Heartland Health Research Institute

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Medical Tort Reform Does Not Fix the REAL Problem

By: David P. Lind

Medical malpractice tort reform bills were recently introduced in both chambers of the Iowa legislature. According to a January 30 article in the Iowa Capital Dispatch, the bills are fast-tracking through various subcommittees after being touted by Governor Reynolds in her Condition of the State address.

This new version of tort reform would put a $1 million hard cap on noneconomic damages in lawsuits against healthcare providers for cases of substantial or permanent loss or impairment of a bodily function, substantial disfigurement, or death. Noneconomic damages may include awards for pain and suffering and emotional distress.

Supporters of tort reform – hospitals, physicians, malpractice insurance companies – say there are too many frivolous lawsuits that cause ‘runaway’ and ‘shock’ verdicts that are out of control. The argument is that this causes a shortage of healthcare providers in our rural communities and drives OB-GYN clinics and hospitals out of business.

Not to be lost in this discussion, the New England Journal of Medicine recently published findings on the estimated progress of patient safety, using a sample of hospital admissions in 11 Massachusetts hospitals in the pre-COVID year of 2018.  At least one adverse medical event was identified in 23.6 percent of the admissions, and 9.0 percent of the admissions included an adverse event that was rated as serious, life-threatening, or fatal. About 23 percent of the adverse events were judged to be preventable.

These findings are disturbing, yet should not be surprising. The results serve as notice that all other states – including Iowa – are not exempt from having similar results. For example, in 2018, I released an Iowa report that found nearly one-in-five Iowa adult patients experienced medical errors in the past five years, either for themselves or for someone close to them.

A seminal report in 1999, “To Err is Human: Building a Safer Health System,” estimated the annual number of lives lost to medical errors was up to 98,000 in hospitals alone. Subsequent estimates put this number much higher at 250,000 to 400,000 annual deaths.

Has progress been made since ‘To Err is Human’ was published? Donald Berwick, noted physician and former Administrator of CMS, indicates the safety movement has, at best, stalled.

The campaign effort in Iowa to thwart ‘excessive’ tort awards is a tired approach that continues to ignore the true facts. The medical establishment would rather spend their efforts and financial resources to chase tort reform protections rather than fixing the inherent problems that cause egregious medical errors in the first place.

Numerous studies continue to prove that tort reform does little to nothing to entice more physicians to practice in states that have implemented tort reform. In January, the Center for Justice & Democracy (CJ&D) released a briefing book, “Medical Malpractice: By the Numbers,” which provides a wealth of information that disputes many tort reform arguments. One 2019 analysis summarized, before and after tort reform was implemented: “Texas, like many other states, faces a challenge in attracting physicians to rural areas. But we found no evidence that tort reform lessened that challenge.”

Six top medical researchers found that “tort reform” does not reduce “defensive medicine” or healthcare costs. In fact, tort caps may actually increase costs.

According to a December 2020 edition of Medical Economics (found on page 17), Iowa has been identified as having the eighth lowest medical malpractice rates in our country. Iowa’s Governor and elected officials can make a true impact by proposing and implementing legislation that holds hospitals and medical providers more accountable for the dismal patient safety results.

Iowans should not have to rely on arbitrary caps established by special interest groups who benefit at the public’s expense. It is now time to serve the entire public, rather than a handful of those unwilling to practice safe and effective care. Tort reforms merely mask the real problem that politicians are unwilling to confront.

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More Accurate Death Certificates are Necessary

By: David P. Lind

More Accurate Death Certificates are NecessaryTwo days before Christmas 2014, my 88-year-old dad was unexpectedly taken to the emergency room at a West Des Moines, Iowa hospital. Shortly after his arrival, he passed away. No family members were allowed to be with him in his final minutes of life. A week following his death, a completed death certificate stated the cause of death was a ruptured thoracic aneurysm. The death certificate functioned as the official document on the cause of my dad’s death and was of interest to our family since we were in shock and didn’t get a clear answer at the time about how he died.

The Purpose of Death Certificates

A death certificate serves as a legal document that proves a person has died. Without having a completed death certificate, families are unable to settle their legal affairs following a loved one’s death. 

Typically, after a person dies in this country, the death certificate is generated by the funeral director, who records personal and demographic information of the deceased. Next, depending on the circumstances, a physician, medical examiner, or coroner provides the cause of death information. Physicians will normally certify the cause of death when that cause is natural. Medical examiners and coroners examine injury-related deaths, suspicious deaths or deaths where the deceased wasn’t attended by a physician. 

