The plethora of recent studies pointing to the high cost of carrying excess body fat prompted this question: Could Americans start saving money if thousands of much-too-hefty nurses, doctors, and other health providers across the country led a national initiative to lose weight themselves?
Might they not only pare down their own healthcare bill, but could they become models for their families and their patients as well, and perhaps provoke a sea change in attitude to reflect the very significant dangers associated with being overweight and obese?
What if by their activities, it became as socially unacceptable to be severely overweight as it now is to be a cigarette smoker? What if people stopped saying that they can't do anything about their weight, or, that it's nobody's business but their own?
Obesity is a bigger problem in rural areas, some studies say, than it is in urban ones, so such an initiative might be especially important for small towns.
A study last week underscores what's at stake.
Writing in the journal Health Affairs, Eric Finkelstein of RTI International and his co-authors analyzed national survey data and discovered that obese people incur more medical costs, $1,429 (42%) a year more, than people of "normal weight," in 2006 dollars.
Extrapolating to 2008, their report said, the costs of obesity could have risen to $147 billion, or one in every $10 spent on healthcare. Roughly half that bill is paid by Medicare and Medicaid—in other words, the taxpayers.
"What this says, basically, is that for those lifestyle decisions (resulting in obesity), the taxpayers and normal weight people end up paying their cost of care," Finkelstein told me in a phone interview.
Much of the cost is for treating diseases that are the consequences of adult onset diabetes, which is largely preventable, he says.
"Ultimately, it's a decision by employers and policymakers to decide if it's acceptable to finance those costs," Finkelstein says. "And if they decide it's not, they can create incentives or strategies so people who engage in healthier behaviors can get rewarded for doing so."
For obese Medicare patients, non-inpatient medical services and pharmaceuticals were major drivers of spending. "Our results suggest that spending within these categories for each obese beneficiary was more than $600 per year higher than for a normal weight beneficiary," the authors wrote.
For obese privately insured payers, medical cost increases ranged from $284 for prescription drugs to $443 for inpatient services. "In percentage terms, these increases represent 82% and 90% increases in costs, respectively, compared with people of normal weight."
According to a recent report from the Centers for Disease Control and Prevention, 26% of the population is now fully obese with two thirds of America either obese or overweight.
It occurred to me that the message has special relevance for rural areas.
After all, rural communities experience much higher rates of obesity than urban areas, and the health care workforce in rural areas is probably similarly affected.
It's known that many rural providers, hospitals, and clinics, take care of large numbers of the uninsured, and many of them are obese or overweight as well. It's also known that many rural facilities struggle to stay solvent and maintain a respectable level of care for their communities. These lifestyle choices are adding to the hospitals' challenges.
"Rural residents tend to eat diets higher in fat and calories, exercise less and watch more television, all of which can contribute to unhealthy weight gain," according to the Obesity and Weight Control section of the Rural Assistance Center.
So what if whole communities, led by their doctors, nurses, and other health professionals, just got together and said they'd give it a try? That's a suggestion of Nick Yphantides, MD, now consulting medical director for the San Diego County Health and Human Services Agency, who lost 270 pounds himself after realizing his ineffectiveness in trying to counsel his patients to lose weight.
It seems like there's a potential win, win, win situation here.
Maybe they could lead exercise activities several days a week that their patients could join. Or perhaps they could amass support groups. How about "Biggest Loser" competitions in their hometowns?
Given the ultimate increase in the cost of care that often is absorbed by the healthcare system, maybe there could be financial incentives for health workers to meet and maintain their goal?
A recent New England Journal of Medicine paper discussed a successful experiment in Philadelphia to get long-time smokers to quit. In a clinical trial, 878 employees who smoked cigarettes were randomized to either receive information about smoking cessation or to receive that information plus financial incentives if they succeeded in quitting for six months. The project was financed by the Centers for Disease Control and Prevention and the Pennsylvania Department of Health with cooperation from a large multinational company's employees.
Those in the second group received $100 for completing a smoking cessation program, $250 for cessation of smoking as confirmed by a biochemical test, and another $400 if they were still clear of tobacco, as confirmed by that test, six months later.
The results? Those who received the full $750 were three times more likely to have stopped smoking than those who only received information about quitting.
Could something like that be translated to a weight loss campaign? Say, $500 to get one's weight to an optimal level by the end of a year? What about $1,000?
Heck, it'd still be cheaper than making taxpayers spend that extra $1,429.
