Studies: Tobacco still stinks

Research on tobacco’s effect on health continues to be popular, even though the results rarely surprise.

The surgeon general’s office issued its 30th report on tobacco in December 2010. The 704-page document describes in detail how tobacco damages every organ in the body, resulting in disease and death. It noted that tobacco smoke contains more than 7,000 chemicals, of which hundreds are toxic and at least 70 cause cancer.

Cigarettes alter a smoker’s DNA within 30minutes of the first puff. The immediate genetic damage raises the short-term risk for cancer. Smokers’ arteries stiffen with age twice as fast as those of nonsmokers. Stiff arteries are more prone to blockages that promote stroke, heart attacks and other cardiovascular disease.

A 55-year-old smoker has the same chance of dying in the next 10 years as a 65-year-old nonsmoker. The number of cigarettes smoked dictates how swiftly health-related quality of life deteriorates, even in those who eventually quit the habit.

Pipes and cigars have an impact on health similar to that of cigarettes, especially on lung function. While cigarette smoking has decreased in the past four decades, pipe and cigar smoking have increased in popularity.

In health care, cost does not equal quality

Cost and quality are not the same in health care. Many health-care providers charge high prices because they can. However, there are physicians and organizations that deliver high-quality care at 20 percent below the average price. If everyone could do the same, the percentage of GDP devoted to health care would decline from 17 to 13 percent – an annual savings of about $640 billion.

Most Americans have two perspectives on health-care quality and costs: the nation’s and their own. About 80 percent say they are dissatisfied with the cost of health-care nationally, and more than half are dissatisfied with overall quality. However, nearly 9 out of 10 are satisfied with their own insurance coverage and the quality of care they receive. More than half are satisfied with their own health-care costs.

Those who are dissatisfied with national costs point to several culprits. About half blame what they believe are excessive profits for drug and insurance companies. About a third blames fraud and waste, physician and hospital profits and medical-malpractice lawsuits for rising costs. About 30 percent say unnecessary treatments and Americans’ unhealthy lifestyles are boosting costs. Only 28 percent agree with health-policy experts who say expensive technology is the main culprit. One in 8 says higher costs are yielding better care.

The U.S ranks poorly in international comparisons of health systems.  A 2000 World Health Organization report ranked the U.S. 37th in the world. The report measured the extent to which investments in public health and medical care improved health, reduced disparities and protected citizens from medical impoverishment.

The Commonwealth Fund ranked seven industrialized nations in 2010 on quality, efficiency, access to care, equity and the ability to live long, healthy and productive lives. The U.S. was last.

In these rankings, the glaring conclusion is that the U.S. does not create value in proportion to what it spends. While there are certainly inefficiencies in other U.S. economic sectors – such as education, transportation and energy – health care stands as an egregious outlier. However, health-care providers are paid for quantity, not quality, of care. We get what we pay for.

Mirror, mirror …

Two-thirds of Americans are overweight or obese, so the qualitative lines blur on what is considered normal weight.

An August 2010 Harris Interactive/HealthyDay poll found that 30 percent of overweight people believed they were normal size. Moreover, 70 percent of obese people felt they were merely overweight, including 39 percent who were morbidly obese. Interviewers asked respondents for their height and weight to calculate an accurate body mass index (BMI). Interviewers then asked them to describe whether they were obese, overweight or normal size.

“While there are some people who have body images in line with their actual BMI, for many people they are not, and this may be where part of the problem lies,” said Regina Corso, vice president of Harris Poll Solutions. “If they don’t recognize the problem or don’t recognize the severity of the problem, they are less likely to do something about it.”

More said excess weight is an exercise problem, rather than a food problem. Even though exercise has little impact on weight loss, 6 of 10 respondents believed their excess weight is a result of lack of exercise. About half that many – including only 27 percent of the morbidly obese – said they ate more than they should “in general.”