Since the beginning of last century, another vital role of death certificates is that it helps influence public health policy. Dr. Robert Anderson, chief of the mortality statistics branch at the National Center for Health Statistics (NCHS) put it succinctly in a Los Angeles Times article, “If you know why people die, very often then you can develop programs to prevent people from dying from those causes.”

A record of all deaths is required to be completed and registered by each state and shared with the NCHS for inclusion in the national data base that lists the CDC’s Leading Causes of Death. Tracking deaths due to epidemics – such as the 1918 influenza and COVID-19 – is critical to compiling health statistics and for studying population-based mortality. Equally important are tracking of drug overdoses, heart disease, cancer, and a host of other causes, which is critical to funding research on prevention. In fact, the death certificate was designed to provide an underlying cause of death, such as the disease or injury that started the chain of events leading to death. 

Inaccurate Death Certificates

Our trust in the accuracy of death certificates, however, may be misplaced. Dr. Anderson admits that accuracy of death certificates is unknown, but he sets his own estimate of inaccurate causes of death nationwide at 20 to 30 percent. Despite the clear importance of death certificates in the U.S., research has found that critical errors in death certificates are quite common, with the frequency of errors ranging from 18%–96% in hospital-based studies. Clearly there needs to be a better understanding of why there is such a wide range of inaccuracy.

Inaccuracies can be in the form of an array of errors. One example of an error was described in Medium Daily Digest by Lori Nerbonne, a nurse who founded New England Patient Voices. Medical records revealed the author’s mother died due to a medical error, but that fact was never disclosed on the death certificate. Losing a loved one is difficult enough, but when the true cause of death due to a medical error has been omitted on the death certificate, it creates a distortion of facts that can misguide efforts to prevent leading causes of death, as well as, causing emotional and financial implications for families. 

Fatalities due to Medical Errors

The annual estimate of fatalities in the U.S. due to preventable medical errors range from 250,000 to 440,000. One study found that 90 percent of medical errors in hospitals are not reported. Unfortunately, as a result of inaccurate death certificates, we have no reliable way to determine the true number of fatalities caused by medical errors.

The consequence of unreported medical errors is that death certificates do not reflect the vital statistics that would jump-start initiatives to help mitigate a solvable cause of death. This dereliction of duty creates a huge undertow of misinformation to the general public and policymakers. If we rely on the low-end estimate of 250,000 deaths due to medical errors, it would be the third leading cause of death in the U.S., following heart disease (659,041 deaths) and cancer (599,601). According to a CDC report, over 2.8 million deaths occurred in 2018, and medical errors were not tabulated anywhere in this report. 

Because medical errors are not “counted” as the third leading cause of death, it isn’t getting the public health investment it merits. We need greater attention to this major PREVENTABLE cause of death. Just like we invest billions in preventive care for heart disease, we need to invest in the systems and training needed to prevent medical errors.

Possible Solutions:

  • Revise/Update the Death Certificate Form to Include Medical Error/Injuries and Infections – Other causes of death, such as hospital-related infections, medical and medication errors should be treated no differently than the way other causes of death are treated. The death certificate forms should be revised to include medical injuries and infections as causes of death so the work of preventing medical errors can be measured.
  • Patient Advocates on Death Certificate Committees – Patient representatives should be added to death certificate committees. Patient advocates can represent an otherwise unrepresented group when the CDC reviews and updates the death certificate.

Making Death Certificates More Accurate

The COVID-19 pandemic has prompted the CDC to issue guidance that reminds doctors to ask a basic question when completing a death certificate: “Why did the patient die when they did?” As Ms. Nerbonne states in her piece, if accurate reporting is necessary for COVID-19 deaths, it should also apply for ALL causes of deaths. 

How can the information found in death certificates, specifically as it relates to cause of death, become more accurate? It should be noted that there are little to no incentives for those who complete the certificate to report accurate ‘causes.’ Death certificates are currently governed by state laws, and, as a consequence, the push for accurate reporting primarily begins locally. 

