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Is the Body Mass Index (BMI) Useful? (Part 2)

By: David P. Lind

This series on obesity continues with the discussion of body mass index (BMI), and whether BMI is over-valued when assessing the health of individuals.

BMI is a medical calculation that is almost 200 years old. Developed in 1832 by a Belgian mathematician, Lambert Adolphe Jacques Quetelet, the BMI was designed to quickly estimate the degree of overweight and obesity in a defined population that would help governments decide the allocation of health and financial resources. Quetelet believed the BMI was useful only in providing a snapshot of a population’s overall health – his intent was not to measure the health of single individuals.

BMI is derived from your height and weight, calculated by dividing weight (in pounds) by height (in inches squared) and multiplying by 703.  If you’re curious, you can quickly learn your own BMI here. Once calculated, the BMI is compared to the BMI scale, which is broken down into five categories:

  • Underweight: BMI below 18.5
  • Normal: BMI ranging between 18.5 and 24.9
  • Overweight: BMI between 25 and 29.9
  • Obese: BMI of 30 or higher
  • Severe Obesity: BMI of 40 or higher

Is BMI Outdated?

Critics believe BMI is being overused and not very useful when analyzing the health of individuals. In fact, BMI is considered too simplistic, if not misleading. The critics make a number of points, including the following factors:

  1. Fat versus Muscle – Some people have high BMIs, but not much body fat. One prime example is an athlete, such as a football player. This athlete can have high muscle tissue (and low body fat) which pushes up his weight – and his BMI number.
  2. Activity Level – An individual who is very inactive, has lots of body fat and low levels of muscle and bone, may have a BMI in the normal range. But this individual is often elderly, in poor shape and sometimes sick. However, this individual with a ‘normal’ BMI has risks similar to people who carry a high amount of body fat and have a high BMI. These underlying risks are not reflected in the BMI score.
  3. Body Type – The location of your fat can make a big difference to your health. The belly fat (apple shape) type is generally at higher health risk, and the chance of heart disease and type 2 diabetes increases. This fat settles around the waist instead of the hips. Likewise, fat that appears on the hips and thighs (pear shape) is not considered to be as harmful. BMI does not indicate the location of fat and, therefore, does not reflect those risks.
  4. Age – As one ages, they may carry a little more weight, which may actually be beneficial. One possible reason is that as we age, a little extra weight can serve as reserves to draw on when fighting an illness. Because of this, an ideal BMI score may change as one ages.
  5. Ethnicity – The BMI can be different based on ethnic groups. For example, people from India face higher health risks at relatively lower BMIs. As mentioned earlier, the standard definition of overweight is a BMI of 25 – 29.9. However, people of Indian descent may begin to develop a risk of diabetes when the BMI is 21 or 22. Asian-Americans tend to develop health risks, such as diabetes, at lower BMIs than whites. In other words, a healthy BMI for Asians ranges from 18.5 to 23.9, which is one point lower than the standard range. Asians are considered obese at 27 or higher. Compared to whites with the same weight and BMI, African-Americans may have less fat around their organs and more muscle mass. This means that African-Americans, despite having a high BMI, may have fewer health risks than whites.

These five factors give credence to the argument that BMI is both outdated and inaccurate when assessing the health of individuals. 

So why continue to use BMI?

The counter-argument to continue using BMI can be equally persuasive.

Despite the concern of accurately identifying whether a person is healthy, most studies do link low and high BMI scores with a person’s risk of chronic disease and premature death. As an example, a 2017 study of 103,218 deaths found that people who had a BMI of 30 or greater (“obese”) had 1.5 to 2.7 times greater risk of death after a 30-year follow-up.

A 2014 study that included 16,868 people showed that “obese” BMI individuals had a 20 percent increased risk of death from all causes and heart disease when compared to those in the “normal” BMI range.  From this same study, researchers found that people in the “underweight” category and the “severely obese” or “extremely obese” categories, died an average of 6.7 years and 3.7 years earlier, respectively, than those in the “normal” BMI category.  Adults with a BMI greater than or equal to 40 are considered severely obese.

The data on BMI greater than 30 is quite substantial as it relates to the increased risk of chronic health issues such as heart disease, type 2 diabetes, breathing difficulties, kidney disease, non-alcoholic fatty liver disease, and mobility issues. (See references below)

In short, having a 5-10 percent reduction in an individual’s weight has been linked to decreased rates of metabolic syndrome, heart disease, and type 2 diabetes.

Summary

Despite the criticism of BMI, one can safely assume that BMI may be more useful at predicting future health – rather than diagnosing the current health. 

Standard BMI definitions of overweight and obesity were based on white populations, which differs from other races and ethnic groups. Because of this, BMI should not be the only diagnostic tool when estimating a person’s risk of developing various chronic diseases. Many alternative measurement assessment tools exist to determine obesity and related health issues. The Harvard T.H. Chan School of Public Health has listed such measurements here.

Though BMI oversimplifies the health of individuals, research suggests it can serve as an important barometer to estimate a person’s risk of chronic disease, risk of early death and metabolic syndrome.

It’s important to know your BMI, but it is equally important to recognize its limitations.

This post is the second in a five-part series. You can read “Obesity Requires Employer Attention and Focus – (Part 1)” here.

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References:

Obesity Requires Employer Attention and Focus – (Part 1)

By: David P. Lind

Employers have a great deal on their plates, and much of it relates to the ongoing COVID-19 pandemic. Attracting and retaining workers has always been a challenge, but the pandemic-ravaged economy has nudged this to a whole new level of urgency. The COVID virus dangerously challenges the workplace in another way, and it requires long-term thinking by employers. 

This challenge relates to obesity.

