The health care debate has been hijacked by fears about cost and how we will pay for universal coverage. Will it cost $1.6 trillion or $900 billion over 10 years? This is beside the point. Every other industrialized nation spends far less (about half) and creates much better health for its citizens. We are next to Cuba in life expectancy, yet they spend $184 per capita annually on health care and we spend over $8,000. The only way this will shift is if we focus on investing in quality not quantity - namely medical care that creates better outcomes through programs that address the causes of chronic illness - diet, sedentary lifestyles, stress, and social disempowerment.
If we produce a higher quality "product" in health care - namely "good health", then we will have more than enough money for comprehensive health care reform. If not, we will be simply re-arranging deck chairs on the titanic.
Not only will our nation's health and health care system decline, but our nation will fall to the bottom of the global sea of failed nations as 34% of our GDP and 75% of all federal spending will be consumed by Medicare and Medicaid by 2040 (according to the Presidents Council of Economic Advisors). Recently President Obama's rhetoric has shifted from health care reform to health insurancereform. Getting more people access to a system that provides worse outcomes at higher costs is not an option for a sustainable health care system, nor a sustainable economy. Political courage is needed to do the right thing, not just something.
Conspicuously absent in proposals for health reform policies from the White House, Senate and Congress, [1] aside from programs for community wellness and prevention, is a way to pay for services that not only better prevent, reverse, and treat the major drivers of disease and cost, but actually creates better health. Think about it. We don't reimburse or provide treatments for obesity, except for gastric bypass (at $100,000 a piece), even though it accounts for about 10% of our health care costs.
In other words, we don't have a health care system that creates increased value-meaning, the money we spend on our health isn't getting us a positive return on our investment. [2] By improving the quality of our health, and focusing on health creation and improved health outcomes, the sinking ship of health care can be righted, and the behaviors of physicians and health care institutions will shift from doing more things (volume), to doing the right things (quality).
We need not only community wellness, but also clinical wellness programs. We need not only more sidewalks and bike paths, and access to healthier food, but to transform visits between health care practitioners and their patients to produce health, not just treat symptoms and diseases. If the medical visit does not incorporate the science of "health creation", in addition to symptom suppression, then the burden of disease and the cost of health care will continue to rise unchecked. There is only one problem. The focus in health reform is on doing what we already do better, not doing the right thing. We are looking for ways to pay less for what we are already doing, not pay less as a result of improving the "product" of health care - the health of the individual, and communities.
More than Financing and Delivery Systems
Current proposals have focused on mechanisms for financing and delivery of health care such as employee and individual mandates for coverage, taxes on employee provided health benefits, surtaxes on high income earners, eliminating waste, bundling payments, the medical home, reducing errors, implementing electronic records, decreasing hospital re-admissions, false cost "savings" by cost shifting, and restricted services and payments.
Over the next 10 years the hospital industry agreed to $155 billion in reduced payments (a mere 1.4% of total revenues over 10 years which they will recoup many fold because they no longer will have to absorb the cost of the uninsured). [3] The drug industry agreed to reduce costs for medications by $80 billion. The insurance industry and physician organizations are brokering similar deals, which trim fat, but don't address the diseased underbelly of health care.
While enlisting health care stakeholders to tighten their belts, and improving how we deliver health care is necessary, it is beside the point if the foundation on which we deliver care is flawed. Asking pharma to accept reduced payments for medication, or hospitals lower payments for hospitalizations, or AMA to accept reduced fees for doctors may reduce costs in a bloated system designed to profit from overutilization of medical services, it will not correct one simple problem. We pay for more volume and utilization of medical and hospital services, medications and procedures, not quality or improved health.
Medical services that we hold as sacred such as medications, procedures and surgery, often don't work, or don't work as well as we thought to treat the diseases that account for the majority of sickness and costs today, namely heart disease, diabetes, obesity, prostate and breast cancer (and many other chronic diseases including digestive disorders, mood disorders and autoimmune diseases).