Possible Solutions: 

  • Enhance Certifier-of-Death Training – To affect future practices, it will be important to train medical school students to accurately complete death certificates. Additionally, we need to include/expand death certificate training for doctors under continuing education curriculums. Better clinician education is paramount to having accurate death certificates.
  • Audit Death Certificates – Audits of death certificates are both infrequent and/or inadequate. Timely and robust audits of death certificates are needed and audits should be mandated at the state and/or federal level. Electronic medical records (EMR) audits and/or billing codes could be one method that would trigger audits for accuracy. Audits could be generated shortly after the death certificate has been completed when key information is still relatively fresh to determine accuracy. Audits of sampled death certificates can be used to provide ‘correction’ to those who inaccurately certify the death certificate, thus it can serve as an accountability tool. To prevent undue influence and conflict of interest problems, auditing must come from an independent third party.

Another Solution – Autopsies

Autopsies can provide great insight into how a person died and how to keep us healthier longer. In fact, the Journal of American Medical Association (JAMA) argues that autopsies are a public good and, therefore, should be funded by the government. In addition to many preventable medical errors, an autopsy may determine either undiagnosed conditions – or misdiagnosed conditions. The autopsy remains the standard against which clinician death certification accuracy is assessed. Autopsies also are a valuable tool for physician and medical student learning. 

The latest data available from the CDC shows in 2007, 201,000 autopsies were performed, but this accounted for just 8.5 percent of all deaths. Although autopsy rates have plummeted in the last 50 years, medical experts and pathologists consider the autopsy to be the ultimate quality assessment tool in understanding the exact cause and circumstances of a death. Obviously, an autopsy is only as good as the pathologist performing it, and more pathologists would be needed to significantly increase autopsies in the future.

Autopsies can be expensive when paid for by the family of the deceased. According to Frontline PBS, a private autopsy by an outside expert may cost between $3,000 and $5,000. Medicare and Medicaid, in addition to most health insurance companies, do not pay for autopsies. 

Resuscitating the slow death of the autopsy may actually be a solution to learning more about the frequency of fatal medical errors and to advance the scientific knowledge of medicine. 

Conclusion

Americans deserve to receive an accurate determination of how a loved one has died. I know it was important to my family when my dad passed. The COVID-19 pandemic may serve as a reminder, regardless of the cause of death, to reform the accuracy and completeness of the death certificate. But naively relying on states and the CDC to improve accuracy will not work. It requires public support for a more transparent approach, possibly using some of the initiatives mentioned above. Public support can push states to consider new approaches that can reform the completion of death certificates to reflect the true causes of death in our country. 

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Promotion of a Healthy Workforce – Part 5

By: David P. Lind

As mentioned in earlier blogs within this series, the cost of obesity among employees is immense, and employers need to understand that workplace and employment conditions can actually contribute to employee health. Efforts by employers to encourage physical activity and healthy eating among all employees should be implemented to slow this growing non-COVID epidemic.

Comprehensive Obesity Treatment

Comprehensive obesity treatment coverage offered by employers serves as a complement to the promotion of physical activity and healthy eating. This treatment will typically include three types of coverage benefits: 1) Behavioral/Nutritional Counseling, 2) Weight-Loss Surgery, and 3) Pharmacological Treatment. It is critical, therefore, that employer’s partner with their health plans (insurance companies) and other vendor partners to promote seamless coverage to ensure sustainable success.

  • Behavioral/Nutritional Counseling

Improving access to healthy foods and physical activity is a key component to success. But this is just the beginning. Offering evidence-based health promotion programs with proven success may help nudge behaviors in new, healthy directions. One example of this is the National Diabetes Prevention Program (National DPP), which is part of the Centers for Disease Control and Prevention (CDC).

National DPP offers a lifestyle-change program designed to prevent Type 2 Diabetes. This initiative is a year-long intervention that is delivered in person, online, through distance learning, or through other approaches in group settings. This 16-segment curriculum is spread over 12 months and is designed to meet stringent CDC requirements. Research demonstrates that this program is highly successful. People with prediabetes who have taken part in this program, and have lost 5-7 percent of their body weight, can reduce their risk of developing type 2 diabetes by 58 percent. Results a decade after initiation of the program are impressive: “Program participants were one-third less likely to develop type 2 diabetes than individuals who did not join a program.”

