The rising tide of arthritis and fake knees

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It is stunning that about 1 out of 20 adults 50 and older have fake knees. The demand for knee replacements have doubled in the last decade, rising to 600,000 in 2009.

Two opposite factors are fueling this trend: baby boomers who want to “fixed” to be able to pursue active lifestyles, and the fact that people are carrying more weight longer.

About 50 million Americans – or about 1 out of 5 U.S. adults – have been diagnosed with arthritis. That number is expected to rise 1 out of 3 adults by 2030 the entire baby boomer generation becomes elderly. About half of those over age 65 have arthritis.

Arthritis is also the nation’s most common cause of disability. Nearly 21 million Americans say they have activity limitations because of the condition.

Two-thirds of diagnosed arthritis patients are under 65. Of those, about 4 out of 10 have work limitations because of it.

The lifetime risk of developing knee arthritis that causes pain is 45 percent. That rises to 57 percent for those with a past knee injury, and 60 percent for obese people.

Arthritis is composed of more than 100 rheumatic diseases and conditions. Osteoarthritis, the most common form, mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over each other and absorbs the shock of movement. In osteoarthritis, the top layer of cartilage breaks down and wears away as people age. This allows bones under the cartilage to rub together.

Rheumatoid arthritis is an autoimmune disease that can develop at any age. Common symptoms for both include pain, aching, stiffness, and swelling in and near the joints.

In 2003, the total cost of arthritis was $128 billion, including $81 billion in medical costs and $47 billion in lost earnings. The condition results in nearly one million hospitalizations annually. Nearly half of the hospital discharges are for knee replacement procedures.

Exercise is an effect way to combat arthritis. However, those with the condition find physical activity a challenge. More than half of U.S. adults with diabetes or heart disease also have arthritis. This impedes chronic-disease management. More than half of women and about 40 percent of men with arthritis get no physical activity. Fewer than 1 out of 7 men and 1 out of 12 women met the federal physical activity guidelines of 150 minutes of moderate exercise a week. Exercise can reduce pain, lessen joint stiffness, increase strength and increase mobility. This is contrary to a common myth that people with arthritis need to rest their joints.

 Self-management education initiatives such as the Arthritis Foundation Self-Help Program can teach people how to manage arthritis more effectively. Research has shown the program helps reduce depression and fatigue, and reduced pain by 40 percent.

Weight loss is also an important component of arthritis management. A loss of 15 pounds can cut knee pain in half and reduce disability.  About 2 out of 3 arthritis patients are overweight or obese, which puts excess stress on joints.

Health care’s post-recession toll

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According to the Congressional Budget Office, the rate of unemployment has been above 8 percent since February 2009, making this stretch of high unemployment the longest since the Great Depression. The CBO expects it to remain there until 2014.

Health care, long considered immune from economic cycles, have felt this deeply. About 10 million lost employer health insurance between December 2007 and June 2009. About 40 percent of Americans had trouble paying medical bills in 2010. More than half of patients delayed care because of cost in 2011. Even 1 out of 4 insured households had problems with medical debt. All of this has contributed to a slower rise in medical inflation.

Hospitals have felt this downturn deeply as well. According to the American Hospital Association, 90 percent say charitable giving is down and do not expect it to recover until 2014. Two out of 3 have delayed capital projects and 1 out of 4 have cut services.

The question is whether the slowdown is structural or cyclical. Health-care spending generally rises when the economy improves. However, there is evidence that the rapid rise in high-deductible health plans is becoming a factor. Those with high-deductible plans are 3-4 times more likely to delay care. About half of that foregone care is considered an “unmet need.” Self-diagnosis is becoming increasingly common in U.S. households.

The underappreciated effects of air pollution

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Three major studies this week underscored the dangers of air pollution, even at what the government deems safe levels.

The studies – here, here and here – show higher levels of air pollution are associated with greater risks of stroke, heart attacks and cognitive decline.

Air pollution is a deeply underappreciated risk to health. More than half of the U.S. population lives in areas where either the ozone or particle pollution – or both – are often dangerous to breathe.

Ozone is the primary ingredient of smog. Unlike the beneficial ozone layer in the upper atmosphere that shields the sun’s ultraviolet radiation, ground-level ozone attacks lung tissue by reacting chemically with it. Ozone is formed when nitrogen oxides (NOx) and volatile organic compounds (VOCs) come in contact with heat and sunlight. NOx are emitted by power plans, motor vehicles and other sources of high-heat combustion. VOCs sources include motor vehicles, chemical plants and factories.