The ROI of workplace wellness

One of the most comprehensive studies found that medical costs fall $3.27 for every $1 spent and absenteeism costs fall $2.73 for every $1 spent.  A Harvard Business Review study also concluded thatproperly run wellness programs could save up to $6 for every $1 spent.

Wellness programs are relatively inexpensive to fund. The average business spends about 2 percent of its total health-care claim dollars on them. Yet most program administrators have no clue how well they are performing. Two out of 3 have no measurable program goals, and 60 percent do not know their return on investment.

Some of the bigger payoffs are less obvious. Two types of ROI are typically calculated. “Hard ROI” consists only of direct medical costs. “Soft ROI” also includes productivity gains. The indirect costs of poor health can be double or triple those of direct medical costs. They include productivity losses from absenteeism or attempting to work with a brief illness or chronic condition, also known as presenteeism. The payback rises to as much as $15 for every $1 invested when indirect costs are included.

It typically takes a few years to have adequate information to determine the return on investment. Start-up costs can be substantial, and improving employee health behavior takes time. The long payback period is enough to deter some organizations, especially small businesses with limited resources. Such programs also make less sense in industries with high employee turnover and younger employees, such as hospitality, restaurant and retail.

Businesses prefer to measure the impact of their programs by overall health-cost increases. The most consistent performers have kept cost increases to about 2 percent over the last four years, compared with nearly 7 percent for all companies.

With alcohol, cost rules

The biggest alcohol deterrent? Price

A bar in a college town during “happy hour” is a perfect laboratory to gauge the effect of price on alcohol consumption. Cash-strapped young adults jam these establishments where binge drinking is acceptable, even encouraged.

University of Florida researchers analyzed more than 100 studies spanning four decades on price elasticity of alcohol. The results were consistent: When prices go down, people drink more. When they go up, people drink less.

In fact, price decreases alcohol consumption more effectively than law enforcement, media campaigns and school health classes. And price is most efficiently manipulated by taxes.

Doubling alcohol taxes would reduce alcohol-related deaths by more than one-third, traffic accidents by 11 percent and sexually transmitted disease by 6 percent, according to one study. For example, a fifth of gin in New York State had a tax of $.55 in 2010. It also estimated that a 10 percent increase in retail price would reduce drinking by 5 percent.

But alcohol prices are going in the other direction. Federal and state alcohol taxes have declined significantly since the 1950s when adjusted for inflation, as has the overall price of alcohol. That is likely a result of high profit margins on alcohol and the industry’s powerful lobbying presence in state capitals and Washington.

Doctors aren’t paid to talk

When it comes to counseling patients on health behavior, the doctor lacks faith – and compensation

Counseling of patients by physicians could have an impact on health behaviors, but it rarely happens. Physicians are paid by insurance companies and government health programs to perform tests and procedures, not to talk to patients. The average 15-minute doctor-patient encounter does not leave much time for lectures. Doctors also do not think they are very good at it. According to a survey of 620 physicians, less than half felt competent prescribing weight-loss programs because they believed they had been inadequately trained.

This lack of reimbursement and confidence yields predictable results. Doctors advise only about one-third of their obese patients to lose weight. That proportion rises to about one-half only if the obesity has created some other medical conditions. Physicians offer to help about 1 out of 4 smokers quit.

Doctors also do not have faith that patients will change their habits. Who could blame them? Barely 1 in 10 diabetics follow dietary guidelines limiting saturated fat. About 18 percent of heart-disease patients continue to smoke, which is not much better than the smoking rate for everyone.

A doctor’s pep talk at the end of the visit does not do much. Success requires a joint action plan and a commitment to follow up. In one study, physicians counseled inactive patients to exercise and had a staff member call later to monitor progress. Those patients walked five times more than those who had standard care.

The American Heart Association advises physicians to use this sort of approach to lower the risk of heart disease. The organization reviewed a decade of research to determine what works best. Joint goal-setting, physician feedback and monitoring topped the list. Self-monitoring, such as food diaries, also helps. However, clinical initiatives are employed infrequently because they are time-consuming and insurance companies will not pay for them.