  • Weight-loss Surgery

Weight loss surgery is also known as bariatric and metabolic surgery. According to the American Society for Metabolic and Bariatric Surgery, there are five different weight loss surgeries, each having advantages and drawbacks depending on the medical history of the patient and unique medical circumstances based on risks. The goal of these surgeries is to modify the size of the stomach and intestines to treat obesity and other related diseases. By making the stomach smaller and bypassing a portion of the intestine, less food will be consumed and changes will occur in how the body absorbs food for energy. This results in decreased hunger and increased fullness. The surgery improves the body’s ability to achieve a healthy weight.

Weight loss surgery also requires an overall treatment plan that includes lifestyle modifications, such as nutrition guidelines, exercise and behavioral counseling. To qualify for one of these surgeries, general medical guidelines use body mass index (BMI). An adult with a BMI of 40 or higher may qualify. But surgery may also be an option for an adult who meets other conditions if they have a BMI of 35 or higher – such as having at least one obesity-related medical condition and at least six months of supervised weight-loss attempts. Mayo Clinic provides these guidelines here.

Because safety of any procedure is paramount, using an Accredited Center for obesity surgery is usually stipulated by insurance companies. Based on a 2019 Bariatric Surgery Source article, most insurance companies cover weight-loss surgery. In Iowa, Wellmark, the state’s largest health insurance company, covers weight-loss surgery, subject to the provisions of the various policies they offer.

  • Pharmacological Treatment

According to a 2016 study, only one percent of individuals with obesity who are eligible for medication treatment actually receive the medication. One explanation is that there is a tremendous variability in provider prescribing rates and restricted coverage by health plans. Medications used to treat overweight and obesity work in different ways. Some medications, for example, help the patient feel less hungry or full sooner. Other medications make it harder for the body to absorb fat from the foods being consumed.

Similar to weight-loss surgery, qualification for medications to treat obesity typically begin with the individual’s BMI number. If an adult has a BMI of 30 or greater, a physician may prescribe medication for treatment. If the adult has a BMI of 27 or greater, but has a weight-related health problem, such as high blood pressure or type 2 diabetes, medication may be prescribed. Such medications are not a replacement for physical activity or healthy eating habits – all three work together to provide optimum weight loss. The National Institute of Diabetes and Digestive and Kidney Diseases provides an overview on medications to lose weight.

A New Game Changer in Obesity Medication?

In June 2021, the Food and Drug Administration (FDA) granted the approval to Novo Nordisk for semaglutide 2.4 mg (Wegovy™) for chronic weight management in adults with overweight or obesity. 

The safety and efficacy of semaglutide 2.4 (Wegovy) were studied in four, 68-week randomized controlled trials. More than 2,600 patients received semaglutide 2.4 for up to 68 weeks and more than 1,500 patients received placebos. From this, individuals who received Wegovy lost an average of 12.4 percent of their initial body weight compared to individuals who received placebo. The most common side effects of semaglutide 2.4 included nausea, vomiting, and diarrhea that were most common during the first several weeks of treatment. These symptoms reportedly abated thereafter. Of course, with about any new medication that reaches the market after FDA approval, little is known about the long-term safety of the drug for those who require ongoing use.

From a local physician perspective, Dr. Kara Thompson, who specializes in weight loss/bariatric surgery and nutrition at MercyOne Des Moines Bariatric Surgery in West Des Moines, confirmed, “The medications for weight loss are safe and effective if given to the correct patient and in conjunction with lifestyle changes. Studies have shown the most effective medications for weight loss is the GLP-1 class that includes Saxenda and Wegovy – but they are extremely expensive. 

I inquired with Wellmark about whether this new medication was approved as a ‘covered’ benefit under my health plan. A Wellmark customer service representative responded “this drug is excluded from your pharmacy benefit…prescription drugs for weight reduction are excluded.” Representatives from Novo Nordisk indicated that Wegovy is priced “around $1,340” monthly. For health plans that do cover this medicine, this price may be ‘negotiated’ downward by insurance companies and their selected pharmacy benefit managers.

Prior to Wegovy’s approval, many insurance companies have not covered weight-loss medications. It is unknown how many insurance companies will approve coverage for Wegovy. Novo Nordisk does offer a Wegovy Savings Card that can provide some financial relief, but cost will generally determine just how accessible semaglutide will be for patients. Large, self-insured employers can decide whether or not to include this medication as a ‘covered’ benefit under their health plan, but it will vary by employer. Dr. Thompson states that employers requiring their insurance companies to cover weight loss medications under their health plans would be very helpful in the treatment of persons living with obesity.

