Supermarket nutrition labeling

The Institute of Medicine has recommended nutrition labeling on the front of food packages that would highlight four key ingredients: calories, saturated fat, trans fat and sodium. The FDA is also planning to establish a single format for front-of-package labels. Labels currently are on the side or back panels of most food packages.

Beginning January , the federal government required nutrition labels that reveal the calories and fat content of 40 popular meat and poultry items. This should cut through the marketing hype of “80 percent lean,” which means 20 percent is not.

Grocery stores are beginning to assist shoppers in selecting healthier food. Grocery chain Hannaford Bros., located in New York and New England, began its Guiding Stars program in 2006. Each food item in the store was assigned zero to three stars based on fats, sodium, added sugars, vitamins, minerals, fiber and whole grains. Excluding produce, only about 15 percent of Hannaford’s food items qualified for at least one star. During its first two years, shoppers bought 2.9 million more starred items each month.

Exercise won’t make you thin

An enduring myth ties exercise to weight loss. What is often ignored is that physical activity generally stimulates appetite. People who exercise strenuously are also less active afterward than they would have been otherwise. Therefore, the tendency is to eat more and move less after exercising.

According to a 2000 study, willpower is a muscle. It paradoxically weakens with use. So the self-discipline that propels people onto a treadmill can be extinguished with the effort, making that post-workout beer much more inviting.

Another dubious claim is that greater muscle mass burns more calories at rest. A pound of muscle burns about six calories a day, compared with two calories for a pound of fat. Packing on 10 pounds of muscle, which is extremely difficult, would burn an extra 40 calories a day. That is the equivalent of six baby carrots.

What exercise can do is play a supporting role in weight control. The National Weight Control Registry chronicles the lives of those who have shed pounds and kept them off. About 90 percent of the people on the registry exercise in addition to eating less food.

Obesity is highly genetic. British researchers examined 20,000 people to determine the effects of 12 genes associated with a higher risk of obesity.  They determined that an hour of daily exercise cut the genetic obesity risk by 40 percent.

Counting on medical homes

Health-care experts are placing a lot of faith in what is called the patient-centered medical home (PCMH). The term is off-putting to some because it sounds like “nursing home.” However, it is simply a physician’s office organized in a different way.

The PCMH recognizes that health care is rarely one doctor treating one patient. It requires a team of health-care providers, educating family members and using community resources. Physicians are more like team leaders, coordinating care with staff members as well as specialists and hospitals. The doctors are rewarded more for keeping their patients healthy and out of the hospital rather than for short face-to-face visits with lots of tests and procedures. Medical homes are usually paid a monthly fee for patients under their care.

The “patient-centered” aspect assumes patients will participate in their own care. They will ask for and receive the care they want and need, and act on the medical advice they are given. The medical home has a number of features that are missing in most doctors’ offices: electronic medical records, email communication, remote monitoring of chronic conditions and frequent reminders about preventive care.

There are many strengths to this kind of approach. Physicians have fewer incentives to provide unnecessary care. Participants recognize that most patient transactions can be handled by email or telephone. A Mayo Clinic pilot study found that “e-visits,” or care provided over the Internet, made office visits unnecessary in 40 percent of the cases.

A 2010 Health Affairs article described the future physician’s office, using medical-home principles. The office might treat 100 patients a day. The doctor might be involved with 30 to 40, of whom perhaps 10 would have traditional face-to-face individual appointments. The other patients interacting with the doctor would do so by telephone, email or group appointments. The remaining 60 to 70 patients would be treated by nurse practitioners, physician assistants or medical assistants, who would handle less complex cases and counsel people with chronic conditions on disease self-management. These team members would spend more time – and likely be more effective – than a physician could in a 15-minute time slot.

The doctor’s office currently is set up to deal with brief illnesses or disease that can be cured mostly by time and medication. It is ill-suited to treat chronic disease, which accounts for about 75 percent of health-care spending. Effective chronic-disease management requires close monitoring and tweaking of treatment to avoid complications that require hospitalization or emergency department (ED) visits, such as heart attacks, stroke or respiratory failure. Medical homes typically have after-hours arrangements for their patients to be able to see a physician or nurse without going to the ED. Less than one-third of doctors’ offices have such an arrangement now.

