A few weeks ago, I went to the Aspen Institute which just held an astonishingly good symposium on health. Special thanks to Michelle McMurry. It was particularly amazing and interesting to hear the talks of Peter Agre and Michael Bishop whose stories about winning the Nobel prizes were fascinating because both started in many ways as outsiders to the world of biology and without the relentless pre-professionalism of today’s kids and perhaps because of this initial distance changed science and medicine as we know it.
The obvious focus at the conference was on the train wreck that is US health care today. It became clear at the conference that if things continue as they are right now, we will manage to be spending $4.4 trillion dollars by 2015 or almost the entire Federal budget and still be delivering less than high quality health care and probably not solving the new epidemics of obesity and diabetes in this country. Clearly, this can’t go on. We are currently spending over 16% of our GDP on healthcare whereas France is around 8% and our overall health is worse. To go to the projected 30% would be a disaster and it was telling that not one but two heads of the congressional budget office (one past and one present) were attending the conference. One of the moments I found most unintentionally ironic was Bill Frist saying that of course we needed universal insurance as an obviously frustrated Elizabeth Teisberg pointed out with her usual lapidary clarity that insuring all would actually be cheaper because we would have preventative medicine rather than disaster handling, clinic care rather than ER care, and much less money spent by insurers trying to duck covering people since all would be guaranteed coverage. Where were the Republicans on this during the last eight years? But there was a thoughtful discussion about how this, all by itself, isn’t a solution, and we need to alter the system to actually reward people for good overall care and wellness of patients and good outcomes rather than paying doctors for procedures. It short we need the system to help keep people well rather than only treat them (at best) when they are sick.
There was an interesting talk given at the conference where it was claimed that of the four things you want from insurance:
- Access for all
- Affordable by all
- Quality care
- Constant innovation
you can only get two. The European system was held up as one that delivers on access and price, but not quality. Frankly, while I’m aware of some of the long and even unacceptable waits in the UK and the limited access of cancer patients there to new drugs, it isn’t clear to me that Europe isn’t in general getting three out of four while we get only one (innovation).
The most striking and shocking graphs at the conference were about type II diabetes and its rise in this country from a rare occurrence to a national epidemic in just 16 years due to an epidemic of obesity. Watching the time lapse graphs of this spreading across the US is like watching some terrifying science fiction movie about aliens taking over the country except that this is real and has happened. The terrible cost of this disease will dwarf that of cigarette smoking which, even now, kills 440,000 US citizens a year or ten times as many as breast cancer for example and compared to all coronary disease killing about 2,400,000 a year including those due to cigarettes. As it is, we cannot afford Medicare and as I said above, within eight years the cost of the current health system is projected to approach the total cost of the entire Federal government and we haven’t saved any money for this. Furthermore, incredibly, despite these crushing expenditures we are getting worse outcomes and longevity than countries spending half of what we do such as France and Japan.
So the focus was largely on why do we have this catastrophe and how do we do better? I’ll talk more about this later. While sitting at this conference it was depressing to watch the Republicans fighting and Bush vetoing the proposed extensions to SCHIP where the states are trying to extend to just guarantee medical coverage to poor kids who otherwise aren’t getting it where again the alternatives are ER room, much more severe problems, years of illness (these are kids!), or families going deeply into debt to keep their kids healthy.
It was fascinating to learn about how much genetics is now able to play a role in diagnosing illnesses and in even predicting high risk, but my overall take was that while it is amazing what we do now know, it is still a very very long step from here to actual drugs which take advantage of what we know to cure the diseases in question. What genetics clearly can do for us, even today, is start to inform us about when we need to live our lives with particular care because of an unusually high risk of diabetes or breast cancer or ventricular fibrillation.
Overall, I was struck by two very basic points:
- We need to work much harder to help people stay healthy. The epidemic we face is largely avoidable. If we could reach out to the huge number of people currently at risk of type II diabetes or in the early stages and just get them to eat better and slightly less and exercise 30 minutes a day, we’d literally save this country hundreds of billions of dollars or thousands of dollars for every man, woman, and child in this country not even counting the terrible costs in lost productivity and illness and poor quality of life for those who suffer.