Summary

This five-part series on obesity touches on the basics of why employers may desire to implement workplace health programs for employees. There are plenty of financial and health reasons for employers to help mitigate obesity in the workplace. Although the body mass index (BMI) is considered to be a fundamental tool in these programs, there are important limitations that must be recognized. Obesity is now widely considered to be a disease, rather than a ‘lifestyle choice,’ and wellness programs that merely address nutrition and physical activity may miss other important approaches that can guide successful opportunities for each individual. Counseling and nutrition programs that address the needs and desires of each individual is a good first step.

Finally, surgery and medication are only meant to serve as a complement to diet, exercise and behavioral mindfulness. Learning as much as possible about the efficacy and safety of these treatments will be key for employers when considering the best ways to support and encourage the health of their employee population. Requesting coverage of weight related treatments, such as doctor visits, nutrition and behavioral counseling as well as weight loss medications and bariatric surgery by health insurance providers is a good first step. If insurance companies have enough fully-insured employers requesting this coverage, perhaps they will provide it as an option. Of course, self-insured employers can elect to include this coverage under their own health plan. No doubt, there are no ‘silver bullets’. However, the core of any program needs to ensure that stigma, prejudice and discrimination are removed from the workplace.

This post is the fifth in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1),” “Is the Body Mass Index (BMI) Useful? (Part 2),” “Obesity – a Disease or a Choice? (Part 3),” and “Employers: Establishing A Culture of Healthfulness – Part 4.”

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Employers: Establishing A Culture of Healthfulness – Part 4

By: David P. Lind

According to a 2020 report, adults spend one-third of their lives (about 90,000 hours), at work. No doubt, since the outbreak of COVID-19, the workplace has changed. However, because employees often move about less while working from home, the urgency to address obesity in the workplace has arguably increased. 

It is extremely important for employers to understand that obesity must be treated as a disease because it has become: 1) much too common, 2) a serious threat for developing other comorbidities, and 3) very costly both in lost productivity and increased healthcare costs. (NOTE: It is equally important to understand that being underweight – having a BMI below 18.5 – is also a risk factor for serious complications of COVID-19 and other health issues.)

Addressing obesity solely to reduce healthcare costs and boost productivity will send the wrong message to employees. A successful obesity program must project a culture of acceptance and inclusivity, rather than stigmatize and dehumanize persons with obesity. Therefore, the more effective way to help employees living with obesity is to establish a culture that encourages healthfulness for all employees.

Dr. Kara Thompson, who specializes in weight loss/bariatric surgery and nutrition care at MercyOne Des Moines Bariatric Surgery in West Des Moines, provided her viewpoint for this blog about how employers can make their wellness programs more effective. She said employers having conversations with employees about their weight would not be well received. Instead, Dr. Thompson feels employers should focus on the general health of their workforce, as a much better approach to get employees engaged. “Successful programs are those backed by a culture that supports health.” 

Standard Lifestyle Modification Intervention Programs

Standard worksite wellness programs that address obesity interventions include financial incentives to employees for keeping their cholesterol and lipids within healthy range, attending health education classes, lunchtime walks, activity trackers and step counters and other opt-in health programs that primarily focus on behavior change. However, employers must be aware of the HIPAA nondiscrimination rules and the U.S. Equal Employment Opportunity Commission (EEOC) final rules when offering incentive plans for wellness programs. 

Science and research on physical activity continues to evolve. In fact, according to a New York Times article published in September 2021, there are two new large-scale studies of physical activity and longevity that suggest a ‘sweet spot’ of 7,000-8000 daily steps that will provide optimum benefits for those in middle adulthood.

Lifestyle modification workplace interventions have proven to produce modest weight loss and improvements to weight-related health problems. According to a 2018 review of workplace obesity programs by the American College of Occupational and Environmental Medicine (ACOEM), these modest improvements do not result in sustained employee engagement and long-term results. The authors suggest that lifestyle behavioral modification must be coupled with other approaches, including medical intervention. 

Other research on wellness programs, such as one from Harvard Medical School, suggests limited success in realizing large investment returns – at least in the short term. The authors concluded that wellness programs did not have, after 18 months, better clinical measures of health such as BMI, blood pressure or cholesterol. These programs did not exhibit lower absenteeism, better job performance or lower health care use or spending.