While stumping for healthcare reform, President Obama often trumpets the idea of more health insurance regulation. A topic he isn't as keen on mentioning is an individual mandate to require all Americans to have health insurance.
That was evident during his prime-time news conference last week in which he took aim at private insurers while remaining mum on requiring Americans to buy health insurance. The president, who opposed the individual mandate during his campaign, has not spoken as much about the individual mandate as he has about more health insurance regulation and the areas of improving quality, cutting Medicare Advantage payments, creating a public insurance option to make private insurers "honest," and bundling payments to hospitals and doctors.
Health insurers, led by America's Health Insurance Plans, say an individual mandate and added regulations go hand-in-hand. AHIP says it is willing to guarantee insurance for all Americans regardless of pre-existing conditions and stop using gender rating to charge women more for individual insurance. In exchange, they demand an individual mandate, which would mirror the Massachusetts model.
"Market reforms without a mandate are not sustainable in the long run," says Robert Zirkelbach, director of strategic communications at AHIP in Washington, DC.
Health insurers say the reason for the individual mandate is clear: The healthcare system would not work without an individual mandate if insurers are required to accept all members regardless of health status.
Justine Handelman, executive director for legislative and regulatory policy at the Blue Cross and Blue Shield Association in Washington, D.C., which is a national federation of 39 independent and locally operated Blue Cross and Blue Shield companies, says a three-pronged approach is needed:
A "strong and effective mandate"
A requirement that insurers accept everyone regardless of health status
Subsidies to help those who cannot afford health insurance pay for coverage
"Only with a strong individual mandate will we be able to keep premiums affordable in a guaranteed issue market. As state experience has shown, guarantee issue can only work if everyone—the young and healthy, as well as higher-risk individuals—purchases coverage. Otherwise, individuals will wait to buy insurance until they are sick and need coverage, which not only undermines the goals of reform but will drive up costs for everyone," Handelman says.
Health insurers predict adding health insurance regulations without requiring everyone to have insurance would simply pass costs from the new sicker members, who were not accepted previously because of pre-existing conditions, to other members.
Requiring everyone, most notably the so-called "young invincibles," who often don't buy health insurance because they don't believe they need it, would help offset the added costs of the new sicker members.
Bob Coli, MD, a physician in private practice and healthcare entrepreneur who is the founder, chairman, and CEO of the Diagnostic Information System Company, says any legislation mandating guaranteed issue will fail unless everyone is mandated into the system.
He adds it's hard for him to believe that "enacting new private insurer regulations (such as gender ratings and excluding pre-existing conditions), without an offsetting individual mandate, can avoid further increasing annual private health plan costs and premium increases and eliminate any ability to compete with a new public health plan option."
However, Marty Trussell, senior vice president of First Horizon Msaver in Overland Park, KS, a health savings account financial administrator, says an individual mandate without underwriting and pre-existing condition exclusions could conceptually work, but the reform would need a mechanism that "would allow carriers to underwrite those individuals who did not become insured during some designated enrollment window. Without this type of protection, the system would invite individuals to hold off on purchasing coverage until such time as they need it. This is sort of like selling someone an auto policy after they wrecked the car," Trussell says.
Though Obama has not been an outspoken supporter of an individual mandate, there is still good news for insurers and individual mandate supporters. The fact is that the individual mandate remains an important piece of the healthcare reform proposals on Capitol Hill.
It's true that the individual mandate is in every major reform proposal, but that doesn't mean it's going to happen. And with the president not making the idea a major part of his healthcare speeches, you have to wonder if Democrats will ultimately look to strip out that critical piece of reform, while adding new regulations, such as guaranteed issue.
That's something all health insurers should watch closely in Washington.
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Peer Assistance Services, a Colorado nonprofit organization that provides guidance, support, and rehabilitation services for healthcare professionals, has seen an increase in nursing clients this year—a majority of whom needed help for alcohol and drug abuse.
But, the growing number of nurses seeking treatment for substance abuse doesn't necessarily reflect a growing problem, according to Rebecca Heck, BSN, RN, MPH, program director of the Nursing Peer Health Assistance program at Peer Assistance Services in Denver.
"We are seeing more nurses come forward, but the problem of substance abuse among healthcare professionals mirrors that of the general public," she says. "I don't know if there is an actual increase in the problem or if nurses are becoming more comfortable coming to us for help."
