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Fixin' Healthcare

Wednesday, May 31, 2006

The Lifestyle Chronicles - Demand And Need

Perceived needs become demands that become needs. Consumers and providers alike reinforce this process. It is a process that fosters continuing regeneration of need and refinement of need. There is competition between needs but needs are mutually supportive to grow the overall enterprise. This is commerce and it is the American way. In medical care this process has become a "perfect storm". Nothing personal, it's just business.

There are numerous examples of this process in action ranging from universities (billion dollar capital campaigns), to hospitals (deploying the latest technology, building new wings and advertising that I'm bigger and better than the other guy), to professional and speciality associations (a powerful urge to procreate and protect turf), to pharmaceutical and medical device corporations (the masters of advertising to create demand and need), to patient advocacy groups (usually specific diseases with high public sympathy), to foundations (imaging worthy causes). All of these are well-meaning, worthy of support and ultimately self-serving. All of them suffer from linear thinking. Treat the need and find more of the need.

The medical care enterprise does not change; it enlarges and becomes more refined. New technologies and methods are added in layers to grow the enterprise without disturbing what is already there. Any increase in effectiveness is directed more to the process than the outcome. Diagnosing and treating the need has made little progress toward the cure or prevention of the chronic diseases that generate need. For these reasons, efficiency has steadily declined.

Creating greater capacity to address perceived need is not an answer for health care in America. The task is to define the need and create the enterprise for greater capability of achieving optimum health status for everyone. And, we had better start before everyone is an invalid, bankrupt or dead.

Now, I am begining to understand Kafka.

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Saturday, May 27, 2006

The Lifestyle Chronicles - Basic Values And Lofty Goals

Yes, yes, rehabilitate America. I agree. But, where to start? There are so many, many issues and a plethora of special interest groups supporting each one.

Well, I met with my consultant, Pogo. He called in another consultant and we reviewed the matter in great detail. It was my first time to meet the Lorax in person. Impressive fellow. Focused and no nonsense. Very little humor. But, Pogo made up for that and together they are a great team. Like most consultants they spent some of the time telling me what I already know.

Americans lead unhealthy lifestyles and as a result they are unhealthy. The point was made that Americans are confused and lack understanding about healthy lifestyle. To counter this situation they turn to "experts" of all stripes and rely upon the medical care system to save them. This has made a shambles of public health, which has severely limited the capability for achieving optimum health status.

Both Pogo and the Lorax were insistent about the issue of American lifestyles polluting the environment. In turn, a polluted environment is an equal opportunity danger. It increases risk of poor health for everyone.

It was interesting to listen to these fellows discuss how American society defends and justifies its lifestyle. They were tossing around concepts like individual freedom, privacy, and economic development. However, it was agreed that concepts such as these are possible only when there is a clean, stable environment and optimum health.

The well-being of individuals and society depends upon stability of the environment and healthy lifestyles to maintain optimum health status. It is the basic role of society to protect the integrity of the environment and maintain a vigorous public health system. Both of these areas are subject to catastrophic events and both are absolutely dependent upon healthy lifestyle. All functions of government and society must support and serve these crucial areas.

I hasten to add that this report is my responsibility. Pogo and the Lorax gave their best advice. They are in agreement with the conclusions but they are not in position to endorse a specific report. (How's that for commentary on CYA and relativism in American society?)

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Sunday, May 21, 2006

The Lifestyle Chronicles - More Of Pogo Knows

Pogo is a cartoon chararcter with a famous saying - "I have met the enemy and the enemy is us."


But the lesson for Americans is clear. These days, and especially in the United States, with its screening and testing, "we are labeled," said Dr. Hadler of North Carolina.

"I call that medicalized," he added. "And one of my creeds is that you don't medicalize people unless it is to their advantage. When you medicalize people, they think they're sick, and in our culture it's, 'Do something, Doc. Don't just stand there.' "

The Dartmouth Atlas of Health Care (www.dartmouthatlas.org) reports a five-fold difference between academic health centers for hospitalization or admission to intensive care units of patients with chronic disease during their last six months of life. And, the cost of providing care to these patients over the final two years of life varies more than two-fold at some of the most prestigious medical centers.