Unfortunately, studies have shown that yo-yo dieting can actually cause weight gain in the long run.  One theory, known as “set point,” says our bodies have a natural weight and will always fight to stay within a certain weight range (the patient’s “set point”) and that dieting will not change that weight permanently.  When asked about this, Dr. Thompson said this is a complicated question.

“We truly don’t have all of the answers to why some people lose more than others, or why weight loss can stall out. We do know that if someone drops calories really low, the body can fight that decrease by increasing hunger, decreasing calories used and even pulling more calories out of the food that was eaten, and that happens even if the body has lots of fat stores. My experience has shown that if one’s body thinks it is not getting adequate nutrition, fat or protein to support all of its demands, it does the same thing. I am frequently telling patients to eat more protein or more healthy fats, and that can often stimulate weight loss.

Dr. Thompson summarizes with this:

“It’s the types and quality of food eaten along with the individual’s genetics, age, activity, hormones, sleep, stress, muscle mass and even medications taken influencing all of this and you can see why it is so complicated.”

A 2020 Milken Institute report, “Obesity in the Workplace: What Employers Can Do Differently,” succinctly wrote the following about existing mainstream wellness programs:

To date, obesity programs in the workplace have failed to meet people where they are. They promote impersonal behavior change rather than provide employees with tailored support. The consensus among experts is clear: Interventions commonly characterized as targeting worksite wellness” have not adequately demonstrated improved health outcomes.

What Can Employers Do About Obesity?

First of all, there is no silver bullet for employers to eliminate employee obesity. There are, however, a number of strategies that employers can take that will hopefully result in a healthier workforce. 

To begin, employers must understand that obesity is a disease and address the stigmatization of obesity.

Dr. Thompson agrees that obesity is a disease. “Some people are genetically set up to carry more weight and some are in the situation where making better choices is difficult…like most diseases, outcomes for obesity can often be influenced by lifestyle and medical management.”

Coming from various resources, some recommended action steps employers can pursue include the following:

  • Understand the Science

It is important to understand the science of obesity that impacts both appetite and energy, and why losing weight and keeping it off is so difficult. 

  • Reduce/Eliminate Stigma 

Stigma begins with how obesity is perceived and communicated in the workplace. One primary example of this stems from the words we use when addressing obesity. Instead of inappropriately labeling people as “an obese person” or “an obese employee,” employers should approach obesity as a disease that affects individuals. People-first language, such as “a person with obesity” or “an employee living with obesity” may appear to be a subtle difference, but it more appropriately refers to the person first and their condition second. When carefully used, words can avert harmful stigma and stereotypes.

  • Prevention

Having a culture of healthy eating at work, both in-person or remotely, is one important aspect of obesity prevention. Employers can help influence the choices of healthy food options in the workplace cafeteria and at the vending machines. Employers can pursue initiatives and education that encourage nutritious and healthier eating habits at home. The promotion of active lifestyles – both at the workplace and at home – are also critical components to any program promoting good health. Of course, monitoring employee uptake of these programs will help the employer understand patterns of employee engagement.  An improved culture of healthfulness will positively impact all employees.

  • Treatment and Health Plan Coverage

Does your health plan view obesity as a lifestyle ‘choice’ or as a disease? The answer to this question reveals a big difference in treatment and whether coverage is included in the health plan. Obesity treatment covers a full range of healthcare options, including behavioral counseling, medical visits for obesity, dietician visits, anti-obesity medications, and bariatric surgery. Dr. Thompson states that it is very frustrating, from a physician’s perspective, to not be able to prescribe the medication best suited for a patient’s condition because the medication is not covered by insurance and is, therefore, cost prohibitive. Employers making this coverage a priority would go a long way in supporting their employees who seek obesity treatment.

Summary

Obesity is not a lifestyle choice, but rather, a disease. Employers should mindfully establish a company culture that encourages healthfulness.  This will benefit all employees, including those employees living with obesity. A culture that encourages healthfulness might include access to individual counseling, as well as dietary education and accessibility to healthy food in the workplace.  Also, education about other obesity risk factors such as physical activity vs sedentary time, stress and poor sleep can encourage changes that result in better health, especially when coupled with other employer sponsored work-life balance initiatives. Committed employers should also investigate coverage options available through their health plan that affect pharmacological and surgical treatments. When considering how to develop a comprehensive benefits package for outcomes-based obesity treatment, George Washington University provides a guide that identifies core components of a successful strategy – STOP Obesity Alliance.

