Following is a three-part series Cindi Ross Scoppe wrote in 2007 exploring the role chronic medical conditions play in our health and our health-care policies.
Part 1: Obesity, smoking the root of chronic health crisis
Part 2: Prevention key for individuals, society
Part 3: Replacing sick care with health care
The big seven chronic diseases share a common thread, or two
THE FOLKS at the Partnership to Fight Chronic Disease have been working very hard to get the public, and through the public the presidential candidates, focused on The Big Seven — seven chronic diseases that consume the bulk of our health care spending and will suck ever more life out of our society and economy until we decide to manage or prevent them. And it’s beginning to work; more and more people can recite the litany — cancer, diabetes , hypertension, stroke, heart disease, pulmonary disease and mental disorders.
What hasn’t yet quite sunk in is how this list intersects with smoking and the twin sins of gluttony and sloth.
We’re only beginning to come to terms with the fact that “obesity epidemic” is not just the latest nanny-government call to arms, but rather a serious public health threat. Still, “fat” usually translates in our minds into “ diabetes .” And while we understand that smoking is deadly, we tend to think primarily in terms of lung cancer.
But gluttony, sloth and smoking lie at the heart of the Milken Institute’s big new report on how we can reduce the incidence and costs of The Big Seven, as the triggers of a cascade of deadly and expensive diseases.
In disease after disease, the difference between sickness and health, spiraling costs and controllable costs comes down to whether we stay on our current course or make modest improvements in our nation’s rates of obesity, smoking and exercise:
• Breast cancer. “The principal source of variance” between a projected 51 percent increase by 2023 and an optimistic-case 32 percent increase is “ a lower projected trend for obesity.”
• Prostate cancer. “ Increased physical activity, lower obesity rates, and an increase in early screening for prostate cancer together produce 393,000 fewer cases (21.5 percent) in 2023 in the optimistic scenario than in baseline projections.”
• Stroke. “ Lower smoking rates, changes in obesity and exercise levels, and an increase in early intervention” could prevent 589,000 strokes, a reduction of 19 percent. Lower smoking rates would save $4 billion in treatment costs, and lower obesity rates would save more than $1 billion.
• Diabetes . “ The obesity epidemic will have the greatest and most direct effect on diabetes,” with a lower rate resulting in 13 percent (2.8 million) fewer cases, saving $10 billion in treatment costs and $43 billion in productivity.
• Hypertension. “ Changes in obesity and exercise levels could prevent the rapid progression of prevalence,” resulting in 12 percent (5.7 million) fewer cases and saving $9 billion in treatment costs and a whopping $91 billion in productivity costs.
• Heart disease. “Population aging and obesity are likely to cause an increase in heart disease cases . Fortunately, changes in behavioral risk factors could significantly alter the path of heart disease.” Lower rates of obesity could reduce the incidence by 20 percent (4.4 million) and save $28 billion in treatment costs and $46 billion in productivity costs. Reduced smoking rates would cut the incidence by 1.35 million.
• Colon cancer. “Increased screening, greater reductions in ’at risk’ smoking (defined as smoking at least 100 cigarettes over the course of a lifetime and still smoking), and obesity declines related to increased physical activity” could reduce the incidence by 17.7 percent.
• Lung cancer. “ Lower smoking rates in the optimistic scenario result in 92,000 fewer cases of lung cancer (18.4 percent fewer).”
• Other cancers. “Skin cancer is the most prevalent of ’other cancers,’ but liver, kidney, brain, bladder, and uterine cancer, and leukemia are also significant. Obesity is expected to have a detrimental impact on future cases . Lower smoking, cholesterol, and obesity rates cut rates” 18 percent (by 2.3 million).
• Pulmonary conditions. “The principal sources of variance between the current and alternative case scenarios are lower projections for smoking prevalence and average air quality. Cases grow by 12.8 percent between 2003 and 2023, resulting in 9.1 million fewer cases.” The total is staggering.
In all, “An Unhealthy America; The Economic Burden of Chronic Diseases” concludes, “if the country could reverse the growth rate of obesity and return to 1998 levels in 2023,” the number of people on track to one of The Big Seven would drop by 15 million, or 14 percent. That would reduce the 2003 health care price tag by $60 billion, and increase productivity by $254 billion.
Smoking will decline to 19 percent by 2023 if we stay on our current course; but if we cut it to 15 percent instead, the study said, we could reduce the 2023 incidence of The Big Seven by 9 percent (9.6 million cases), cut treatment costs by $31 billion and increase productivity by $79 billion.