Obesity

As we have learned during the past 20 months of the pandemic, obesity is a worrisome risk factor for hospitalization and death for those with COVID-19. A March 2021 Morbidity and Mortality Weekly Report, prepared by the Centers for Disease Control and Prevention (CDC), revealed evidence of a relationship found between body mass index (BMI) and COVID-19 severity. Obesity rates have nearly tripled in the U.S. over the last 50 years (Source: USA Facts).

The CDC uses the BMI scale that relates weight with height to determine obesity level. For adults, a BMI over 30 qualifies as obese. It should be noted that BMI is not a perfect measure of one’s current health. More about this in the next blog.

COVID-19 highlights the many risk factors for people who are both overweight and obese. For employers, these risk factors should be of great concern when promoting a healthy and productive workforce. In fact, employers must double-down on their efforts to confront this long-term threat to the wellbeing of employees. Pandemic or not, the associated risks with having high-BMI numbers will not go away any time soon.

Iowa Obesity Rates

Based on new CDC 2020 Adult Obesity Prevalence Maps of 50 states, Iowa adults are in the top 16 states having the highest rate of obesity (35 percent or more). A 2018 survey by The Behavioral Risk Factor Surveillance System (BRFSS), which is part of the CDC, found that almost 70 percent of adult Iowans are considered to be either overweight or obese. Put another way, 34.1 percent are overweight while another 35.3 percent are obese. However, 2020 data reveals that Iowa’s obesity rate has risen to 36.5 percent. This new map shows how Iowa compares to all other states, including the District of Columbia and two U.S. territories. 

Data from the 2020 U.S. Census Bureau shows that Iowa’s population was 3,190,369, of which 77 percent are adults aged 18 and over (2,456,584 total). Using 2018 BRFSS data, this means approximately 867,174 Iowa adults live with obesity, while another 837,695 have BMI numbers between 25.0 to 29.9 – which is considered overweight.

According to ConsumerProtect, which used CDC-based data, adult Iowans tend to move a bit more than their counterparts from other states, with ‘only’ 25 percent of adults engaging in zero physical leisure activities – ranking Iowa as the 31st state having the highest percentage of adults engaging in no activity. Kentucky was the state with the highest percentage of adults reporting no activity (34.4 percent).

Impact on Individuals and Employers

The risk factors of having a higher-than-healthy BMI number comes at a substantial cost. The aforementioned risk factors for obesity and excess weight on the individual include, but are not limited to, the following:

  • All-causes of death (mortality)
  • High blood pressure (Hypertension)
  • High LDL, low HDL cholesterol, or high levels of triglycerides
  • Type 2 diabetes
  • Coronary heart disease
  • Stroke
  • Many types of cancer
  • Mental illness such as clinical depression, anxiety, and other mental disorders
  • Body pain and difficulty with physical functioning

According to a 2016 report by Wellmark, “The Health of Iowans,” obesity is a common factor that contributes to the most costly conditions among Wellmark’s members in Iowa. For employers, obesity is both a sensitive and challenging issue and varies by industry. The associated costs for obesity are primarily twofold: 1) treatment-related expenses, and 2) reduced worker productivity.  Treatment expenses are typically covered by employer-sponsored health insurance and workers compensation while reduced worker productivity adversely impacts employers through absenteeism, presenteeism and wage replacement due to disability. Together, both represent a drag on productive output and profitability – which adversely impacts local and state economies.

A 2014 report in the American Journal of Health Promotion found that an obese employee with a BMI of 35 has nearly double the risk of filing a short-term disability claim or a workers’ compensation claim than an employee with a BMI of 25. This report also revealed that morbidly obese employees cost an average of $8,067 per year in covered medical claims, sick days, short-term disability and workers compensation, which is more than double the cost for normal-weight employees ($3,830). 

According to a 2018 Milken Institute report, the chronic diseases that result from obesity and excess-weight were estimated to cost more than $480 billion in direct healthcare costs and $1.24 trillion in indirect work loss costs in the U.S. Together, both costs are equivalent to 9.3 percent of the U.S. gross domestic product (GDP).

Summary

The pervasive nature of an overweight and obese population is a profound challenge to all Americans and to employers. Changing behaviors on dietary and physical activity is the desired goal, but is often met with disappointing results. 

Depending on how incentives and disincentives are aligned with desired outcomes, implementation of wellness programs have had limited success for employers. Organizations must develop new, targeted approaches that are sensitive to their employees, yet impactful enough to provide positive outcomes.

My next installment will focus on the criticisms of BMI and its use as a measure of health.

This post is the first in a five-part series.

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New Executive Order on Hearing Aids: Music to my Ears!

By: David P. Lind

It happened on January 14, 2018. My ears went bonkers, and they were still ringing months later. My daughter, Emma, brother, Joe, and I attended the NFC divisional playoff game in Minneapolis between the New Orleans Saints and my favorite, but too-often-cursed team – the Minnesota Vikings.

As we found out late in the game, we had phenomenal seats on about the 10-yard line – only three rows up from the playing field. The Vikings led at halftime 17-0, but the Saints came back in the second half and established a 24-23 lead with 10 seconds remaining in regulation. The Vikings had the ball on their own 39-yard line with some disgruntled Viking fans already beginning to exit the stadium with little hope of a home team victory.

However, Viking’s quarterback Case Keenum threw a 27-yard pass to receiver Stefon Diggs, near our side of the field. While staying in bounds and missing a poor tackle, Diggs saw there were no Saints defenders between him and the end zone. He immediately turned up field and sprinted down the sidelines – right in front of us (see video of TD) – for a touchdown. The game was the first in NFL history to end in a touchdown as time expired. This game is now popularly known as the Minneapolis Miracle!

Following this now historic NFL play, the stadium erupted into huge chaotic joy. In fact, it was the loudest noise I had ever experienced in ANY sport or rock concert attended. While exiting the stadium, I was having problems re-living the ‘miracle’ moment with Emma and Joe. I remember having to ask numerous times, “What did you say?” The ringing in my ears continued into that next week and I assumed it was the residual side-effect of that game.