The patient-doctor disconnect

A 2009 poll of 2,000 Americans by GE Healthcare, the Cleveland Clinic and Ochsner Health System in New Orleans is an elegant example of optimism bias at work. More than half the respondents said other people’s health “was going in the wrong direction,” compared with 17 percent who characterized their own health that way.

Only one-quarter to one-third knew their personal basic health numbers – body-mass index, blood pressure, cholesterol, blood-glucose level – yet the majority said keeping those numbers in a good range was important to health.

About 95 percent said regular physician checkups were important, but 70 percent admitted avoiding their doctors by hoping health problems would go away or asking a friend for medical advice.

Pollsters asked respondents to grade their health behaviors, and asked doctors to do the same. One out of 3 gave themselves an “A” for nutrition, exercise and personal health management. More than 90 percent of the doctors, however, graded patients “C” or worse on these.

Let someone else foot the bill

Another survey reflected Americans’ strong sense of personal control over their health, but also their reluctance to accept financial responsibility for it.

The Vitality Group surveyed more than 1,000 U.S. adults in 2008. About 82 percent said they alone were responsible for their health. However, 44 percent said they should bear no responsibility for paying for their health care, while 56 percent thought they should pick up part of the cost. Six out of 10 thought their employer should be partially responsible, and about one-half believed the government should pick up the tab.


Chronic disease in 2020

Chronic disease is the major battleground in 21st-century health care. Baby boomers will add 15 million to the 65-or-older population between 2010 and 2020. The biggest predictor of chronic disease is age. About 81 million people are expected to have multiple chronic conditions by 2020, compared with 51 million in 2000.

Here is what is expected for three of the most expensive conditions by 2020.

Cancer: The National Cancer Institute (NCI) expects spending on cancer treatment to rise 27 percent, to $158 billion, in 2020. NCI officials expect increases in the numbers of prostate- and breast-cancer patients. If new treatments and diagnostic tools add 2 percent to the annual cost, the 2020 price tag will be $173 billion, or a 39 percent increase. If they add 5 percent to the annual cost, the 2020 spending would be $207 billion, or a 66 percent increase.

Heart disease: The cost of treating cardiovascular disease is expected to rise by 75 percent, to $470.3 billion, in 2020. The cost estimate also assumes no major changes in treatment. About 37 percent of U.S. adults have some form of heart disease. Treatment costs are expected to triple between 2010 and 2030.

Diabetes: More than 50 percent of Americans may have diabetes or prediabetes by 2020, according to UnitedHealth Group’s Center for Health Reform & Modernization. Treatment is expected to account for 10 percent of health-care spending and cost about $500 billion annually. Pre-diabetes refers to elevated blood-glucose levels that are not high enough for a diabetes diagnosis.

Book review: The Blood Sugar Solution

Diabetes may well be the fastest-growing non-communicable epidemic in world history.

From 1983 to 2008, diabetes increased seven-fold from 35 to 240 million worldwide. From 2008 to 2011 alone, 110 more people became diabetics.

Dr. Mark Hyman does a good job of explaining how this is happening in The Blood Sugar Solution: The UltraHealthy Program for Losing Weight, Preventing Disease and Feeling Great Now (Little Brown, $27.99).

He describes “diabesity” as a continuum of health problems from overweight and mild insulin resistance to obesity and diabetes. It is almost entirely caused by environmental and lifestyle factors and, therefore, preventable. About 1 out of 4 cases of diabetes remains undiagnosed, as well as nearly all of those with prediabetes.

Hyman points to the usual dietary suspects that contribute to the problem: excess sugar consumption, processed food and sodium. However, he expands the culprits to include environmental factors such as pollution, pesticides, hormones and antibiotics in food.