Particle pollution is a mix of tiny solid and liquid particles. Particle pollution is visible when trucks spew a dirty stream of exhaust. Coarse particles, defined as those between 2.5-10 microns, are created by mechanical processes such as construction, demolition, mining and agriculture. Fine particles, less than 2.5 microns, primarily are created by chemical processes such as burning fossil fuels in factories, vehicle exhaust and burning wood.

A recent study calculated that air pollution is a greater threat to the risk of heart attack than cocaine. The reason is that many people are exposed to unhealthy air, compared with the relatively small number of those who use cocaine. Other factors with a lower heart-attack risk included extreme physical exertion, excess alcohol use and depression. Traffic and air pollution account for about 1 out of 8 heart attacks worldwide.

In an accompanying editorial, Dr. Andrew Baccarelli pointed out: “The important message here is that while an individual’s risk from air pollution is moderate or small, each of us is exposed, making the amount of risk intolerable for the entire community.”

Air quality is improving. According to The American Lung Association, the nation’s 25 most-polluted cities improved their air quality in the previous year and 15 registered its best-ever lowest pollution levels.

However, ozone exposure even at levels deemed safe by current air standards can negatively affect lung function. There is direct correlation between higher ozone-level exposure and decrease in lung function.

Ozone pollution  can shorten life. Conversely, a drop in particle pollution between 1980 and 2000 lengthened life expectancy in 51 U.S. cities by an average of five months. Particle pollution is associated with increasing the risk of asthma, diabetes and chronic obstructive pulmonary disease (COPD).

Those most sensitive to the effects of air pollution are children, the elderly, people who work or exercise outdoors, and those with existing lung diseases such as asthma and COPD.

Ways to minimize pollution’s effects include staying indoors on poor air-quality days, keeping windows closed near busy roadways, use recirculated air in cars, and avoid exercising during morning and evening rush hours.

Health care budget as sacred cow

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The recently released $3.8 trillion budget essentially gives a pass to Medicare and Medicaid. President Obama relies on a liberal political tactic: brute cuts to providers, without regard to quality or attempting to address the 30 percent of health-care spending that is of no benefit to patients.

Health care continues to get a pass, despite the fact that is approaching 20 percent of the gross domestic product and is expected to account for 40 percent of the increase in the federal budget over the next decade. There is no health-care budget, in the sense that it is limited. These costs simply are accommodated. No other part of the budget operates this way. Neither should health care.

Health literacy: Going in the wrong direction

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The Obama administration is showing a disappointing lack of courage by shying away from one of the best provisions of health reform: requiring consumer-friendly summaries of what insurance plans are offering their customers.

The insurance industry has been complaining about the cost of doing this, and the administration seems to be listening because it does not want to seem to be imposing costly regulations in an election year. Arguably, insurance companies should have been doing this all along. This is simply a no-brainer. Consumers are being asked to become more engaged in their health and the cost of care. Not giving them the tools to do this is going in the wrong direction, with or without regulations.

One-third to one-half of U.S. adults do not have the literacy skills to navigate the health-care system. Studies have shown that poor health literacy is associated with higher rates of hospital readmissions, treatment complications and death.

 Health literacy is the capacity to obtain, process and understand basic health information and services to make appropriate health decisions. Reading comprehension and understanding numbers are the key components.

 This problem is not entirely the patient’s fault. Anyone can have difficulty navigating densely written medication-insert instructions or medical-consent forms loaded with jargon and technical language. More than 300 studies have found that such health-related reading materials are written beyond the average reading comprehension of U.S. adults.

 

However, even my highly educated friends openly admit they refuse to read their health insurance information because it makes no sense to them.

 

 

 

 

The reality of health reform

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The Obama administration announced last week that 3.6 million Medicare Part D recipients received $2.1 billion in pharmaceutical discounts in 2011, thanks to health reform.

Because of the law, drug companies are required to give seniors discounts once they reach the so-called doughnut hole, at which point they have to pay up to $4,550 out-of-pocket after their prescription costs pass $2,840 in a given year.

This is an excellent example of why health reform likely will not be repealed even with a Republican president and majority in Congress. The pharmaceutical industry agreed to these discounts to help pay for reform because Medicaid expansion and the health insurance exchanges would expand the market. Seniors are now enjoying them. Repealing reform would (1) spit in the eye of one of most powerful lobbies in Washington, and (2) deeply disappoint the most powerful voting bloc.