The predominant influence on cost was volume of service. "There isn't any evidence that people are sicker in the markets of high-intensity servives than in low ones, says Dr. John Wenneberg (principal investigator for the Atlas Project), but when beds are available physicians figure out a way to fill them." (Wall Street Journal, May 16, 2006, Ron Winslow).
The Partnership for a Drug Free America reports that one in five teens (about 4.5 million) has tried prescription drugs for pain (Vicodin or OxyContin) to get high. The survey also reported that many teens feel experimenting with prescription drugs were safer than illegal drugs. Thirty-one percent of teens feel there is nothing wrong with using prescription drugs once in a while.
A government survey estimates that the number of adults aged 50 or older with substance abuse problems will double to 5 million in 2020 from 2.5 million in 1999, in large part due to their comfort with prescription drugs.
Unnecessary medical tests are costing the U.S. health care system millions--and potentially billions-- of dollars per year, and add unnecessary patient stress, say researchers from Georgetown University Medical Center and Johns Hopkins University in the June issue of the
American Journal of Preventive Medicine.

Not only are the tests unwarranted, but false-positive results lead to further tests and compound the expense, says the study's lead author, Dan Merenstein, MD, an assistant professor in the Department of Family Medicine at Georgetown.
"There is a distinction between what people say they eat, say they want to eat, and what they eat," Jim Skinner (McDoanld's CEO) said at an April 17th press conference. "It's about choices.
It's about opportunities for people to come to McDonald's and get a meal that they feel good about having eaten that fits into their lifestyle."

Skinner said the company's marketing panels and surveys determine what consumers most want to eat.


The enormous success of the Dollar Menu, where all items cost $1, has helped stimulate 36 consecutive months of sales growth at stores open at least a year. In three years, revenue has increased by 33 percent and its shares have rocketed 170 percent, a remarkable turnaround for a company that only four years ago seemed to be going nowhere.

McDonald's has attracted considerable attention in the last few years for introducing to its menu healthy food items like salads and fruit. Yet its turnaround has come not from greater sales of healthy foods but from selling more fast-food basics, like double cheeseburgers and fried chicken sandwiches, from the Dollar Menu.

"America's diabesity problem is not about moral failure, laziness, or lack of effort. It's about the wrong philosophical underpinnings. We have fallen for the idea that there is a quick fix for everything -- especially weight loss. We look to fad diets, extreme athletics, diet pills, and surgical interventions as a miracle cure for all of our problems.

We must make a philosophical frame shift towards a rehabilitation model of weight control. Why rehab? Because rehabilitation involves a long-term commitment; an acknowledgment that the opportunity for weight regain will never go away; and that an individualized, multidisciplinary approach has the best chance of success.

Rehabilitation literally means "the restoration of lost capabilities.[1]" It is a hopeful word, because it presumes that individuals have the capacity to improve, to walk farther, feel better, maintain a healthy weight, and add life to years. Rehabilitation medicine physicians use an integrative, holistic approach to wellness. They coordinate teams of physical therapists, occupational therapists, social workers, psychologists, and nutritionists to help patients meet their goals. For this reason, I believe that rehab specialists are the best equipped to provide the kind of complex, long-term solution that is required to reverse the diabesity epidemic. Let's rehabilitate America!"


Rehabilitation. Wikipedia. Available at: http://en.wikipedia.org/wiki/Rehabilitation Accessed April 28, 2006

by Val Jones, M.D.

Enhanced health insurance and expanding health insurance to everyone will address the problem of paying the bills for the U.S. health care system. However, it will do little for the problem of achieveing optimum health status for the greatest number of people in the U.S. The U.S. health care system and the current national debate on health care reform perpetuate a national perception that caring for the sick is the best way to achieve optimum health. This would not be such a tradegy if it did not mask lifestyle as the greatest contributor to poor health.

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Wednesday, May 17, 2006

The Lifestyle Chronicles - First Things First

A curious aspect of American health care and American society is the focus upon specific diseases. There are societies, foundations and institutes dedicated to specific diseases. Add to this the very large chunk of health care devoted to a specific age group and a compelling picture emerges. It is a proven method for generating popular, political support and resources. But, where does it lead and what are the goals?

Type-2 diabetes is an example worth consideration regarding this point. The number of Type-2 diabetics in the U.S. has doubled during the past two decades to involve an estimated 20 million people. This makes the disease the country's fastest growing public health problem. Definitely a problem worth attention. Yet, diabetes is an under-funded disease.

On the other hand, how would increased funding for diabetes be used? What is the origin of such rapid growth in the incidence of diabetes? Increasing basic research and clinics devoted to diabetes would provide useful information and limited relief. But, could these efforts be expected to decrease the incidence or prevent the disease?

Type-2 diabetes is the hallmark for chronic diseases that are the result of unhealthy lifestyles, just as lung cancer is for smoking. Immunization for polio is superior to improving iron lungs. Cessation of smoking is superior to surgery, chemotherapy and radiation. This is where the road forks for public health and medical care. Attack the cause, not the manifestation. In the situation involving diabetes the true focus is upon better health for everyone not a specific disease.