Tinnitus

But weeks and months following the game, it made me realize that my ears were not functioning properly. I had difficulty listening to others in a small group setting, especially in restaurants. My ears would continue to ring and it often felt as if I had water in both ears. The more I spoke, the ear problem became more acute. After seeing an ENT physician a few months following the Minneapolis Miracle, I was diagnosed with mild hearing loss due to tinnitus, which is a relatively common problem. Most likely the ‘Miracle’ was not the sole cause of mild hearing loss, but it certainly did not help.

According to Mayo Clinic, tinnitus affects between 15-20 percent of people, most commonly in older adults. The Hearing Health Foundation estimates that 48 million Americans have some degree of hearing loss, ranking just behind arthritis and heart disease as a leading cause of disability. Based on some research, hearing loss may point to increased risk of dementia, cognitive decline and falls. Social effects can also be impacted, such as causing social isolation because taking part in conversations can be troubling to those with hearing issues.

During the summer of 2018, I was fitted with hearing aids to help improve my hearing and overcome the uncomfortable symptoms I experienced. Through this process, I learned that one must have a prescription from an audiologist to obtain hearing aids. Hearing aids are not historically sold over-the-counter (OTC) without having a prescription, but this will likely change due to President Biden’s July 9 executive order which asks the FDA to produce guidance within 120 days. (More details found below.)

Hearing Aids

About 27 million Americans age 50 and older have some type of hearing loss, but only one in seven use a hearing aid as a solution. On average, hearing aid users wait 10 years before getting help for hearing loss. According to a new study by the University of Michigan Institute for Healthcare Policy & Innovation, 80 percent of Americans over the age of 50 have not been asked about their hearing by their primary care physician in the past two years.

The purchase price for hearing aids is quite expensive. Many insurance plans do not consider hearing aids to be a ‘covered’ benefit, so the entire out-of-pocket expense is typically borne by the patient. The average cost for a pair of hearing aids ranges from $2,000 on up to more than $10,000, depending on the technology. Few states require health insurers to cover the cost of hearing aids for people of all ages. Medicare parts A and B do not cover hearing aids. The four largest hearing aid manufacturers control 84 percent of the market, and due to the high cost of hearing aids, only 14 percent of 48 million Americans with hearing loss use them.

Additionally, it is common that many people fight the vanity and stigma of wearing hearing aids because it will make them appear to look ‘old’ to others. During the first year or two of usage, I have also entertained these same thoughts, but no longer.

Biden Executive Order on High Cost of Hearing Aids

As previously mentioned, President Biden’s new executive order of 72 initiatives includes a directive to Health and Human Services to consider issuing proposed rules within 120 days for allowing low-costing hearing aids to be sold over the counter (OTC). OTC hearing aids, by the way, will allow adults with mild-to-moderate hearing loss to purchase hearing aids without consulting a hearing professional. Once the proposed rules are published, there will be a comment period of 60 days and the FDA will have another 180 days for a finalized rule.

In 2017, Congress passed a bipartisan proposal – signed into law by President Trump – to allow hearing aids to be sold over the counter. The FDA, however, did not issue the proposed rules by the deadline of August 2020 because of the ongoing COVID-19 pandemic. Because the FDA gave no further guidance on this issue, the Biden executive order includes the FDA to issue guidance within 120 days.

Once the FDA issues its ruling and the proposed timeline, consumers should soon be able to purchase OTC hearing aids at their local pharmacy without first being required to visit a medical provider. The specifics are still unknown at this time, but the goal of this initiative is to lower hearing aid prices for consumers, so more affordable hearing aid alternatives should make their way to consumers in the near future.

Final Thoughts

As one who now must use hearing aids, I am keenly aware of the associated costs. Millions of Americans also need hearing aids, and gaining access to OTC products should be music to their ears, and hopefully, relief to their pocketbooks. For medical reasons, it is always a good idea to seek professional attention when confronted with hearing problems. But the hope is, if hearing aids are necessary, the prices should become more reasonable over time.

Now, about those Vikings in 2021…?

With daughter, Emma, at the ‘Miracle.’

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The Cause of Physician Burnout May Surprise You

By: David P. Lind

Physician ‘Burnout’ is More About the Culture of MedicineSummer is a time for relaxation. It is now becoming safer to go to the beach, attend concerts and sporting events, and gather with family and friends at our favorite venues. Enjoying backyard grilling and other outdoor activities make our summers seem almost ‘normal’ again.

Summer is often associated with reading ‘leisurely’ topics that may not be too taxing on our minds. To that end, my wife always reminds me that I need to adhere to this philosophy and read something that is non-work related and ‘enjoyable.’

That is why I just finished yet another book about…healthcare! This book, “Uncaring: How the Culture of Medicine Kills Doctors and Patients,” written by Dr. Robert Pearl, was a real gem to read.

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The credibility of authors can be unusually powerful, especially if the author has brutally-honest viewpoints that directly correlate with their particular profession. In Uncaring, Pearl is a highly-credible source in spades while writing critically about his own profession. He backs his insights from research and, just as importantly, his own personal experiences. Pearl is the former CEO of The Permanente Medical Group – the nation’s largest medical group – and former president of The Mid-Atlantic Permanente Medical Group. He is one of Modern Healthcare’s 50 most influential physician leaders. That’s right, he is also a physician who is board certified in plastic and reconstructive surgery.

Noted author Malcolm Gladwell wrote about Pearl, “No one is better qualified to write about what ails healthcare than Robert Pearl.”