The fifth and final installment of this series will address the treatment of obesity through healthcare interventions.

This post is the fourth in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1),” “Is the Body Mass Index (BMI) Useful? (Part 2),” and “Obesity – a Disease or a Choice? (Part 3).”

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Obesity – a Disease or a Choice? (Part 3)

By: David P. Lind

The public often views obesity as a failed lifestyle stemming from poor diet and little physical activity. Yet, research ties obesity to a variety of genetic, metabolic, hormonal and systemic factors that predispose individuals to obesity.

According to a 2016 report from NORC at the University of Chicago, almost half of Americans (48 percent) tend to believe that obesity is not a disease – it is caused and perpetuated by a person’s lifestyle choices (eating and exercise habits). In fact, the biggest barrier to weight loss, they believe, is largely due to lack of willpower, laziness, lack of self-control – all untrue stereotypes.

During the past 18 months, COVID-19 has increased awareness of obesity. This is because obesity has been identified as a risk factor for severe COVID-19 symptoms. People are increasingly expressing concern about gaining weight during the pandemic, the so called “quarantine-15.”

Genetics, Environment, Behavioral and Emotional

Researchers, however, have found that obesity, which affects at least one-third of Americans, is not caused by sloth and gluttony. According to The Centers for Disease Control and Prevention (CDC), hundreds of human genes give the body instructions for responding to changes in its environment. Individuals are attracted to inexpensive food with abundant portions. ‘Food deserts‘ are a prime example. People in a given geographical area have restricted access to affordable, healthy food options – especially fresh fruits and vegetables.  Absence of grocery stores within convenient traveling distance creates barriers to healthier eating. The CDC terms this as part of the social determinants of health, which “are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”

In 2013, the medical community – including the American Medical Association (AMA) and other influential medical groups* – has generally reached a consensus that obesity is a disease. Part of the motivation for making this decision can be tied to pharmacotherapy and surgical intervention – both of which go beyond the standard lifestyle prescription of “improving diet and exercise more.”

Although experts have divergent views on the science of losing weight, it is the consensus of medical experts that obesity is caused by a combination of genetic, environmental, behavioral, and emotional factors. Some illnesses, such as Cushing syndrome and polycystic ovary syndrome, may lead to weight gain and obesity. Using steroids and specific antidepressants can also cause weight gain.

The Stigma of Obesity Must End

‘Lack of willpower’ is not a valid cause of obesity. It is a form of shaming based on uneducated philosophies and beliefs. Labeling obesity as simply being an individual lifestyle ‘choice’ has no scientific basis. Such stigmatization threatens the health of obese individuals, generates health disparities, and just as importantly, interferes with effective intervention efforts.

Obesity can effect individuals regardless of gender, job title, education, age, location, or political preference. However, there are known disparities in obesity rates based on race/ethnicity, gender, and socioeconomic status. The stigma, prejudice and discrimination that is pervasive in the workplace, healthcare facilities, educational institutions, mass media and other places perpetuates a narrative that it is socially acceptable to negatively stereotype obese individuals. Some argue that this stigma will help serve as a useful tool to motivate obese people to adopt healthier lifestyles…this thought process is grossly misguided.

A June 2010 paper, “Obesity Stigma: Important Considerations for Public Health,” published in the American Journal of Public Health, takes a deep dive into this issue. Obesity is a public health priority. The resultant suffering and comorbidities require local and national discourse addressing this epidemic. In short, the stigmatization of obesity is not an effective way of addressing this disease.

Summary

As mentioned in “Obesity Requires Employer Attention and Focus – (Part 1)” in this blog series, a new employer mindset must evolve to alter the alarming trajectory of the obesity epidemic. Employers have a fundamental interest in addressing this persistent health crisis. The final two segments of this obesity series will focus on approaches employers might consider when addressing obesity.

* World Health Organization; National Institutes of Health; Centers for Medicare and Medicaid Services; Obesity Society; Institute of Medicine; and American Association for Clinical Endocrinology.

This post is the third in a five-part series. Click here to read “Obesity Requires Employer Attention and Focus – (Part 1)” and “Is the Body Mass Index (BMI) Useful? (Part 2)“.

To stay abreast of healthcare-related issues, we invite you to subscribe to this blog.

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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