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Monday, May 15, 2006

The Lifestyle Chronicles - Feeling Good And Doing Better

Frequent public messages in various forms have been urging Americans to change their dietary habits and increase physical activity. The message is getting through and people are trying to change, but they are confused about details and how to go about making the changes. A survey determined that taste and price were more influencial than health benefits in purchasing food. With a little thought, it is possible to have both.

If it was easy to make these changes, then no one would have a problem. A group effort helps, constant and consistent reinforcement helps, guidance that fits the individual situation helps, confidence and focus helps, a day to day detailed plan helps, a pat on the back and a kick in the butt can help, looking and feeling good helps.

The message is out there. Now, we have to find out how to make it work.
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Thursday, May 11, 2006

The Lifestyle Chronicles - Health Works For Everyone

The recent death of Jane Jacobs at age 89 years provided occasion to review her contributions to critical thought and to society (Leonard Gilroy, Wall Street Journal May 2, 2006). A working mother with no formal education in urban planning, she published in 1961 a book entitled “The Death and Life of Great American Cities”. She mobilized citizens to fight the redevelopment and highway construction plans for New York City that would have displaced 10,000 residents and workers and destroyed thousands of historic buildings.

The central theme of her work is that cities are vibrant living systems, not the product of grand, utopian schemes concocted by overzealous planners. She believed the focus should be on how cities function rather than how they look and no other expertise can substitute for local knowledge. Her ideas were born from the urban renewal efforts that resulted in isolation or destruction of previously vibrant neighborhoods and failed to realize the goals of the planners.

Other than a fascinating concept by an astute lady, how does this fit with the current situation in health care? Well, medical care is a highly engineered enterprise that treats the sick but falls short of achieving optimum health for individuals and communities. Once a person has a chronic disease such as diabetes, hypertension, arthritis or cancer, the potential for achieving good health is limited and highly inefficient. And, unhealthy lifestyles are creating chronic diseases at an alarming rate.

The tragedy of American health policy and American society is excessive reliance and emphasis upon medical care to treat people after the onset of illness and disease. The results speak for themselves in the escalating cost and deteriorating health status. This situation can be countered by increasing the emphasis upon public health and prevention as an active community enterprise and an active health care practice.

People are responding to the escalating cost of medical care and to the realization they are paying so much and feeling so lousy.

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Tuesday, May 09, 2006

The Lifestyle Chronicles - Think About It, Plan For It, Do It

What is lifestyle? Everyone talks about it and there is a lot written about it. But, what is it?

Hmmm. Jet airplanes to Paris and Rome? Leather jackets and motorcycles? Mountain biking? Hiking the Appalachian Trail? Yep, these and much more.

Perhaps it is that lifestyle is what each of us does during 24 hours everyday. And, perhaps each of us would benefit from planning more of the details for the upcoming two days. The perception of lack of time may be lack of planning. Planning increases physical activity and improves diet. Managing stress requires planning. Planning clarifies priorities and distinguishes between must do, should do and want to do.

In other words, everyone has a lifestyle whether or not they regard it as such or recognize it. And, everyone is much more in control of their lifestyle than they care to admit.

The development of a healthy lifestyle requires planning for each upcoming two days. The plan is immediate; it is here and now. A good plan includes checking in every two weeks to be cheered or beat. No sympathy, no victims, no drugs, no surgery.

Today is last month's next month and last year's next year. Get with it!

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Sunday, May 07, 2006

The Lifestyle Chronicles - Lead Me Not Into Temptation

Have you noticed how fast the press is to report early scientific findings as breakthroughs? It is as if the cell nucleus is city hall. As it turns out, the scientists and health care providers enjoy and profit from the attention, and the public laps it up like it was gossip.The caveats about the data being preliminary and potential applications being many years away are lost in the rush.

Wow! What a marketing machine!. Expectations for miracles make ready customers with lots and lots of price elasticity. Doesn't hurt grant applications or the possibility of royalties for the university, either.

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The Lifestyle Chronicles - Leopards And Their Spots

There is the parable of the frog and the scorpion where the scorpion asked the frog to carry him across the river. The frog is reluctant for fear of being stung but the scorpion assures him that would make no sense because both would drown. Then, while crossing the river the scorpion stings the frog. As they are drowning, the frog asks why and the scorpion replies that it is his nature.

Pfizer spent $117 million advertising Celebrex the year before an ad moratorium in December 2004. In 2004, Celebrex sales were $3.3 billion and during the ad moratorium sales fell to $1.7 billion. Now, Pfizer has resumed ads for the drug including a warning about the possibility of heart disease.