You can find the Milken report at www.fightchronicdisease.org. You can read more about how we as a society can respond to this information in my columns next week.
Reach Ms. Scoppe at(803) 771-8571 or email@example.com.
Those ounces of prevention add up to healthier, less costly society
WE KNOW that 75 percent of the costs of medical care are attributable to The Big Seven chronic diseases. While there are exceptions, we know that most people with chronic diseases didn’t have to get them. They wouldn’t have Type 2 diabetes , hypertension or heart or pulmonary disease or even some cancers and mental disorders, they wouldn’t stroke out if they weren’t so overweight and inactive or didn’t smoke so much.
We also know that exercising more, eating less, tossing the Joe Camels in the trash and making other lifestyle changes are easier said than done. So the question is, how can we drag our gluttonous, lazy, smoking neighbors (and selves?) away from the all-you-can-eat buffet and into the gym?
The challenge for society, just as for individuals, may be less figuring out what to do and more deciding to do it.
Until somebody produces that magic pill, there are essentially three ways to get large numbers of people to make the lifestyle changes that will make them healthier and keep our nation’s medical costs from bankrupting us: education, incentives and disincentives. All three can be administered through government, community organizations, employers and insurers. But all three are imperfect cures.
Education is by far everyone’s favorite tool, because it costs the least and is the least intrusive. But it’s not entirely clear how much of the problem is that people don’t know they ought to eat less, exercise more, stop smoking and drink less, and how much they know but either can’t or won’t make the changes.
Still, I think education is worthwhile, because if it’s done right, it can transform societal attitudes, and create one of the most powerful forces for change: peer pressure. This is particularly true with kids, who also can be educated more easily than adults to look at health in a healthier way.
That was the idea behind Rage Against the Haze, a viral anti-smoking movement started with state tax dollars that has become a national model. It is essentially the idea behind the “Healthy SC School Video Contest” that First Lady Jenny Sanford and Education Superintendent Jim Rex launched Nov. 1. That contest marks our state’s first attempt to harness peer pressure and youthful exuberance to battle the bulge, and it shouldn’t be the last.
Disincentives and punishments are likewise a mixed bag. Every state except South Carolina has decided it’s a good idea to give people a disincentive to smoke — with a higher cigarette tax. But you won’t catch many politicians talking about slapping a heavy tax on Krispy Kremes and Cokes. Although the principle is similar, that gets a lot closer to meddling.
In the absence of government action, a few employers are exploring disincentives to the bad choices that they know will hurt their bottom line, through rising insurance costs and absenteeism. They’re basing insurance premiums on lifestyle choices and refusing to hire or even firing people who smoke, or who don’t exercise enough, or who weigh too much — or for that matter, who maintain a healthy weight by unhealthy means. Outlandish nanny-creep?
The Chicago Tribune recently dug up this bit of historic perspective: “A century ago Henry Ford created a so-called Sociological Department, a team of 150 investigators who visited employees’ homes and asked them about drinking, gambling, diet, how much they had in their savings accounts and other personal matters. Those who didn’t meet Ford’s standards within six months were fired.”
Flash forward to 2007. The Tribune reports that the Cleveland Clinic no longer hires people who fail a nicotine test and Weyco Inc. has fired employees for using tobacco — both market decisions that the S.C. Legislature has prohibited. And starting in 2009, Indianapolis- based Clarian Health will charge employees $5 per pay period if they use tobacco or exceed allowed levels of blood pressure, cholesterol and other tests.
Incentives, rewards and even removing barriers to healthy choices tend to cost the most, and require the greatest leap of faith. They’re sort of like investing in educating kids: You know that if kids get a good education, they’re far less likely to become criminals or deadbeats, which means spending much less on police, prisons and social services on the back end. But for several years, you have to pay for both the extra education (prevention) and the social services and police for the grown-ups we didn’t turn into productive citizens.
But there’s reason to believe this is the most effective route. That’s why even South Carolina pays for smoking cessation for government employees, Medicaid recipients and, under some circumstances, the general public.
It’s why the Safe Routes to School movement — a program designed to clear the physical obstacles to kids walking and biking to school — is gaining steam nationally and in our state.
It’s why we’re replacing some (although not enough) of the unhealthy food with healthy food in public schools — and why we should do the same in every government building. If people want to drown their sorrows in deep-fat-fried potatoes and high-fructose-corn-syrup-sweetened gunk, let them — but the government shouldn’t help them.