- If we can just agree that the job of medical care is to keep people well or get them better and reward people for doing this well rather than paying insurers and middlemen and doctors for procedures, we would save even more not even counting again the terrible costs in lost productivity and the damage to our overall competitiveness.
I was asked in some comments since I restarted blogging to discuss what I learned while running Google Health at Google. It is a delicate subject because I’ve publicly blogged about a fair amount of what I learned and some of the rest I think is now Google’s business. So, I’ve added a sidebar listing the talks I did give publicly on health while I was still at Google. This is a starting point for learning what I learned while working on health during the last two years.
Lastly, while I was at the conference, Microsoft launched HealthVault. I want to commend Microsoft for launching HealthVault in Beta. The web desperately needs an ATM networks for health records so that we can find and connect to the expertise we need online with our health data as context be it interpreting our labs or warning us about medicine issues or helping us recover from an illness. I read a snarky blog complaining that they were copying Google Health. I don’t see it that way. They launched. They are doing a good thing. Consumers need to be able to take charge or their health data and control it. Not the federal government. Not the hospitals. Not the insurers. Us. Even if Google does launch something similar, competition is a good thing for all of us. That being said I certainly hope that Microsoft follows the principle that our health data is our data for us to control and allows those of us who put data into the health vault to easily take it out of the health vault or copy from it electronically if we so choose and provides an open doorway to those who have programs to help us make sense of our health data. But I bet they will and if so, congratulations to them.
Adam Bosworth's Weblog 
Wow it’s really incredible how staggering the numbers are.
I’m happy I live in Canada. I’d be so exasperated by people just blindly ignoring the oncoming disaster if I lived in the US. I wish you luck, I really hope you succeed in helping the American health system.
[…] Health and the Aspen Institute « Adam Bosworth’s Weblog fascinating look at the state of health care and potential approaches (tags: healthcare adambosworth) […]
Healthcare will benefit greatly from a more proactive approach. Hospitals are making great strides to prevent dangerous and costly infections for patients while reducing costs. MRSA infections are not only deadly but can cost around $30,000 dollars per patient in treatment costs. With an estimated 90,000 patients in the US contracting an MRSA infection this past year, MRSA infections alone cost the healthcare system around $2.7B in treatment costs as well as around 18,000 lives per year. To prevent these infections, Illinois and the VA system have recently mandated that all incoming patients are screened for MRSA before entering the hospital. More preemptive efforts like this are needed in order to save lives and reduce healthcare costs in our country.
Healthcare will benefit greatly from a more proactive approach. Hospitals are making great strides to prevent dangerous and costly infections for patients while reducing costs. MRSA infections are not only deadly but can cost around $30,000 dollars per patient in treatment costs. With an estimated 90,000 patients in the US contracting an MRSA infection this past year, MRSA infections alone cost the healthcare system around $2.7B in treatment costs as well as around 18,000 lives per year. To prevent these infections, Illinois and the VA system have recently mandated that all incoming patients are screened for MRSA before entering the hospital. More preemptive efforts like this are needed in order to save lives and reduce healthcare costs in our country.
One of the challenges, which you point out Adam is thee need for the consumer to take greater control of their health and to begin offering incentives encouraging such or dis-incentives for the converse. But event ot get to that point, a massive education program is required. Today, most consuemrs do not take a pro-active role in their healthcare inclduing the management of their own health records. Recent surveys such as the recent WSJ/Harris survey showed that the vast majority of Americans do not manage their own health records, and thus, one could argue do not take a pro-active stance in managing their health. This is where I beleive the physician/providers need to step in and play that critical role of education. They are on the front lines, closely followed by employers who also are a major stakkeholder and are in the best position to offer those incentives for good health practices or dis-incentives for those who employees who chose otherwise.
Also, while you discuss Google (logically) and mention HealthVault, do not forget such efforts as Dossia, which already has a captured audience (via the employees they represent) of over 8.5M. They have the potential to be a major player as well. Recently wrote a past on them which you’ll find at http://www.chilmarkresearch.com
Adam,
I just arrived home after listening to you speak at the NCI/NIH Consumer Health IT forum in Bethesda.
