Monday, August 10, 2009
AP/J. Scott Applewhite
Health reform is in danger of failing because the focus has been too much on who is covered and not enough on what is covered. Health care reform is primarily about health insurance reform, with the main battle being over coverage and the payment system.
Of course, we need to provide coverage for the 48 million Americans who do not have health insurance. It is morally indefensible that we have not already done so.
But we also need to transform what is covered. If we want to make affordable health care available to the 48 million Americans who do not have health insurance, then the fundamental causes of many chronic diseases need to be addressed -- which are primarily the lifestyle choices we make each day -- rather than only literally or figuratively bypassing them.
If we just cover bypass surgery, angioplasty, stents, and other interventions that are dangerous, invasive, expensive, and largely ineffective on 48 million more people, then costs are likely to increase significantly at a time when resources are limited. As a result, painful choices are being discussed -- rationing, raising taxes, and/or increasing the deficit -- and these are threatening the public acceptance and thus the viability of health reform.
Meaningful health reform needs to provide incentives for physicians and other health professionals to teach their patients healthy ways of living rather than reimbursing primarily drugs and surgical interventions. If lifestyle interventions proven to reverse as well as prevent many chronic diseases are reimbursed along with other strategies for improving cost-effectiveness across the U.S. healthcare system, then it may be possible to provide universal coverage at significantly lower cost without making painful choices, and the only side-effects are good ones.
The U.S. "health-care system" is primarily what Senator Harkin [D-Iowa] calls "a sick-care system." Last year, $2.1 trillion dollars were spent in this country on medical care, or 16.5% of the gross national product, and 95 cents of every dollar were spent to treat disease after it had already occurred.
Heart disease, diabetes, prostate/breast cancer, and obesity account for up to 75% of these health care costs, and yet these are largely preventable and even reversible by changing diet and lifestyle.
Our research, and the work of many others, have shown that our bodies often have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. Medicine today focuses primarily on drugs and surgery, genes and germs, microbes and molecules, but we are so much more than that.
Many people tend to think of breakthroughs in medicine as a new drug, laser, or high-tech surgical procedure. They often have a hard time believing that the simple choices that we make in our lifestyle -- what we eat, how we respond to stress, whether or not we smoke cigarettes, how much exercise we get, and the quality of our relationships and social support -- can be as powerful as drugs and surgery, but they often are. Often, even better.
These choices are especially clear in cardiology as an example of this larger issue. Large-scale studies have shown that changing lifestyle could prevent at least 90-95% of all heart disease. 1 Thus, the disease that accounts for more premature deaths and costs Americans more than any other illness is almost completely preventable, and even reversible, simply by changing lifestyle.
In contrast, many people are surprised to learn that bypass surgery and angioplasty don't work very well. In 2006, for example, according to the American Heart Association , 1.3 million angioplasties and stents were performed at an average cost of $48,399 each, or more than $60 billion. In addition, 448,000 coronary bypass operations were performed at a cost of $99,743 each, or more than $44 billion -- i.e., more than $100 billion for these two operations.
Despite these costs, a major randomized controlled trial found that angioplasties and stents do not significantly prolong life or even prevent heart attacks in stable patients (i.e., in most patients who receive them). 3 Earlier randomized controlled trials of coronary bypass surgery found that this procedure prolongs life in only a small fraction of patients -- those with left main coronary artery disease or equivalent and left ventricular dysfunction (ejection fraction less than 30%). A recent randomized controlled trial in diabetics found that neither bypass surgery nor angioplasty prolonged life or prevented heart attacks. 4
Lifestyle changes also can be reframed not only as preventing chronic diseases but also as reversing the progression of these illnesses -- i.e., as intensive non-surgical, non-pharmacologic interventions.
What we eat, how we respond to stress, whether or not we smoke cigarettes, how much exercise we get, and the quality of our relationships and social support may be as powerful as drugs and surgery in treating (not just preventing) many chronic diseases.
Our studies showed that people with severe coronary heart disease were able to stop or reverse it by making intensive lifestyle changes, without drugs or surgery, and these findings have now been replicated by several others. 5 There was some reversal of heart disease after one year and even more improvement after five years, and there were 2.5 times fewer cardiac events when compared to a randomized control group. 6
Almost 80% of patients eligible for bypass surgery or angioplasty were able to safely avoid it by making comprehensive lifestyle changes instead, saving almost $30,000 per patient in the first year when compared to a matched control group. 7 In a second demonstration project with Highmark Blue Cross Blue Shield, these comprehensive lifestyle changes reduced total health care costs in those with coronary heart disease by 50% after only one year and by an additional 20-30% in years two and three when compared to a matched control group.
Thus, the disease that accounts for more premature deaths and costs Americans more than any other illness is almost completely preventable, and even reversible, simply by changing lifestyle. We don't have to wait for a new breakthrough in drugs or surgery; we just need to put into practice what we already know.
Reimbursement is a major determinant of how medicine is practiced. When reimbursement changes, so do medical practice and medical education.
Some question whether or not prevention saves money, asking whether these approaches actually prevent or only delay the onset of disease. Part of the reason that preventive approaches are usually scored by the Congressional Budget Office (which estimates the overall costs of any legislation) as significantly increasing costs is that lifestyle changes are viewed only as primary prevention -- paying money today in hopes of saving money later.
But even primary prevention saves money, although the cost savings per person are not as high as when intensive lifestyle changes are offered as treatment to those who are already sick. For example, three years ago, Steve Burd (CEO of Safeway) realized that health care costs for his employees were exceeding Safeway's net income--clearly, not sustainable. I consulted with him in redesigning the corporate health plan for his employees in ways that emphasized prevention and wellness, provided incentives for healthful behaviors, and paid 100% of the costs of preventive care.