And it’s why all the delivery agents — government, employers, social organizations and insurers — need to concentrate on finding the most effective incentives to healthy living.
Reach Ms. Scoppe at(803) 771-8571 or firstname.lastname@example.org.
You get what you pay for, and we’re paying for the wrong things
WHETHER THE government, employers or individuals write the check for medical care, it’s going to cost too much until we transform our sick-care system into a health-care system.
Of course the best way to cut medical costs is to prevent chronic diseases, which eat up 75 cents of every medical dollar. That’s a tough battle to win, but fortunately the war isn’t over just because we fail at prevention.
With proper treatment, some chronic diseases are reversible. And early detection and proper management of diseases not reversed can still save a tremendous amount of money and suffering.
The problem is that we don’t do that, because our insurance system was designed before chronic diseases were our main problem. We didn’t know statins and ACE inhibitors could lower cholesterol and blood pressure, weren’t able to monitor blood-glucose levels so it was safe to tightly control diabetes . We didn’t have chemo and coronary bypass surgery, kidney and heart transplants.
If you got cancer or had a heart attack, you died, and there weren’t that many bills to pay. Insurance paid for surgery, childbirth, setting broken bones.
It’s still geared to do that.
That’s why an impressive group of public health, medical, business, labor, insurance and civic organizations is working this campaign season to get the public and the presidential candidates focused on The Big Seven chronic diseases. And that’s why the most important proposal from the Partnership to Fight Chronic Disease is to “refocus our health system on preventing, detecting, and managing chronic disease.”
“In an era when we have the knowledge and expertise to prevent disease and to better treat chronic conditions,” the partnership says in a platform released last month, “it simply doesn’t make sense to have a ’1960s’ model health care system built around episodic and acute care — a system that, for instance, will pay to amputate a leg or perform open-heart surgery, but too often fails to provide preventive care and disease management that could prevent much more costly interventions down the road.”
Mike Huckabee doesn’t need convincing. Bring up medical care, and the former Arkansas governor, who came to national attention when he dropped 110 pounds and led his state on a health crusade, sounds like he could be reading straight out of the partnership’s platform. Actually, he sounds like he could have written it, with such lines as these:
• “We don’t have a health care crisis in America, we have a health crisis.”
• “The challenge is not universal coverage. Frankly we could afford that, if we had a healthier population.”
• “What you’re really doing is building an intervention-based system that intervenes at the catastrophic level, when you should be focusing on a prevention-based system that keeps us from ever getting there.”
Part of Mr. Huckabee’s prescription for a healthier Arkansas was a smarter insurance system for government employees. Reduce their insurance premiums if they’ll take a health assessment. Encourage them to get cancer screenings by eliminating the deductibles and co-payments.
“We found that a lot of people who should be getting those screenings weren’t doing it,” Mr. Huckabee told our editorial board earlier this fall. “So when we asked them why — well if you have a copay or deductible (and) you don’t present symptoms, you’re not going to go, when that $200, $300 could send your kid to summer camp for a few days. Do I want to go to the gastroenterologist and have him scope me — done that; it’s not very pleasant — or do I want to get rid of my kid for a week? Guess what I choose to do?
“Take the deductibles and the co-pays off, and women get their beast exams, men get their prostate-cancer exams, and you don’t have people waiting until they’re in a significantly advanced stage of cancer before you get the diagnosis and then the treatment becomes extraordinarily expensive, cost-prohibitive, and the costs are passed on to the payers.”
Some employers are beginning to take that approach one step farther, applying it to the drugs people need to manage their diseases and avoid the $30,000 foot amputations and $200,000 bypass surgeries. For the last several years, I’ve had to pay just a single $15 copay each month for insulin, syringes and glucose test strips, rather than the $100 to $150 I would have to pay in a more shortsighted insurance plan.
The payoffs mount quickly. When the city of Asheville, N.C., eliminated co-pays for the medications needed to treat chronic diseases if employees signed up for an education and oversight plan, it saved more than $2,000 per year per patient — and reduced absenteeism by 50 percent.
The other component of smart disease-management — physician reimbursement — has been slower coming, perhaps because early attempts by HMOs were so bungled. We pay doctors to perform procedures. That “does not really give them incentives to lower your blood pressure, A1C, hemoglobin and cholesterol,” Mr. Huckabee said. “But the system rewards them for seeing you as often as possible or doing a procedure on you.”
It’s time to start working on that last component — and to work harder on the others.
Reach Ms. Scoppe at(803) 771-8571 or email@example.com.