Why did they do that?

It is in their nature.

Make no mistake, pharmaceutical companies are not health care providers. They are commercial enterprises. They make products that are used in health care.

Hospitals are not health care providers. They are facilities and equipment that are utilized to provide health care.

Insurance companies are not health care providers. They are financial institutions that conduct and verify transactions to facilitate health care.

Use these resources when and as necessary. And, keep them in perspective because the total perspective for health care is not in their nature.

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Saturday, May 06, 2006

The Lifestyle Chronicles - Connect The Dots

When compared to other industralized countries the cost of medical care in the U.S. is high and associated with deteriorating health status. As this situation has developed, the number and percent of the population without healthcare insurance also has increased. Many have linked the rising cost and deteriorating health status to the lack of insurance. Undoubtedly, each situation aggravates the other but it is much more difficult show basic cause and effect.

Indeed, there is reason to question this assumption and bring into consideration the influence of American culture, lifestyles, public perspective of health, distorted profit motivation and how medical care is practiced. Insurance has been part of the problem in that it has contibuted to the behavior of practitioners and consumers of medical care. The appropriatness, effectiveness and efficiency of medical care and patient compliance with therapy are issues to be considered.

Prevention is neglected as a basic, functional concept in the American culture. For example, governments at all levels are notorious for lack of preventive maintenance. When treatment begins after the patient is sick, the leverage shifts from the long arm to the short arm of the lever for effectiveness, efficiency and outcome.

1. Annual U.S. per capita medical care expenditure = $5,274
2. Annual British per capita medical care expenditure = $2,164
3. Wealthier and better-educated people in both countries were much healthier than poorer and less-educated people. But, those in the top education and income level in the U.S. had similar rates of diabetes and heart disease as those in the bottom education and income income level in Britain.
4. Only 41.7% of adults with diabetes in the U.S. reported receiving all three of the tests considered critical for medical management of the disease - hemoglobin A1C, dialated eye exam and foot exam.
5. Half of individuals who suffer a stroke and have elevated levels of LDL cholesterol are prescribed statin therapy, and fewer than half of those taking a statin meet recommended lipid
6. Analysis of 25 to 30 years of follow-up for type-1 diabetes revealed reduction in mortality and renal failure rates but there was no difference for rates of cardiovascular disease events and cardiac intervention procedures.
7. The Robert Wood Johnson Foundation reported that 3 million fewer U.S. workers eligible for employee-sponsored health insurance enrolled in 2003 when compared with 1998.

1,2,3 - JAMA, May 3, 2006
4 - HHS Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey
5 - Neurology, April 25, 2006
6 - Diabetes, May 2006

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Wednesday, May 03, 2006

The Lifestyle Chronicles - Look Homeward Angel

The U.S. spends $5,274 per capita annually on medical care and Britain spends $2,164 per capita annually. Yet, U.S. citizens age 55 to 65 years have higher rates of diabetes, heart disease, heart attack, stroke, lung disease and cancer than the same group in Britain.

Smoking was similar for both countries. Obesity rates were much higher in the U.S. and heavy drinking was more common in Britain.

Wealthier and better-educated people in both countries were much healthier than poorer and less-educated people. Those in the top income and education group in the U.S. had similar rates of diabetes and heart disease as those in the bottom income and education level in Britain.

The May 3rd issue of the Journal of the American Medical Association (JAMA) contained an article reporting this information. The article concluded that health insurance cannot be the central reason for the better health outcomes in Britain because the top socio-economic status tier of the U.S. population have universal access but their health outcomes are often worse than their English counterparts.


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Tuesday, May 02, 2006

The Lifestyle Chronicles - Bet To Win

I grow old ... I grow old ...
I shall wear the bottoms of my trousers rolled.

Shall I part my hair behind? Do I dare to eat a peach?
I shall wear white flannel trousers, and walk upon the beach.
I have heard the mermaids singing, each to each.

I do not think they will sing to me.

from The Love Song of J. Alfred Prufrock
by T. S. Eliot

When I was young, I thought about medicine and I spent many years caring for the sick. Now that I am older, there has grown an appreciation and perspective for health.

Good health is more than the absence of illness and disease. Good health does not indicate the need for medical care nor does it require the use of health insurance. At any given point in time, the majority of the population place few demands upon medical care or health insurance.

The desire for good health does not assure good health. But, "the desire for good health" is more likely than "the fear of illness and disease" to be associated with good health. America must take great care to avoid fear overwhelming hope.

If the endpoint is death and the objective is good health, then the goal is to die in good health avoiding accidents, homicide and suicide.

Think about it. Plan for it. Do it.

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