Overall health care costs decreased by 15% in the first year and have remained flat since then. Many other worksite wellness programs have shown cost savings as well as a happier and more productive workforce. This approach is bringing together Democrats and Republicans, labor and management.
In each of these studies, significant savings occurred in the first year -- medically effective and cost effective. Why? Because there is a growing body of scientific evidence showing how much more dynamic our bodies are than had previously been believed.
The same intensive lifestyle changes that may reverse the progression of coronary heart disease may also slow, stop, or even reverse the progression of early-stage prostate cancer 8, whereas conventional treatments such as radical prostatectomy and radiation may not prolong life except in the small percentage of patients who have the most aggressive disease. 9
These lifestyle changes also may beneficially affect gene expression in only three months, turning on genes that prevent disease and turning off genes that promote heart disease, prostate cancer, breast cancer, and other illnesses. 10 Often, people say, "Oh, it's all in my genes, there's not much I can do about it." For many people, it captures their imagination to know that changing lifestyle changes their genes for the better.
Last year, my colleagues and I published the first study showing that these intensive lifestyle changes significantly increase telomerase, and thus telomere length, in only three months. 11 (Even drugs have not been shown to do this.) Telomeres are the ends of your chromosomes that help control aging -- as your telomeres get longer, your life gets longer. (Like all research, these relatively small studies need to be replicated in larger randomized controlled trials.)
Lifestyle changes are not only as good as drugs but often even better. For example, a major study showed that lifestyle changes are even more effective than diabetes drugs such as metformin in reducing the incidence of diabetes in persons at high risk, with lower costs and fewer side-effects. 12
"Prevention" often conjures up false choices -- "Is it fun for me or is it good for me? Am I going to live longer or is it just going to seem longer if I eat and live healthier?" Because these mechanisms are so dynamic, most people find that they feel so much better, so quickly, it reframes the reason for making these changes from fear of dying (which is too scary) or risk factor modification (which is too boring) to feeling better.
Many patients say that there is no point in giving up something that they enjoy unless they get something back that's even better -- not years later, but days or weeks later. Then, the choices become clearer and, for many patients, worth making. They often experience that something beneficial and meaningful is quickly happening.
The benefit of feeling better quickly is a powerful motivator and reframes therapeutic goals from prevention or risk factor modification to improvement in the quality of life. Concepts such as "risk factor modification" and "prevention" are often considered boring and they may not initiate or sustain the levels of motivation needed to make and maintain comprehensive lifestyle changes.
In our experience, it is not enough to focus only on patient behaviors such as diet and exercise; we often need to work at a deeper level. Depression, loneliness, and lack of social support are also epidemic in our culture. These affect not only quality of life but also survival. Several studies has shown that people who are lonely, depressed, and isolated are many times more likely to get sick and die prematurely than those who are not. In part, this is mediated by the fact that they are more likely to engage in self-destructive behaviors when they feel this way, but also via mechanisms that are not well-understood. For example, many people smoke or overeat when they are stressed, lonely, or depressed.
What is sustainable is joy, pleasure, and freedom, not deprivation and austerity. 13 When you eat a healthier diet, quit smoking, exercise, meditate, and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. The latest studies have shown that your brain may grow so many new neurons that it may get measurably bigger in only a few months -- this was thought to be impossible only a few years ago. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent -- the same way that drugs like Viagra work. For many people, these are choices worth making -- not just to live longer, but also to live better.
In other words, the debate on prevention often misses the point: the mortality rate is still 100%, one per person. So, it's not just how long we live but also how well we live. Making comprehensive lifestyle changes significantly improves the quality of life very quickly, which is what makes these changes sustainable and meaningful.
Unfortunately, anything involving lifestyle changes gets held to a different standard. Drugs and surgery are not required to show that they save money in order to be covered, only that they work. Lifestyle changes often work even better, and at lower cost.
Finally, it's worth pointing out that what's good for your personal health is good for the planet's health; what's personally sustainable is globally sustainable. For example, eating a diet high in red meat increases the risk of heart disease and many forms of cancer. It also increases global warming: livestock cause more global warming than all forms of transportation combined due to methane production, which is 21 times more powerful a greenhouse gas than carbon dioxide. 14
As Senator Harkin said, "To date, prevention and public health have been the missing pieces in the national conversation about health care reform. It's time to make them the centerpiece of that conversation. Not an asterisk. Not a footnote. But the centerpiece of health care reform."
If we don't, then the escalating costs and resulting painful choices -- rationing, raising taxes, and/or increasing the deficit -- are threatening the public acceptance and thus the viability of health reform.
- Yusuf S, Hawken S, Ôunpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Lancet. 2004; 364: 937-52.
- Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics 2009 update. A report from the American Heart Association statistics committee and stroke statistics committee. Circulation. 2009;119:e1-e161.
- Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1-14.
- The BARI 2D study group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503-15.
- Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. Lancet. 1990; 336:129-133.
- Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-2007.
- Ornish D. Avoiding Revascularization with Lifestyle Changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.
- Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. J Urol 2005;174:1065-1070.
- Barry MJ. Screening for Prostate Cancer -- The Controversy That Refuses to Die. N Engl J Med. 2009;360:1351-4.
- Ornish D, Magbanua MJ, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008;105:8369-8374.
- Ornish D, Lin J, Daubenmier J, et al. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. Lancet Oncol 2008;9:1048-1057.
- Diabetes Prevention Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
- Ornish D. The Spectrum. New York: Random House/Ballantine Books, 2008.
- United Nations Food and Agriculture Organization's report, Livestock's Long Shadow. Accessed on April 16th, 2007.