I have spent almost 10 years writing blogs. Most of my topics relate to employee benefits (through David P. Lind Benchmark) and, more specifically, bloated healthcare costs that emanate from our fragmented system of care (found at this site). It has been my observation that, too often, the healthcare ‘establishment’ is too bent on maintaining the status-quo, even though threats are ramping up to eventually disrupt a system that desperately needs disruption. To this, Pearl bluntly states, “Doctor’s benefit too much, financially, from the way things are and stand to lose too much, culturally (their prestige and privilege), by changing.”

Physician Burnout

Pearl writes that the physician profession is experiencing an unprecedented level of burnout, which impedes the quality of medical care they provide to patients. According to Medscape in 2019, 44 percent of physicians are ‘burned out,’ primarily due to working too many hours at the office, interacting too much with their computers, and not being paid enough to perform the many required bureaucratic tasks. In fact, a 2020 survey (conducted prior to the COVID-19 pandemic) found that all physician specialties reported a burnout rate of at least 29 percent. The physician burnout rates are staggering.

According to Dr. Pearl, however, the variation in burnout rates among different specialties cannot be explained by the amount of money earned, hours worked, or bureaucratic paperwork performed. Pearl’s book comes up with a different reason why physician burnout happens – physician culture.

Why is physician burnout so important? According to a recent report prepared for the Association of American Medical Colleges, by the year 2034, there will be a shortage of physicians ranging from 37,800 to 124,000. This dire projection will affect most Americans when attempting to gain access to quality care.

Physician Culture is influenced by…

Pearl does an extraordinary job of explaining physician culture, which is influenced by two perverse obsessions that doctors historically have within their profession: prestige and status. As described in his book, this physician culture insulates doctors from the financial, ethical, and clinical pressures to change. Strong and harmful culture is embedded in the physician world, and yet physicians are unable to recognize its impact on their lives.

Social and professional status, as determined by British epidemiologist Sir Michael Marmot, have a large influence over a person’s mental and physical well-being. Stress levels and self-esteem are affected by the real or perceived rank one has with friends and society, in general. Psychological studies highly suggest that losing social or professional status will produce the same symptoms associated with burnout – anxiety, fatigue and depression. In today’s world, doctors worry that their profession is losing its power and influence that it once had.

There is an unwritten hierarchy in the medical profession that constantly remind physicians about how they compare with their medical colleagues. In simple terms, the prestige of being a high-volume surgeon at a ‘centers of excellence’ – rather than a general surgeon without having high-volume specialty skills, will determine where physicians fall on the totem pole of hierarchy. Family practice physicians do not fare well in this hierarchy, and therefore, their burnout level is higher than in specialties that require more specific skills. This is unfortunate. Research continues to show that when healthcare organizations place a high value on primary care, evidence-based care and various preventive approaches, the prevalence of chronic disease is reduced among patients by up to half.

This self-imposed hierarchy influences the mental health and overall happiness in physicians. As Pearl indicates, “Their obsession with status will continue to inflict harm on themselves and their patients.” According to Pearl, those physicians who care for patients with urgent, life-threatening problems are more valued than those who attempt to prevent diseases from happening. This culture determines how each physician specialty is placed on the status hierarchy.

Physician preoccupation with status is the culprit of increasing burnout and compromising effective medical care. This long-held culture must require a refreshed approach that will change how physicians see themselves amongst their peers.

Pearl argues that for culture to eventually change, the U.S. must change to an integrated, prepaid, technologically advanced physician-led healthcare delivery system. Under this, no longer are physicians competing with one another, but rather, they collaborate and communicate with one another to serve the patients.

This book serves as a good reminder to all policymakers and the physician community that culture matters a great deal. Cultural change is seldom by choice, but rather, by survival.

Now, it’s on to the next book…and the hammock!

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‘Health’ Care vs. ‘Medical’ Care
It’s About Improving Population Health

By: David P. Lind

Controlling health costs and improving population health – we cannot have one without the other.

Healthcare costs continue to outpace general inflation. PricewaterhouseCoopers recently projected a 6.5 percent medical cost trend in 2022. By comparison, the annual inflation rate for the United States was 5.0% for the 12 months ending May 2021 – the largest increase since 2008. For those of us who have health insurance coverage through our employment or have purchased coverage through a market-based exchange, we live in constant anxiety about paying more for our insurance.

Aside from having a high-cost, inefficient healthcare ‘system,’ the major source of this problem is our unhealthy population. “Upstream” environmental factors greatly impact our “downstream” health – for all of us. Upstream factors are many – primarily poor nutrition, inadequate housing and education, and low incomes – all considered to be social determinants of our health (SDOH). For discussion sake, healthy behaviors, social & economic factors and physical environment are all considered to be somewhat manageable by taking proactive (or preventable) measures – and these are lumped together as Upstream factors.

A great video about addressing SDOH from Broadlawns Medical Center can be found here.

UPSTREAM: 80 Percent is ‘Health’ Related

According to the County Health Rankings Model, as much as 80 percent of the factors that influence our health and well-being – physical environment, social and economic factors, and health behaviors – operate outside the services for which we pay hospitals and clinics. These factors are considered to be upstream, and to a large extent, can be modified and proactively managed. Conversely, only about 20 percent of our actual health outcomes is impacted by the clinical care that we pay to our healthcare providers (see diagram below).

Again, proactively staying healthy comes from determinants such as the social and economic environment, the physical environment, and each person’s individual characteristics and behaviors. This is what should be labeled, “health care.” Our health is primarily determined by our behaviors and the environment in which we live. How we live ‘upstream’ will greatly impact how polluted the ‘downstream’ will become.

DOWNSTREAM: 20 Percent is ‘Medical’ Related

In 2018, the U.S. spent nearly twice as much on medical care per person as did comparable countries ($10,637 compared to $5,527 per person, on average). These expenditures relate to the care we receive from our doctors, hospitals, pharmacies, etc. The healthcare prices we pay in the U.S. are higher because of administrative waste and because prices are naturally higher for hospitalization, physician services, and, of course, the medications we purchase. Numerous sources report this, but a good primer comes from the Peterson-KFF Health System Tracker.