The book includes a six-week “action plan” to lower blood sugar and the requisite recipes section. Buyers beware: While the book contains valuable information, it is also a Trojan horse for a website that sells his expensive “recommended” supplements.

Health care squeezes family budgets

As state and federal lawmakers grapple with skyrocketing health-care costs, households across America are doing the same.

Expecting health reform to provide relief is wishful thinking.

In less than a decade, the annual health-care costs for a typical family have more than doubled, to $19,400. That is the price of a 2011 Hyundai Sonata. The average family bears about 40 percent of that cost, with employers paying the rest. However, a more realistic view is that employees pay for all of it because most wage-and-benefit increases go toward health-insurance costs.

Most people have only a vague notion of how valuable health insurance can be. The median household income for a four-person U.S. family in 2009 was about $70,300. However, the Congressional Budget Office (CBO) estimates the true figure to be $94,900. A footnote on page 65 of a CBO budget forecast said this: “All income is assumed to be from compensation, which includes employment-based health insurance and the employer’s share of payroll taxes.”

That additional value does not mean much to those living paycheck to paycheck. Each family has a different financial pressure point. The media often focus on catastrophic costs inflicted on people with no insurance. The broader story of health-care costs is about financial strain spread across a wide swath of American households. The pain affects much of the middle class and some of the upper middle class as well, including those with employer-sponsored insurance.

Americans actually pay a far lower share of health expenses than they used to. The main purpose of health insurance originally was to cover catastrophic episodes. Before the introduction of Medicare and Medicaid in 1965, patients paid more than half the cost of care out of pocket. That shrank to 15 percent in 2008. Meanwhile, private health plans’ share of the bill rose from 21 to 35 percent and government’s portion doubled, to 50 percent. The perception that medical bills are the responsibility of someone other than the patient has been a prime contributor to health-care demand over the past four decades.

A Deloitte study estimates that consumers pay an additional 15 percent out of pocket on personal health not captured by government statistics. These costs include unpaid caregiving, over-the-counter medications, and complementary and alternative medical care not covered by insurance.

The inability to pay medical bills and buy prescription drugs is the most persistent household finance problem, according to a recent Consumer Reports poll. About 40 percent of Americans had trouble paying medical bills in 2010, up from 34 percent in 2005. More than one-quarter of insured households reported problems with medical debt.

Even more disturbing is widespread self-rationing. Nearly 6 out of 10 adults said they delayed care because of cost. About 40 percent of those in fair or poor health did not fill at least one prescription in the past year. People with chronic conditions who fail to take medication are flirting with disastrous consequences.

Americans generally cite lack of access as the greatest obstacle to health care, followed by costs. Lack of access can mean several things. In some instances, people cannot see a physician or specialist promptly. Nearly 60 percent say they cannot find care after physician office hours, 40 percent cannot get service by phone and 30 percent cannot get a timely office appointment.

Increasingly, though, lack of health-care access means not being able to afford it.

According to an ongoing household survey, the incidence of delaying needed care rose sharply between 2003 and 2007. Insured people are among those facing cost pressures. They are paying more out-of-pocket for care, finding fewer doctors who accept their insurance and facing more limits on what insurance will cover. During those four years, the percentage of those with unmet medical needs increased more among the insured than the uninsured.

It is difficult to pinpoint when health-care costs become burdensome. The Center for Studying Health System Change found that financial pressures increase significantly after out-of-pocket spending exceeds 2.5 percent of family income. Unlike a mortgage, groceries and utilities, medical costs are less predictable and often unexpected. High medical expenses generally are urgent and associated with serious conditions. Significant injury or disease may also result in loss of income. Even two-thirds of Americans earning more than $75,000 a year worry about getting or paying for future care.

Women experience greater cost and access problems. More than half of women have trouble getting care, and more than 60 percent under age 65 have difficulty paying medical bills. Women use the health-care system more than men do. They often must make choices between getting care or paying credit-card bills, the mortgage or for basic necessities.