An estimated 40,000 primary-care physicians work in practices set up as PCMHs. That is about 1 out of 8 physicians and pediatricians. Blue Cross Blue Shield of Michigan said it saved $65-$70 million in 2011 working with PCMHs. It paid an extra $7,500 per physician for the year. However, it saved money because better care yielded fewer hospital and emergency-department visits. The doctors also ordered more generic prescriptions because electronic prescribing allowed them to see lists of covered medicines.

Seattle-based Group Health (GH) is an integrated-care organization with its own health plan. It serves 600,000 members and employs about 1,000 physicians in Washington state and Idaho. Using medical-home care principles, GH has been able to improve quality and lower costs. It resulted in 29 percent fewer ED visits and 6 percent fewer hospitalizations, compared with its patient outcomes prior to becoming a medical home.  In a survey at its clinic in Bellevue, patients expressed higher satisfaction with their care. More patients received recommended health screening tests, chronic-disease management and medication monitoring, compared with its prior traditional approach.

Paying doctors to keep people healthy seems so logical. However, it will not be widespread until health plans recognize this as customary care. In an Internet survey of 1,000 physicians, two-thirds said they believed the current health-care environment is detrimental to care. Less than 1 in 5 said they could make clinical decisions based on what is best for the patient rather than what health plans would reimburse.

While many physicians agree with medical-home principles, they already are stretched thin and are suspicious of what may be unrealistic expectations and extra effort. All of this is fine, they say, if they are properly paid. The government and health plans do not have a good track record in this regard. Many health-delivery innovations have been oversold, only to be swept away after impatient payers fail to see promised savings in short order. Health care has long been regarded as an expense rather than an investment. Unless that perspective changes, the medical home may never gain traction.

The health-care system envisioned by reformers calls for prompt patient access to care despite the next wave of additional demand from health reform and an aging population. They also want to create more  attractive careers for primary-care physicians. That would mean a lightened workload and more income. The math simply does not work.

Two major barriers are money and workflow.

Seattle’s GH invested $1.3 million at its Bellevue clinic to create its medical home. It had a 50 percent return on investment because its patients were also part of its insurance plan. Because GH treats and also insures its patients, it has an incentive to treat patient in ways that minimize hospitalizations and expensive procedures. Few clinics will be able to have that kind of payback. In most cases, the physicians will make the investment while the health plans and patients will reap the savings.

Typical physicians’ offices are built around the doctors’ hectic routines. They see patients at a frenetic pace and have little interaction with staff members. Medical homes, by contrast, require doctors to be managers of care teams, something they have not been trained to do and many are uncomfortable with. The current standard is doctor-centered, not patient-centered, care.

Medical homes will be created by highly motivated, well-funded physician groups willing to overcome the barriers to install an unproven business model. Medical homes appear likely to be islands of excellence rather than the standard of care.

The four leading causes of premature death

The four leading causes of premature death: smoking, high blood pressure, elevated blood glucose and being overweight or obese, according to a Harvard School of Public Health study. Those factors reduced life expectancy about five years for men and four years for women.

The researchers created eight demographic groups they called “Eight Americas.” The Eight Americas were defined by race, county, region and socioeconomic features to demonstrate the impact of health disparities. The Eight Americas were Asian-Americans; Northland low-income rural whites; middle American whites; low-income whites in Appalachia and the Mississippi Valley; Western Native Americans; middle American blacks; high-risk blacks and Southern low-income rural blacks.

For example, Southern rural black men lost almost seven years of life because of the risk factors, compared with less than four years for Asian-American women. Blacks, especially those in the rural South, had the highest blood pressure. Native Americans and Southern black women were the most obese. Native Americans and low-income whites smoked the most.

Health disparities exist on every health measure in the U.S. However, they are particularly pronounced in life expectancy. For example, a black man living in Washington, D.C., on average will die 17 years sooner than a white man in adjacent Montgomery County, Md.