The amount we spend for the “medical care” we receive downstream is different from the aforementioned “health care” found upstream. The high expenditures for medical care paid in Iowa and the U.S. is really for “sick care.” Medical care, for the most part, represents the consequences of our poor efforts upstream. If we fail to make the appropriate investments upstream to promote healthy living environments and behaviors, we eventually pay a proportionately larger price downstream. We all know how that is going for us, right?

In 2016, I co-authored a blog with Dr. Yogesh Shah, Chief Medical Officer and Vice President of Medical Affairs at Broadlawns Medical Center. The blog, “Time to Move Upstream and ‘Invest’ in our Health,” shows just how little the U.S. invests in the social determinants of health issues upstream when compared to other wealthy countries.

The Commonwealth Fund released an issue brief in early 2020 that confirms this troubling trend persists. “The U.S. spends more on medical care as a share of the economy — nearly twice as much as the average Organisation for Economic Co-operation and Development (OECD) country — yet has the lowest life expectancy, the highest suicide rates and the highest chronic disease burden and an obesity rate that is two times higher than the OECD average among the 11 nations.”

The U.S. under-invests in spending for modifiable contributors to healthy outcomes compared to other advanced countries. By under-investing in the ‘social determinants of health,’ we are relegated to pay bizarre prices for a sicker population that uses more medical care. Over decades, we unrealistically rely more heavily on our health providers to ‘fix’ our upstream shortcomings. In the U.S., reimbursement practices reward intervention – or sick care – far more than prevention. This is not an indictment on our health providers, but on our convoluted healthcare ‘system.’

In short, we grossly overspend on the downstream consequences to mask our poor investment efforts upstream.

Summary

We must look upstream to find effective ways to address the social determinants described earlier. There are pockets of health systems and states that are making attempts to alter the environments in which we live, work and play. We live in a world of trade-offs. Trading wasted care (and its associated cost) with preventive health-related strategies seems to make a lot of sense.

As our blog concluded five years ago: “Spending for the ‘right’ community measures that impact health will provide better health outcomes for Iowa and our country. Such expenditures will take time to translate into positive health outcomes but we need to start investing now. It will take cost-shifting from inefficient healthcare spending to re-allocating funds for social determinants that matter most, such as nutrition, adequate housing and education. By doing so, we will make our communities and state both healthier and more productive.”

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A Solution to Physician Conflicts of Interest

By: David P. Lind

A Solution to Physician Conflicts of InterestsAbout two years ago I was contacted by an Iowa physician who shared his concern about an Iowa doctor’s potential conflict of interest. The doctor was receiving third-party financial compensation which, quite possibly, was putting the best interest of his patients at risk.

From this, I wrote a blog and an op-ed piece in the local newspaper. Both physicians involved remain anonymous.

Within both articles, I summarized that medical providers should post on their websites the financial interests they have with third parties, such as drug and medical device companies. Being ethical and transparent with patients and the public about any third-party relationship is not optional in medicine – it is essential. The most important duty of any physician is to act in the best interest of the patient. Informed consent should always apply within the physician-patient relationship.

Unfortunately, Iowa does not require doctors to be transparent with the public and their patients. For now, Iowans must rely on a little-known website, OpenPaymentsData.CMS.gov, to learn whether their doctor (or teaching hospital) has received payments and other transfers of value from drug and medical device companies. Most people are not aware of the important information found in OpenPayments, which is a website established by the Centers for Medicaid and Medicare Services (CMS). 

Medical Device Firms Outspend Drug Firms

According to researchers at the University of Pennsylvania and Columbia business schools, medical device firms paid, on average, $904 million a year to nearly 200,000 surgeons and other doctors who use their products. This payment is estimated to be 1.7 percent of total industry revenue. In comparison, the much larger drug industry paid, on average, $821 million a year to over 300,000 physicians, which was less than one percent of industry revenue. The period of time researched was 2014-17. This information comes from a new study in the April edition of Health Affairs.

California is deciding on a bill that addresses any potential conflict of interest that doctors may have.

California – Assembly Bill 1278

Largely due to the persistence of a harmed patient, Wendy Knecht, along with the initiative of her state assembly member, AB1278 was introduced into the California legislature on February 19. AB1278 will require physicians and surgeons to disclose the source of payments given to them by drug and device companies, in addition to promoting patients’ knowledge of the CMS OpenPayments website resources.

Under the bill requirements, physicians and surgeons must post an OpenPayments database notice in each location where the physician/surgeon practices and in an area that is likely to be seen by all persons who enter the office. Additionally, OpenPayments database notice must be clearly posted on the internet website used for the physician and surgeon’s practice. As stated by this bill: A violation of the bill’s provisions would constitute unprofessional conduct.

Due to minimal efforts to educate the public about CMS OpenPayments, many Americans – including doctors – are not aware this resource exists. Too often, the onus is on the patient to do the research and locate this website. Thanks to Wendy’s efforts, there is now a reference to OpenPayments on the CA Medical Board website. Unfortunately, there is no reference to OpenPayments on the Iowa Medical Board (IMB) website. 

Similar Legislation for Iowa?

The mission of state medical boards should deem this to be an essential public service to Iowans. For the record, I have requested IMB to determine their willingness to post this information. As of the publication of this blog, I have not heard back from IMB.

A federal law would make sense. In the meantime, a similar bill should be introduced in the 2022 Iowa legislative session. Finding a sponsor should not be difficult and both political parties would hopefully agree this language transcends party affiliation.