Ain’t. Gonna. Happen.

We’re all going down together

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U.S. single-payer system proponents like to point to other industrial nations, especially in Europe, who have lower health-care costs. This is true, but it has become clear costs are rising as swiftly elsewhere. This suggests rising health costs are caused by something other than “the system.”

Standard & Poor’s (S&P) recently warned it might downgrade “a number of highly rated” industrialized nations because they have failed to curb health-care spending.

S&P blames the aging populations in the U.S. and elsewhere for endangering public finances during the first half of the 21st century. Absent reforms (and the Affordable Care Act is unlikely to count), S&P plans credit downgrades in the next three years.

S&P cited an International Monetary Fund study as an afterthought – although it should have been the headline – that technology accounts for up to two-thirds of projected health-care increases.

Bottom line: Nearly every nation is grappling with the same thing. However, it is especially pronounced in rich nations who can afford high-tech health gadgets.

Meet U.S. health care, circa 2020

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The high-deductible health plan (HDHP) will be commonplace in 2020 because many will not be able to afford anything else.

People with HDHPs almost invariably use less health care. They usually use self-diagnosis, followed by self-rationing. They generally cut back equally on unnecessary and necessary care. Patients tend to give less weight to the future state of their health than to present costs.

RAND Corp. conducted groundbreaking research in the 1970s that illustrates what happens with high consumer cost-sharing. The so-called Health Insurance Experiment randomly assigned 5,800 working-age adults to different levels of cost sharing, ranging from free to 95 percent. The results showed:

  • As the percentage paid by the patient rose, physician visits decreased.
  • The total amount of treatment received was unaffected once they began medical care, meaning consumers tended to lose control of costs.
  • Health outcomes were unaffected regardless of cost-sharing and medical usage.

Another, more recent RAND study showed that HDHP enrollees cut back on care regardless of their income or health.

A recent study found that families with HDHPs between $1,000 and $6,000 were 3-4 times more likely to delay or skip health care than those on traditional plans.

As Health Care in 2020 points out continuously, this will be our nation’s health-care landscape in a few short years, regardless of what happens to the health-reform law.

Caregivers: The backbone of long-term care

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Caregivers are often called the backbone of U.S. long-term care (LTC). More than 42 million are providing care for disabled Americans at any given time, and more than 61 million did so within a year’s year. who care for disabled spouses, relatives and friends provide nearly 80 percent of community-based LTC.  The estimated annual value of this unpaid, mostly female workforce: $450 billion in 2009, up from $375 billion in 2007.

The value of that care is almost as much as the 2009 gross domestic product of Belgium, the world’s 20th largest economy.

The typical caregiver is a 49-year-old woman who works and provides about 20 hours a week of unpaid care to a parent. Care-giving duties include emotional support, meal preparation, assistance with dressing and bathing, supervising and administering medication and therapy, and coordinating care with providers.

 Nearly one half of the U.S. workforce has provided some form of elder care in the past five years, and nearly 1 out of 5 are doing so currently.  About half also expects to be a caregiver within the next five years.

Until the mid-1990s, unpaid care-giving was supplemented by paid help. Since then, the trend has been toward caregivers going it alone.

The rise of widespread care-giving is a direct result of longer life expectancies. In 1900, life expectancy was 47 and many died of communicable diseases. The current life expectancy is 78, and is expected to rise to 80 years old in 2020. Most contemporary deaths are from lingering chronic conditions that often disable patients.

The percent of adult children caregivers has tripled since 1994. Of those, about 10 million were 50 or older in 2008. More than 1 out of 4 report either a moderate or significant financial hardship because of caregiving. According to an online survey, more than 4 out of 10 spend more than $5,000 annually on caregiving expenses. A separate survey found that caregivers of those over 50 years old spend more than 10 percent of their annual income on caregiving, or an average of $5,531. An analysis of lifetime income-related losses for caregivers of those over 50 exceed $300,000, including wages, benefits and pension income.

Caregivers pay an even higher price with their health. More than 2 out of 3 family caregivers say caring for a loved one was their No. 1 source of stress, outranking economic difficulties and other family problems. Family caregivers are at greater risk of their own chronic conditions, including heart disease, high blood pressure, depression and fatigue.

The supply of family caregivers is shrinking as life expectancy grows and baby boomers become elderly. Nearly 20 percent of older women do not have children. Moreover, nearly half of women are in the labor force, compared with 33 percent in 1960.