Ralph Keeney, a Duke University professor, bluntly declares that nearly half the people who die before age 65 have only themselves to blame.  The list of poor decisions is a familiar one: smoking; binge drinking; overeating; not exercising; unprotected sex; not wearing a seat belt; using drugs; suicide and homicide. By comparison, only 5 percent of deaths in 1900 and 25 percent in 1950 were self-inflicted.

Nearly one-quarter of American women and one-third of American men die before age 75 of causes that potentially could have been prevented by timely and effective health care. They either chose not to seek care or could not afford it. The U.S. ranked 15th out of 19 industrialized nations on regular use of health-care facilities. If the U.S. had performed as well as the top three nations – France, Japan and Australia – it would have averted more than 100,000 deaths a year.

In 1975, Americans who reached 50 years old could expect to live slightly longer than Europeans did. By 2005, the U.S. had fallen significantly behind Europe in life expectancy, primarily because of chronic disease among the near-elderly. Americans are twice as likely to have high blood pressure, be obese or have diabetes. Economists calculated that the U.S. could save up to $1.1 trillion by 2050 if its health status were comparable to that of its peers.

A Health Affairs study measured survival rates in 12 other industrialized nations and compared them with national health-care costs. In 1975, the U.S. was close to the average per-capita cost and ranked last. By 2005, health-care costs had tripled and were twice as much per capita than any other nation – and the U.S. still ranked last. This was despite the fact that smoking decreased more rapidly and obesity grew more slowly than in other nations.

The pros and cons of health screenings

Many consider routine screening almost a duty, not unlike voting. But there are disadvantages as well as advantages.

Screening can detect medical conditions before symptoms present themselves. The best-case scenario is that treatment is more effective in a disease’s early stages and perhaps lives are saved.

But there are several downsides:

  • Screening people with low disease risk is expensive and needlessly clogs the medical system.
  • Screening can produce anxiety, discomfort, and exposure to radiation and chemicals.
  • A false positive can be stressful and lead to additional expensive tests and possibly unnecessary treatment.
  • A false negative, on the other hand, creates a misleading sense of security that could delay a definitive diagnosis.

False-positive screening results can be unsettlingly high. One in 5 falsely tested positive for syphilis, according to a recent CDC study of five U.S. laboratories. This no doubt led to unnecessary treatment and untold anguish.

In a national survey, nearly 9 out of 10 adults said they believed that cancer screening is almost always a good thing, and 3 out of 4 said it saves lives. But more than one out of 3 had received a false-positive screening test, and more than 40 percent of those called it “very scary” or the “scariest time of my life.” Remarkably, 3 out of 4 said they would choose to get a full-body CT screening instead of $1,000 in cash – despite no scientific evidence of the screening’s benefit or safety.

Many credit widespread cancer screening for an increase in the five-year survival rate of cancer patients. But a comprehensive review of the 20 most common tumors from 1950 to 1995 showed that screening simply identified the cancer earlier and patients were aware of it longer. There was little effect on the death rate.

The sad truth is that the deadliest cancer sprouts and kills so quickly that routine screening rarely catches it. Cancer screening finds lots of what Dr. Gilbert Welch of Dartmouth Medical School calls pseudo-disease. That is an abnormality that meets the criteria of being cancerous but will never grow to become harmful. High-resolution MRIs and CT scans are especially good at discovering these. However, the doctor and patient often feel compelled to do something. This often leads to unnecessary treatment that can create harmful side effects.

Dr. Laura Esserman is director of the breast cancer center at the University of California, San Francisco. She was co-author of an essay in the Journal of the American Medical Association reflecting on her experience. She wrote: “After (25 years) of screening for breast and prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has had some effect, but it comes at a significant cost, including overdiagnosis, overtreatment, and complications of therapy.”

Oddly, people with advanced cancer continue to be screened long after there is any useful purpose. Up to 1 in 5 Medicare patients with poor-prognosis cancer were screened for cholesterol, prostate cancer and breast cancer. Researchers speculated that screening is such an ingrained habit that the terminal patients believed they should continue to do what they have always done regardless of their circumstances. Why health-care providers indulged them is another issue.