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The Safety of Covid-19 Vaccines

By: David P. Lind

The Safety of Covid-19 Vaccines

The U.S. public’s views and attitudes on the available Covid-19 vaccines can vary widely, which is a consistent finding from the Kaiser Family Foundation. The differences by age, ethnicity, politics and location can be very striking. Any hesitancy toward accepting the vaccine largely boils down to trusting that the vaccines are safe. But this rather tenuous faith in the available Covid-19 vaccines is no different than historical attitudes about vaccines from yesteryear.

With almost one-third of Americans having received at least the first Covid-19 vaccine dosage, what do we really know about the safety of the vaccines?

ANSWER: The preliminary findings appear to be very encouraging, even to those who may have personal doubts.

According to the Centers for Disease Control (CDC) on March 13, there have been 529,301 deaths from Covid-19 out of 29,113,651 total known cases. That is 1 death for every 55.0 cases.

Also reported on the CDC website (March 13), “Over 92 million doses of COVID-19 vaccines were administered in the United States from December 14, 2020, through March 8, 2021. During this time, the Vaccine Adverse Event Reporting System (VAERS) received 1,637 reports of death among people who received a COVID-19 vaccine.” 

The number of vaccination deaths (1,637) – out of 92 million vaccinations given – results in 1 death for every 56,200 vaccinations. 

Given this data, the risk of you dying from Covid-19 if you become infected is 1,022 times greater than the risk of you dying from being vaccinated. 

Regarding Covid-19 risks versus vaccine risks, Dr. Robert E. Oshel, former Associate Director for Research and Disputes for the National Practitioner Data Bank, said it quite well:

Only if you are virtually certain that you could never be exposed to Covid-19 and become infected would it be safer not to be vaccinated. I don’t think that (this data) is particularly disturbing.  In fact, that seems pretty safe to me in comparison to the risk from Covid-19. I’d rather take the vaccine risk instead of the risk of getting Covid-19 and its serious complications or death.  I’d also prefer taking that small personal risk over the possibility of becoming infected and passing the virus on to others and potentially causing their deaths.

The effectiveness data for the Pfizer, Moderna, and Johnson & Johnson vaccines appear to clearly outweigh their risks. Of course, if you have certain medical risks, it is always advisable to consult with your physician about your particular medical situation.

Through March 12, the number of administered vaccines in the U.S. was 101,128,005 – which includes both first and second doses. Below is the breakdown by vaccine type:

Source: Centers for Disease Control – March 13, 2021

New data from the CDC suggests that Americans have been remarkably vigilant about getting their second Covid-19 shot.

Any hesitancy that I may have had about Covid-19 vaccines are now a thing of the past.

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Reforming State Medical Boards is Essential

By: David P. Lind

Two identical medical malpractice bills (SSB 1225 and H.F 592) have been introduced in this year’s Iowa legislature that would raise the non-economic damage cap from $250K to $1 million. In return, the bill would remove language that would allow juries to determine whether to lift the $250K cap if the losses were “substantial or permanent” to the patient. Basically, the bill’s limit of $1 million would no longer allow a jury the flexibility to award higher non-economic damages in particularly egregious cases.

Why are harmed patients held to a much higher standard (with additional barriers) than other victims of harm? (Lori Nerbonne – Patient Advocate)

Quite simply, tort reform legislative measures initiated by the medical community are meant to limit the financial exposure of doctors and hospitals, regardless of the preventability and extent of the harm they cause. Physicians and hospitals are too ensconced in maintaining their comfortable status-quo by not coming to terms with the real enemy in medical malpractice war – themselves.

Two Large Contributors to Medical Malpractice

For medical providers and their insurance companies, tweaking med mal reform is a quick, silver-bullet solution. However, this ‘solution’ is encumbered with five myths that do not address the true drivers of med mal costs. There are at least two large contributors to medical malpractice NOT addressed by this latest tort reform bill:

  1. MASSIVE MED MAL CLAIMS ARE INCURRED BY JUST A FEW DOCTORS – During a 20-year period (1990-2010), only 1.73 percent of Iowa physicians were responsible for one-half of all the money paid out for medical malpractice in our state. Most of these physicians had multiple malpractice payments. Iowa’s rate is similar to the national norms.
  2. STATE MEDICAL BOARDS TAKE LITTLE ACTION ON THEIR OWN – State medical boards are largely derelict about policing the worst offenders who repeatedly cause malpractice payouts. As for Iowa, only 16 percent of Iowa doctors with high malpractice claims had reportable action by the Iowa Board of Medicine. Only 10 percent had any reportable action taken against their clinical privileges by an Iowa hospital. As a result, a meager one-sixth of the 1.73 percent of physicians have had any action taken against their licenses – and only one-tenth of them have had any action taken against their clinical privileges.

Iowa Board of Medicine

Many state medical boards are government entities that consist of politically appointed physician members, which can be an inherent conflict-of-interest when policing physicians. Historically, physicians have a poor record of policing themselves. In January, ‘CBS This Morning’ covered this national problem. The eight-member Iowa Board of Medicine, it must be noted, consists of five physicians and three public non-physician members. There are also two alternate board members, both of which are physicians.

Recent original research by Dr. Robert E. Oshel using the National Practitioner Data Bank (NPDB) Public Use Data File through March 30, 2020, found the Iowa Board of Medicine took an average of just over 15 ‘serious’ actions per year from 2017 through 2019. Consequently, the Iowa board ranks 18th of all state boards based on the number of serious actions taken per 1,000 licensees. This means that if the Iowa board were as proactive as the most active state board, it would have taken 89.6 percent more serious actions (just over 29 more serious actions each year) than it did during that period of time.

