and charging a flat fee for all care for a year. Others are refusing to accept insurance, both commercial and Medicare, and instead are billing the patient just as a lawyer or accountant or other professional would. The billing includes time spend in prevention and coordination. These may well be the future of primary care reimbursement and a means to assist the patient to first prevent chronic illnesses from occurring and second to assist in good coordination of the care when one does develop.
But all of this raises critical questions. What should and what will government do to help us modify our behaviors? Will insurers be allowed and will they accept the responsibility of a two tiered premium pricing system? Will employers accept the added chore of developing wellness programs? Will physicians, even if they are offered adequate payments, actually spend the time needed for good prevention and good care coordination? And, most importantly, will we as citizens accept our responsibility to lead a reasonably healthy lifestyle?
Thursday, March 26, 2009
America Has a Sick Care Not a Health Care System
We Americans like to pride ourselves as having the best healthcare system the world but unfortunately that is not the case. We have a medical care system, not a healthcare system. We give lip service to prevention and spend only about 3% of our $2 trillion in medical expenditures on public health. By many measures we do not rate favorably compared to many of the other industrialized societies. As citizens we have behaviors that are driving more and more illness, illnesses that at chronic, complex, lifelong and life shortening. That $2 trillion is by far more than other nations spend per capita and it is seriously and adversely affecting businesses, government and each of us. Meanwhile, we may be pleased with our doctor but not the delivery system as a whole. Quality is subpar, preventable errors are rampant and some 47 million of us are without insurance access to medical care – the only such industrialized country. Health care reform is now a topic of great interest but politicians and media focus on the access issues predominantly, cost issues somewhat and the quality, safety and prevention/ public health needs only rarely.
Let’s take a closer look at what we have today. The current system of care focuses on “disease and pestilence.” It is a disease oriented system and certainly not a health management system nor a patient-oriented system. Mostly, this is due to a reimbursement methodology that under-rates the generalists and tilts toward those that do procedures. That is not what we need; what we need is a payment system that rewards the generalist for working in rural or socio-economically deprived areas, for taking the time to listen to the patient, for being attuned to prevention and wellness management. Today, that is just not where we are in America. So we need a change to a system that is focused on disease prevention, health promotion and with ready access to primary care and providers. Then, when necessary, access to specialists, hospitals, rehabilitation and all of the other requirements for good medical care when disease or injury does occur.
Let’s take a closer look at what we have today. The current system of care focuses on “disease and pestilence.” It is a disease oriented system and certainly not a health management system nor a patient-oriented system. Mostly, this is due to a reimbursement methodology that under-rates the generalists and tilts toward those that do procedures. That is not what we need; what we need is a payment system that rewards the generalist for working in rural or socio-economically deprived areas, for taking the time to listen to the patient, for being attuned to prevention and wellness management. Today, that is just not where we are in America. So we need a change to a system that is focused on disease prevention, health promotion and with ready access to primary care and providers. Then, when necessary, access to specialists, hospitals, rehabilitation and all of the other requirements for good medical care when disease or injury does occur.
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