The number needed to treat (NNT) is a useful health statistic that measures the effectiveness of a preventive service to avoid one additional bad outcome, such as death or a heart attack. The idea is that one person would benefit by a screening or medication while everyone else would incur the expense, anxiety and potential harm of the intervention.

Welch calculated NNT for mammography to save the life of a 50-year-old woman. Five women out of 1,000 would die of breast cancer without mammography. To lower that rate to four women, 1,000 women would be screened annually for 10 years. What happens to the other 999 screened women?

  • 2 to 10 women will be overdiagnosed and treated needlessly.
  • 10 to 15 will learn they have breast cancer earlier than they would have otherwise, but their prognosis will not change.
  • 100 to 500 women will have at least one “false alarm,” and about half of these will have a biopsy.

In another example, 53,000 men ages 55 to 74 with a history of heavy smoking received CT scans to detect early lung cancer. News reports hailed the results, saying the risk of lung cancer was reduced by 20 percent. But according to the NNT in this study, 300 would need to be screened to extend the life of one person. What about the other 299? One out of 4 had a false positive, resulting in a cascade of more tests, radiation, anxiety and biopsies. The cost of each CT scan is about $300.

An earlier study showed a false-positive rate of 33 percent for those who had two lung CT scans. Among those, 7 percent had either a biopsy or surgery, or both.

The loneliness of individual health insurance

People who buy health insurance for themselves are in an awful place. If you can get a policy at all, the deductibles are high and the benefits skimpy. A 2008 survey found that 1 in 4 adults declined another job opportunity, stayed at a job that they would otherwise have quit or decided not to retire in order to retain their employer-sponsored health insurance.

The average out-of-pocket maximums for insurance purchased individually currently average more than $5,200. One out of 8 have no coverage for physician office visits and less than half have maternity benefits in their basic plans.

Viewed from another angle, the average employment-based health plan paid for 80 percent of all health charges in 2007, compared with 64 percent for individual plans.

These are often stopgap policies. About 11 million Americans bought individual policies in 2006, but only 7 million had them for a full year. People used them to plug coverage gaps between jobs or en route to government-insurance eligibility.

Buying individual insurance can be a harsh experience. Nearly one-half of U.S. adults under age 65 have chronic conditions that can result in policies that are more expensive — or outright rejection. One in 7 who applies for individual insurance is denied coverage because of pre-existing conditions. When consumers with pre-existing conditions find insurers who provide coverage, they are more willing to accept high prices and more reluctant to shop around. This is a clear case of market failure.

The reasons for being uninsured are voluminous . Suffice it to say that more than 20,000 uninsured people die prematurely every year because they lack timely access to care. That is a direct result of the fact that 1 out of 3 uninsured adults have chronic conditions that, if left untreated, have devastating consequences.

Health reform is expected to reduce the percentage of uninsured Americans from about 19 percent to less than 9 percent. The law is expected to insure an additional 32 million, split equally between Medicaid expansion and those buying subsidized coverage from the exchange.

The largest groups remaining uninsured will be young adults eligible for Medicaid who choose not to enroll, undocumented immigrants and adults who will be exempt from the individual mandate because they lack an affordable insurance option.

On the edge of the patent cliff

Worldwide sales of brand-name prescription drugs could be cut in half by 2015 as lucrative brands lose patent protection. Generics generally capture 80 percent of a brand-name’s volume within six months.

Patients are driving the trend toward generics. About 1 in 4 physicians say the patients ask for them or prefer them. And 1 in 5 physicians say they always prescribe generics if they are available.

Surprisingly, just over half of physicians believe generics are clinically equivalent to the brand names they replace. That speaks loudly to the ability of pharmaceutical companies to persuade doctors that equivalent chemical compounds are somehow not equivalent. The FDA requires generic drugs to have the same amount of the same active ingredients of the brand names they replace and to be of equivalent quality.