The Harris Poll about State Medical Boards

According to a 2018 national survey by The Harris Poll, only 49 percent of Americans knew that state medical boards are responsible for the licensing and regulating of physicians in the U.S. Because the public lacks knowledge about the role of state medical boards, only 31 percent of the 2,018 survey respondents correctly understood that state medical boards should be the first authorities to contact if they have a complaint about the competence or conduct of a physician. Fifty-three percent of the respondents thought other entities should be contacted first, and the remaining 16 percent were “not at all sure” whom to contact first. Fewer than a third of Americans (27 percent) know how to find out if a physician has ever received a disciplinary action against their medical license – an indication that Americans do not use the websites of state medical boards.

Twenty percent of the Harris Poll respondents reported being subjected to physician ‘misconduct.’ Respondents living in the Midwest and South were almost twice as likely to cite experiencing physician misconduct than respondents living in the Northwest. Only 33 percent of respondents indicated they filed a complaint against or reported the physician to any organization – including a state medical board.

The Solution?

The solution for malpractice costs is to reduce malpractice acts, not create more barriers for injured patients to seek compensation. (Dr. Robert E. Oshel)

The mission of each state medical board is to protect the health, safety and welfare of the public from all incompetent, unprofessional and improperly-trained physicians through the proper licensing, disciplining and regulating of physicians. Public awareness of state medical boards is absolutely critical for those boards to be successful in achieving this mission. ‘Reform’ measures should be used to help arm and enable peer reviewers and medical boards to correct and/or discipline those outliers who actually commit adverse events in the first place.

Instead of passing the latest tort reform bill, Iowa legislators should pursue approaches that ensure the Iowa Medical Board of Medicine is equipped with legal tools and funding to adequately regulate the medical profession. This can begin by reforming the recruitment of board members to ensure there is no conflict of interest. Additionally, establishing an awareness campaign to educate the public about the purpose of the Iowa Board of Medicine is paramount to enhancing its role in receiving and investigating complaints about dangerous physicians.

Protecting physicians by ignoring repeat instances of malpractice, in addition to imposing penalties that are not commensurate with offenses, will only allow this problem to persist. Med mal claims will drop drastically with appropriate punishments. Such action would send the right message to all physicians that incompetence (and bad medicine) is not acceptable in the state of Iowa. Restoring patient trust is important.

Unfortunately, the newest effort in the Iowa legislature does nothing to do this. This legislation will only satisfy those unwilling to police themselves.

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Telehealth – Will the Pandemic Reveal its Potential?

By: David P. Lind

Telehealth has been around for at least a few decades, but its’ steady growth trajectory was injected with rocket fuel a year ago when the pandemic erupted. Most every medical provider was thrust into embracing telehealth services, and for many, a rather uncomfortable, but necessary pivot to serve patients. Going forward, one key question to address will be if the outcomes of telehealth are at least as effective as in-person visits. 

Technology and Reimbursement Concerns of Telehealth

For telehealth to become deeply rooted in the long-term medical-delivery process, a few important barriers will need to be addressed. Making the telehealth technical systems easy to use – for both physicians and patients – will require additional tweaks to simplify the physician workflow process and patient acceptance. Additionally, physicians desire to have a more-intimate rapport with patients, such as reading body language, listening to breath sounds while providing an actual physical examination.

But the elephant in the room regarding the growth of telehealth is simply this: the complicated challenges of reimbursements from payers – a key component that could determine long-term adoption. State telehealth commercial payer laws vary. For Iowa, the legislature is considering a payment parity bill that would treat telehealth reimbursement no differently than in-person care (HF294).

Telehealth Outcomes – What is Known Today

Is the quality-of-care provided remotely at least comparable to in-person care? Are patients satisfied with telehealth? There are some studies, all from the pre-pandemic period, that evaluated patient outcomes between telehealth and in-person visits. Rest assured, new pandemic data on telehealth will eventually emerge to help connect the dots on satisfaction, safety and outcomes.  

For now, pre-pandemic outcome results appear to be tepidly encouraging. The federal Agency for Healthcare Research and Quality (AHRQ) provided funding to the Pacific Northwest Evidence-based Practice Center to produce two reports on telehealth. Each report provides helpful insights on how telehealth can positively impact appropriate and safe care.

STUDY #1: Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews (2016): This report included over 950 studies of telehealth based on data from 58 systematic reviews published between 2007 and 2015. High-level findings show that telehealth is beneficial for specific uses and patient populations. In fact, “There is a large volume of research reporting that clinical outcomes with telehealth are as good as or better than usual care and that telehealth improves intermediate outcomes and (patient) satisfaction.” Benefit evidence was concentrated in specific uses of telehealth services for: 

  • Remote, home monitoring for patients with chronic conditions, such as chronic obstructive pulmonary disease and congestive heart failure
  • Communicating and counseling patients with chronic conditions
  • Providing psychotherapy as part of behavioral health
STUDY #2: Telehealth for Acute and Chronic Care Consultations (2019):  This report includes evidence about telehealth for acute- and chronic-care consultations from research published between 1996 and May 2018. The findings from this study provides overall conclusions that are relevant to telehealth expansion during the COVID-19 pandemic. Twenty-one studies evaluated remote intensive care units (ICUs), showing lower, statistically significant inpatient and ICU mortality rates and small, nonsignificant reductions in length of stay. Only one study specifically addressed adverse events, reporting lower rates of complications with remote ICUs.

Other Resources for Telehealth Outcomes

A few other 2018 studies also provide insight on telehealth care:

  1. Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System (2018) – Finding: Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.
  2. Effect of the School-Based Telemedicine Enhanced Asthma Management Program on Asthma Morbidity (2018) – Telemedicine intervention significantly improved symptoms and reduced healthcare utilization among urban children with persistent asthma.
  3. Telemedicine in the Mangement of Type 1 Diabetes (2018) – Finding: “Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.”
  4. Telemedicine and Mobile Health Technology are Effective in the Management of Digestive Diseases: A Systematic Review (2018) – Finding: “Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases.”

What Can Be Learned?