Yet we reimburse for these services because of lobbyists and clinical practice guidelines established through industry influence or custom, not science. [4] We pay for what we do even if it is not proven effective, which leads to higher costs and no improved health outcomes, as long it is a medication or a procedure.
In other words we are not getting value (health) for our money. The history of medicine is rife with fallen "heros". Who remembers that a decade ago the number one selling medicine in America was Premarin, a form of hormone replacement, now proven to cause breast and ovarian cancer, strokes and heart attacks? [5] Who, we must ask, is lobbying for science and for the patients? In fact, what does the science tell us today about our most common and expensive treatments for chronic disease like statin medications, cardiac bypass, angioplasty and treatment of diabetes?
Do Current Treatments for Chronic Disease Work?
Services with NO measurable health benefit consume 30% of Medicare dollars. [6] Better access to the same care will not solve our heath care crisis. We labor under two false assumptions that prevent us from access to health care that will reduces costs and improve our health:
1. Current medical interventions and early disease detection strategies (like mammograms and PSA testing) save lives and prevent disease, and
2. True prevention strategies, and lifestyle intervention treatment programs for chronic disease lead to higher costs and don't work.
The data and the logic behind these assumptions are false. Science and true value are off table in health reform, rather than at the center of the debate.
First let's examine treatment and prevention methods for heart disease and diabetes.
Keep these questions in mind as we review the research:
1. Are medications and surgery the most effective, or cost effective treatments?
2. In fact, are our currently reimbursed practices for treatment for the most prevalent and costly diseases based on research or custom?
3. Do they meet the holy grail of "evidence-based" medicine?
4. And if they don't, why do we pay for them if they are not proven?
First let's ask, do cholesterol-lowering medications (statins) prevent heart attacks and death?
According to the "best evidence" presented in the Adult Treatment Panel (ATP) III revised guidelines for primary and secondary prevention of cardiac events in 2001, the number of American's eligible to take statins increased from 13 million to 36 million. For adults between 30 and 80 years old with occlusive vascular disease (proven heart blockages or symptoms), the benefits of statins are proven.
Yet a close look at the research in over 10,990 women of any age, and 3,230 men over 69 years old, statins were not shown to prevent heart attacks or death. [7] For those high-risk males between 30 and 69 for whom statins are proven to reduce heart attacks or death, fifty patients would need to be treated for 5 years to reduce just one cardiovascular event!
Yet at a cost of over $20 billion a year, seventy five percent of all statin prescriptions are for exactly this type of unproven primary prevention. Over 10 years simply applying the science would save over $200 billion from our health care bill. And this is just one example of reimbursed but unproven care. We need not only prevent disease but also prevent the wrong type of care.
We also assume that angioplasty and cardiac bypass prevent future heart attacks and death. We are paying over $100 billion a year for these services according to the American Heart Association. [8] But do they save lives? The COURAGE trial showed that in stable coronary disease (most patients), angioplasty does not prevent heart attacks or prolong life. [9]
Cardiac bypass surgery developed before rigorous evidence was applied, and since 1977, the number of surgeries increased from 82,000 to 448,000 annually (at a cost of $99,743 each). Yet this surgery is helpful in only a small number of select patients. [10]
A new procedure or test or medication is not required to have strong evidence or save money to be reimbursed. It is paid simply for one reason: because we pay for medications and procedures. We don't necessarily pay for the most effective, common sense, or cost effective treatments that deal with the underlying causes of these diseases. In fact, two recent large prospective studies found that lifestyle could prevent 78% of new onset hypertension, [11] and reduce heart failure [12] in the aging population from 1 in 5 people to 1 in 10. Yet treatments to apply this science are not reimbursed.
What about current treatment methods for type 2 diabetes, the fastest growing epidemic in the world, with a 1000% increase in children over 10 years, 24 million Americans affected and nearly 60 million affected with pre-diabetes. Surely lowering blood sugar in diabetics is an effective strategy for reducing the risk of death and heart disease. It would seem obvious that if diabetes is a disease of high blood sugar, then reducing blood sugar would be beneficial.