Some patients are just as skeptical. A Consumer Reports poll found that 22 percent believed generics were not as effective. An equal number said generics had different side effects, despite FDA assurance on its website that generics have the same risks and benefits. In addition, 16 percent said generics were not as safe as brand-name drugs.

Generic drugs saved the health-care system more than $824 billion between 2000 and 2009. The 2009 savings per day was $383 million. In fact, a poll of drug-consuming households found that nearly half of the respondents considered branded prescription drugs “luxury purchases.”

Two-thirds of consumers do not know how much their medications will cost until they show up at the pharmacy counter. People take extraordinary measures to be able to afford their medication. About 1 in 4 use potentially dangerous practices to save money, such as failing to fill a prescription, skipping doses, using expired medicine, splitting pills or sharing medicine. About the same number reduce their spending on clothing, cut back on groceries or use credit cards more often. About 15 percent postpone paying bills.

When less health care is more

Many patients believe more health care is better health care. However, in most cases, it is simply more. Less-expensive interventions are often more effective. For example:

  • One study found that a greater percentage of strokes have been prevented in the last decade by making sure patients took aspirin than by developing more potent anti-platelet medication.
  • Older men diagnosed with low-risk prostate cancer can choose active surveillance rather than invasive treatment without losing quality of life.
  • Recovery from small heart attacks was as successful on drug therapy as with invasive vessel-clearing procedures.
  • Similarly, 22 percent of elderly Americans had coronary bypass surgery or balloon angioplasty in 1990, compared with 2 percent of Canadians. However, the 30-day death rate after a heart attack was the same for each nation.

There are other examples of expensive care that does not do much good:

  • One out of 5 heart defibrillators are implanted without solid evidence that the devices will be helpful. They are implanted to shock an irregularly beating heart back into a normal rhythm. They work well in patients with advanced heart failure, but they have been ineffective in other patients. The procedure costs $35,000 and may cause unnecessary harm.
  • Americans spent nearly $86 billion in 2005 on imaging, physician visits and medication for back and neck pain – most of which did not improve the patients’ conditions.
  • Medical imaging – which includes CT, PET and MRI scans – has become a $100 billion business. However, studies show 20 to 50 percent of the procedures should not have been done because they neither helped diagnose patients nor helped determine their treatment.

The apparent heart-defibrillator overuse is an example of what is often called “technology creep.” After a device is approved for use in a high-risk population, its use expands to a larger, lower-risk population, for whom risks outweigh the benefits. This, in a nutshell, is a major contributor to runaway medical costs and clinical waste. It is not the technology itself. It is technology utilized beyond its original intent – often to recoup its original cost and to bolster profits.

Imaging costs have grown at twice the rate of other health-care technologies, including laboratory procedures and pharmaceuticals. A contributing factor is the financial incentives of self-referral. Federal regulations prohibit physicians from referring Medicare or Medicaid patients to services in which they have a financial interest. However, an exception is allowed if physicians have equipment in their offices – presumably for patient convenience.

Patients of doctors who own or lease MRI equipment are more likely to be scanned for lower back pain. A 2011 study showed an increase of nearly one-third for primary-care physicians and 13 percent for orthopedists. Orthopedic patients who were scanned were 34 percent more likely to have back surgery – meaning the scans induced more surgery. The study’s authors point out there is no definitive evidence that either MRIs or surgery improve outcomes for lower back pain.

How fat happens

Conventional wisdom is that weight gain is a mathematical phenomenon. It requires 3,500 excess calories to produce a pound of fat. One’s metabolism supposedly is dictated by weight and activity. For example, an active 150-pound man should consume 2,250 calories. If he consumes an average of 1,750 calories a day for a week, he would lose one pound. If he eats a daily average of 2,750 calories for a week, he would gain a pound.

If only it were that easy. Weight gain and loss is highly individual and is the result of a complex set of factors.

One theory is that everyone has a genetically determined weight set point that can fall within a range of 20 to 30 pounds, depending upon nutritional and exercise habits. If a person attempts to go below that range, the body rebels by slowing its rate of metabolism and signaling its hunger.  The familiar lament of the yo-yo dieter – “I gained all my weight back, and then some!” – is a result of the metabolic change.