Overall, these pre-pandemic reports suggest that when patients and clinicians had a choice or when telehealth addressed an access issue, benefits of telehealth occurred. Further, this research found evidence that telehealth might benefit groups of patients during the pandemic when expanding critical care, help speed emergency care decisions, and reduce exposure to infection when replacing face-to-face care. But AHRQ issued an evidence summary report in April 2019 cautioning that more rigorous research will be needed to fully comprehend the effectiveness of telehealth consultations.

The rapid expansion of telehealth during the pandemic may provide better opportunities to learn whether telehealth is an appropriate application to use in given medical situations. Measuring the most appropriate outcomes will be extremely important for researchers to assess and analyze.

Summary

Most people agree that telehealth is here to stay. Two important influencers on telehealth growth will likely include documented health outcomes and third-party reimbursement levels. Telehealth usage will not remain at the elevated levels that COVID-19 required, but it will reach a more reasonable level and then grow where it makes most sense. Applying telehealth wisely will be important to research goals coming from the pandemic experience. New research with rigorous and detailed telehealth models will be needed to help answer these questions, and the answers may very well depend on what type of care is given under various specialties of care.

To be sure, the pandemic will reveal important findings that will determine how telehealth will expand in the future.

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Exercise, Diet and Weight Control
Time-Tested Advice

By: David P. Lind

On a recent blustery January day, I decided to seek some preventive medical advice that would sharpen my understanding on how to live a healthier life during a rather static time spent at home throughout this pandemic.

I picked up a monthly periodical entirely dedicated to the wisdom of living a healthier life, and it provided some timeless gems for our lives in 2021.  I found in-depth insight about nutrition, weight control, hypertension, heart disease, emotions, chronic ‘tiredness’ and a host of other factors affecting our physical and mental well-being.

One particular article was chock-full of wisdom that was shared by the “world’s most famous heart specialist” about maintaining a healthy heart through diet, appropriate exercise and weight control.

The kicker is that this particular periodical, Wisdom Magazine, was published 60 years ago. Wisdom Magazine, by the way, ceased publication in 1964. The May 1961 publication spent a sizeable portion on just one man, Dr. Paul Dudley White, who, at the time, was considered to be one of America’s top cardiologists.  Until I opened this periodical, I was unaware of him, nor of his substantial contributions.

Below are just a few arbitrary pearls of wisdom that he shared. Although many sound rather elementary for us in today’s world, they are worth repeating:

  • We know a thousand times more about diseases than our predecessors did generations ago, but apparently infinitely less about health.
  • The greatest challenge of public health today is keeping the middle-aged physically fit.
  • America is physically unfit as a nation and heart disease is definitely on the increase.
  • I have long advocated moderate exercise as one of the best ways to keep the heart in good condition.
  • We must give first priority to research in preventive medicine.
  • In this push-button age, man is overeating and pampering himself and “the life of Riley” often leads us into the lot of early coronary disease, high blood pressure and diabetes.
  • I would like to emphasize the beneficial effect of work on body, mind and soul in any occupation in which it is possible for a cardiac patient to engage. Idleness breeds unhappiness and is actually bad for the health.
  • Overeating may play even more of a role in the destiny of the world than the under-nutrition of hundreds of millions…As a result, the problem of overeating is far broader than that of the so-called starving millions…
  • Exercise is one of the best ways to counteract nervous tension and the best antidote is physical activity when one feels tired.
  • Just how much heredity actually counts in any given case remains for future researchers to discover, but that it plays a most significant role is a certainty.
  • Our medical ancestors were obliged to exercise much more than is the custom of most inhabitants of the so-called more-civilized countries of today.
  • Activity, both physical and mental, within reason, is important for health at any age and I think it is actually helpful for longevity. Many retire long before they should.
  • It is true that those who smoke most heavily are more likely to live shorter lives and also to have trouble with their hearts.
  • I would like to put everybody on bicycles, not once in a while, but regularly as a routine. That is a good way to prevent heart disease.
  • The easiest exercise of all, requiring no equipment except shoe leather, is walking.
  • Improvement of health in middle age and old age in this country today is greatly needed and must begin with well-established habits in youth.
  • One is never too old to exercise.

 

Dr. White was born the same year as my paternal grandmother, 1886, and was President Dwight D. Eisenhower’s physician during his heart attack in 1955.

White’s accomplishments were enormous. He helped create the International Association of Cardiology and International Cardiology Foundation, in addition to serving as executive director of the National Advisory Heart Council and chief consultant to the National Heart Institute. He was one of the founders of the American Heart Association and influential in establishing the National Institutes of Health. He wrote many papers about how lifestyle affected coronary artery disease. An avid walker and bicycle rider, he reportedly inspired Lyndon B. Johnson to return to the Senate in 1955 after his heart attack. Later in 1964, President Johnson presented Dr. White with the Presidential Medal of Freedom.

In countless ways, the world has immensely evolved over the last 60 years. Yet, when it comes to Americans’ health, the challenges we face today with diet and exercise remain daunting. Unfortunately, the population health metrics have changed dramatically during this span of time. In 1960 America, 54.2 percent of adults were not overweight or obese, yet by the year 2020 (60 years later), only 31 percent met this measurement. Conversely, over 14 percent of Americans were either obese or extremely obese in 1960. Today, this number stands at 42.4 percent.

Despite the knowledge that we had in the middle of the 20th century, positive health trends remain elusive from what has been recommended. Until Americans can connect the dots to transform personal behaviors into healthier lives, it is quite evident that Dr. White’s admonishments – multiple decades ago – will continue to be largely ignored and yet stand the test of time.

We should heed the advice of our medical ancestors, who apparently knew more, or at least preached and practiced more than we, a program of positive health habits. The habit of adequate exercise, for example, is just as important, I believe, as one’s sleep, one’s work and one’s food. – Dr. Paul Dudley White

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