With respect to your comments about type II diabetes and health care. “If we can just get people to eat a little better and a little less and exercise 30 minutes a day…”
I could not agree with you more. I think the figure is 54 million Americans have pre-diabetes and they don’t know it. They probably won’t find out until they develop the disease even though the test is extremely easy and cheap. (right now blood is needed, but I am sure they are working on ways to measure blood sugar non-invasively)
The question is how do we get people to change behavior and how can technology help? There is no question that the social network and support system is vital. But I think part of the answer lies in knowledge and information access.
My father-in-law is a hard-working farmer who is now retired from the power company. He has always been slender, plenty of exercise on the farm, but he had a huge sweet tooth. He found out he was pre-diabetic when he couldn’t pass his physical. He “looked” like a picture of health, but he obviously wasn’t. His wife is a registered dietitian and she was able to immediately spring into action. They changed their whole home environment. The chocolate cake for breakfast was replaced with oatmeal or cold cereal. No more candy bars at lunch… you get the idea… until they were able to get his blood glucose back down to normal. Now, he enjoys good health and an occasional treat.
But what if he never had the mandatory work physical? Where would he be? How many people are out there who don’t have mandatory work physicals? How many get regular check-ups but don’t ask for a blood glucose test? A cholesterol test? How many people will go on to develop a costly chronic disease?
I was thinking about all this during the panel discussion today. I was thinking about the free market and cell phones and I thought how can we get people better access to personalized health information?
The answer is Brickbreaker (ok, not exactly)… but think about it. How many people have tried Brickbreaker because it was included on their Blackberry? I know my husband loves playing Texas Hold ‘Em on his phone.
How far away are we from a built in application that comes with your smart phone? Maybe it has games to help improve health literacy? Education tools to help improve behaviors like portion sizes, following a balanced diet etc. Maybe it has http://www.mypyramid.gov integrated so you can grocery tips, ideas, menus and a shopping list while you are at the store?
How about a feature that allows you to place your thumb on a smart pad and it measures your blood glucose? Sure, it can ask you a few questions like “do you have diabetes? when was your last meal?” then it takes the measurement and let’s you know if that is normal, high or low.
Could this “intervention” be enough to cause a person to make a doctor’s appointment if the figure is off? I’m not sure. But if they can do Brickbreaker why not try something more?
There’s a lot of information about the state of the world’s health care systems in Jonathan Cohn’s review of Michael Moore’s “Sicko”, in The New Republic: http://www.tnr.com/columnists/story.html?id=1fef52d3-407c-4a7f-b835-89601c2e1e8d
He fact-checks the film, and although there is a lot of grandstanding and so on, the substantive points in the film are right. Cohn particularly lauds the French system.
Meanwhile, Henry Aaron points out in the latest The New Republic (http://www.tnr.com/politics/story.html?id=7f7e2f07-86f5-4eb6-86f5-047139f05ef6)
that basically all the Democratic presidential candidates have the same overall outlook on what to do about the health care crisis, while the Republican candidates have pretty much nothing to say about it.
On the prevention of infections in critical care (ICUs) there is some good news, and also some rather dispiriting news. See Atul Gawande’s recent article in the New Yorker and his op-ed (today) in the New York Times:
PS: Also see the rather intense discussion here (NY Times ‘Well’ blog).
Also see this insightful discussion on The Health Care Blog, Healthcare and The Long Tail.
Hello, from long ago. I find your comments interesting and informative. It goes without saying, these are not just recent findings. Health care here in the US suffers many maladies including, but limited to: maldistrubution of physicians, a shift in emphasis from Allopathic medicine to other medical/non- medical disciplines, an almost complete disregard for preventative health, and an over -reliance on “hyper-medicine” to save someone in a catarastrophe. And that’s just the beginning. Much more emphasis is placed on after the fact healthcare the prevention, allowing pharmaceuticals to take the place of diet, exercise, and common sense.
US medicine is technically the best in the world, but the delivery falls way short of caring for more than the few with insurance. There is much more to say about this enriched topic, but the space is limited.
All of this makes the upcoming election that much more interesting and crucial…
So why not put disclaimers on soda, like we did with cigarettes?
“The corn syrup in this soda has been shown to cause diabetes from just one can a day”
Anything that makes people think twice is a step in the right direction.
Greg Mendel is also, by huge coincidence, the name of the Augustinian monk who is credited with being the father of modern genetics. ,