Some experts speculate the obesity rate is going to increase more slowly because the nation is reaching a sort of obesity saturation point. That implies that nearly everyone who is genetically meant to be obese is now there.

If one parent is obese, the child has a 50 percent likelihood of also being obese. With two obese parents, the risk rises to 80 percent. Obese children almost inevitably become obese adults. The link is likely to be cultural as well as genetic, because family members have similar eating and physical activity habits.

Genes clearly dictate who is the most vulnerable to excessive weight gain, but other factors determine whether weight gain actually happens. For example, the Pima Indians were originally from Mexico, where they were poor farmers without weight problems and the resulting chronic conditions. Those who moved to the United States adopted a different lifestyle. One-half of the Pima Indians in the U.S. now have diabetes and 95 percent of those are overweight.

Despite obesity’s complex causes, researchers continue to attempt to pin the epidemic on one cause.

An Australian researcher declared in 2009 that obesity has doubled in the past 30 years exclusively because of increased calorie consumption. Physical activity had a minor role, he declared, because physical activity levels had not changed much during that time. Children are consuming 350 more calories a day than children of three decades ago, and adults are taking in 500 more.

A Canadian researcher, however, blamed office-based jobs. According to his research, people are eating better and exercising more than they did three decades ago, so sedentary work must be the culprit.

In 1960, about 50 percent of the U.S. jobs required moderate physical activity. That has fallen to 20 percent. That translates to about 120-140 fewer calories expended daily per capita. That lack of activity closely tracks the nation’s weight gain over the past five decades.

The relentless spread of workplace wellness

A Kaiser Family Foundation survey reflects the rapid increase in wellness programs. Nearly 3 out of 4 businesses offered at least one of the following programs in 2010: fitness newsletter or website information, weight-loss program, personal-health coaching, or classes in nutrition or healthy living. That compares with 58 percent of businesses in 2009.

An Integrated Benefits Institute survey of 500 companies listed 26 health and productivity initiatives that included management of health, disease and disability. Nearly every company provided at least one. The average small company had adopted about 10 of the 26 practices, compared with an average of about 18 for businesses with more than 5,000 employees.

The tip of the spear for most wellness programs is the health-risk assessment. According to a review of three dozen wellness studies, 81 percent of companies offered them. These questionnaires ask employees about their health status and risk factors. Employers use the information to persuade employees to participate in activities that address warning signals. They also hope the information will motivate the employee to act without being prodded.

There is little evidence that HRAs alone change behavior. They rely on self-reported information, and those who volunteer to participate tend to be the healthiest employees. They are more likely to be women, have high-deductible insurance plans and have fewer chronic conditions.

Participation in wellness programs is increasing. About 57 percent of employees were involved in 2009, compared with 46 percent in 2008. Those who did so tended to be successful on a number of fronts. More than 8 out of 10 lost weight, exercised more, improved eating habits, managed stress better, and reduced cholesterol and blood pressure.

Despite the recession, several large businesses have established on-site clinics as a way to control health-care costs. Clinics were common at large manufacturing and industrial companies until the 1980s to handle work-related injuries. As these jobs migrated overseas, the clinics began to fade from the industrial landscape. They are being reborn as patient-centered medical homes for many employees. They offer convenient, inexpensive care tailored to the company’s workforce. They coordinate care with specialists and avoid expensive procedures and tests of marginal value. They lower absenteeism and help retain employees.

Many companies that have taken the plunge have seen a positive return on investment. Pitney Bowes, for example, reports that for every $1 spent on clinics, it saves $1 in health-care costs and gains an additional $1 in worker productivity.

The clinics provide traditional occupational-health and typical doctor-visit care, as well as preventive care, wellness services and management of chronic diseases. These clinics help businesses control prescription costs and specialist referrals, and they proactively treat patients to avoid emergency department visits, hospitalizations and more expensive care later on for untreated complicated conditions.