However elevated sugar is only a symptom, not the cause of the problem. The real problem is elevated insulin unchecked over decades from a highly refined carbohydrate diet, a sedentary lifestyle and environmental toxins. [13]
Most medications and insulin therapy are aimed at lowering blood sugar through increasing insulin. In the randomized ACCORD trial of over 10,000 patients, [14] this turns out to be a bad idea. In the intensive glucose-lowering group, there were no fewer heart attacks, and more patients died. Yet we continue to pay $174 billion annually [15] for this type of care for diabetes, despite evidence that lifestyle works better than medications. We also pay for cardiac bypass and angioplasty in diabetics when evidence shows no reduction in death or heart attacks compared to medication. [16]
The unspoken secret in health reform is that if we are to reduce our costs, including improving value through improving health outcomes per dollar spent, and health care costs are potentially reduced from $2.5 trillion to $1 trillion annually, then some in the health care system will be out significant amounts of cash. We can't just keep doing the same thing and pay a little less and expect a different outcome. The industries that profit from the sickness and obesity of Americans will have to retool to profit from health promotion, or go out of business.
Drinking 48 ounce sodas, eating cheeseburgers and fries and living a sedentary lifestyle, then taking your statin, or blood sugar lowering medication, and undergoing an angioplasty or bypass if the medication fails to prevent heart disease or diabetes, is not only bad science, it flies in the face of common sense. We need to do something radically different. Pay for what works. Pay for health. Pay for quality, not volume. Then costs will come down, not just "bend".
References
1. http://help.senate.gov/
2. Porter ME, A strategy for health care reform--toward a value-based system. N Engl J Med. 2009 Jul 9;361(2):109-12
3. Not So Generous, The New York Times, July 12, 2009, http://www.nytimes.com/2009/07/12/opinion/12sun2.html?_r=1&scp=1&sq=not%20so%20generous&st=cse
4. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831-841.
5. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33.
6. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003 Feb 18;138(4):288-98.
7. Abramson J, Wright JM. Are lipid-lowering guidelines evidence-based? Lancet. 2007 Jan 20;369(9557):168-9.
8. Ornish D. Intensive lifestyle changes and health reform. Lancet Oncol. 2009 Jul;10(7):638-9.
9. Boden WE, O'Rourke RA, Teo KK, Maron DJ, Hartigan PM, Sedlis SP, Dada M, Labedi M, Spertus JA, Kostuk WJ, Berman DS, Shaw LJ, Chaitman BR, Mancini GB, Weintraub WS; COURAGE Trial Investigators. Impact of optimal medical therapy with or without percutaneous coronary intervention on long-term cardiovascular end points in patients with stable coronary artery disease (from the COURAGE Trial). Am J Cardiol. 2009 Jul 1;104(1):1-4.
10. Hlatky MA. Evidence-based use of cardiac procedures and devices. N Engl J Med. 2004 May 20;350(21):2126-8.
11. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009 Jul 22;302(4):401-11.
12. Djousse L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009 Jul 22;302(4):394-400.
13. Codru N, Schymura MJ, Negoita S; Akwesasne Task Force on Environment, Rej R, Carpenter DO. Diabetes in relation to serum levels of polychlorinated biphenyls and chlorinated pesticides in adult Native Americans. Environ Health Perspect. 2007 Oct;115(10):1442-7.
14. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB, Cushman WC, Genuth S, Ismail-Beigi F, Grimm RH Jr, Probstfield JL, Simons-Morton DG, Friedewald WT. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12;358(24):2545-59.
15. http://www.diabetes.org/diabetes-statistics/cost-of-diabetes-in-us.jsp
16. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403.
Mark Hyman, M.D. practicing physician and founder of The UltraWellness Center is a pioneer in functional medicine.