Heck attributes recent media attention surrounding drug thefts by Colorado healthcare professionals as influencing more nurses to seek treatment. The most recent being the case of a former Rose Medical Center surgical technician, Kristen Diane Parker, who admitted to stealing fentanyl-filled syringes and occasionally swapping them with her used syringes filled with saline. The Denver Post reports that 20 patients appear to have contracted hepatitis-C from Parker as a result.
"I think the stigma is still there and is powerful," Heck says. "But this is making the front page and people are getting scared and realizing they need help."
Treatment plans through the Nursing Peer Health Assistance program are individualized depending on nurses' needs and range from one to five years. Rehabilitation requirements can include therapy treatment, psychiatry, pain management, urinary analysis testing for drugs and alcohol, 12-step groups, sponsorship with a 12-step participant, and peer support groups. Any deviation from the rehabilitation may result in a referral to Colorado's Board of Nursing, in which a nurse may deal with consequences, such as a suspended license to practice or a public discipline in the form of stipulation.
"We want to lead nurses to treatment and monitor them to hold them accountable for that treatment," says Heck.
Literature shows that anywhere between 8%-12 % of nurses have substance abuse disorders that affect their ability to practice, says Heck. Studies have found prescription medication use to be higher among nurses than in the general population, while marijuana and cocaine use has been found lower among nurses than in the general population.
Aside from the easy access of prescription drugs on the job, a number of factors make nurses and other healthcare workers at high risk for substance abuse.
"The culture amongst all healthcare professionals is that we know how the drugs work, so therefore we think we can control them," says Heck. "But they control us like they do everyone else."
Nurses' often stress-filled and lengthy work shifts and nature to "take care of others—not ourselves" are other risk factors, says Heck.
Clients receiving Nursing Peer Health Assistance services complete intensive portions of treatment before returning to work. However, some practice while receiving less serious forms of support with approval from Peer Assistance Services, a therapist, a psychiatrist, or other treatment provider.
Nurses' identities are kept confidential, but they are required to disclose of their participation in the program to their nurse managers.
"Our number one goal is public safety," says Heck. "If a nurse relapses, whether through behavioral symptoms or positive drug tests, we remove them from work within 24 hours and we inform the nurse manager. But then we also make sure the nurse gets treatment."
Heck believes increased education about the causes of and prevention of substance abuse in nursing school and in the profession is needed to minimize the problem and push more nurses to get help.
"Nurses, risk management, and nurse educators do all of this work to make hospitals safer for patients, but we are all missing this huge element; to make nurses safer to provide patient care," says Heck.
There's no doubt about it: obesity—especially for children—has become a critical and costly problem in the United States, said Health and Human Services Secretary Kathleen Sebelius at the Centers for Disease Control and Prevention's first conference on the "Weight of the Nation" in Washington Tuesday. And it's a problem that needs to be part of the healthcare reform debate, she noted.
Currently, more than two-thirds of American adults—and almost one out of every five American children—are obese or overweight, Sebelius said. A report released the day before observed that obesity costs the American health system as much as $147 billion a year, a number that has nearly doubled since the CDC last calculated the rate in 1998.
"To put that figure in perspective, the American Cancer Society estimates that all cancers combined cost our healthcare system $93 billion a year," she said. "So ending obesity would save our healthcare system 50% more dollars than curing cancer."
But while this picture is bleak, there is hope—especially at school, community, and federal levels—that obesity can be tackled. A new report released Tuesday on school district wellness policies finds that the mission to promote better health "won't be easy," she said. But steps can be taken toward "developing a national blueprint for how to get Americans to slim down while trimming a significant chunk of our healthcare costs at the same time."
The report, prepared by researchers at the University of Illinois at Chicago and supported by the Robert Wood Johnson Foundation, examined policy opportunities that emphasize wellness to improve a child's quality of life, such as:
Improving the nutritional quality of school meals.
Reviewing standards for competing foods and beverages (such as sodas and snacks in vending machines) sold outside the school lunch programs
Restricting food marketing and advertising
Continuing to strengthen physical activity provisions
Expanding policies to address physical education
These suggestions emphasize "transforming our healthcare system from a sickness system to a wellness system," she said. If the government wants people to start eating healthy food, "we need to start serving it," she said. That means offering more nutritious meals—not just in public schools, but in child care centers, recreation centers, senior centers, and other government buildings.
"And we need to serve these healthy meals at a price that people can afford. Some people say that if kids don't want to eat healthy, they're not going to no matter what," she said. "But there are a handful of high school cafeterias around the country that would disagree. They cut the prices of fruits and carrots and sales started to rise."
Another target area is to give people more healthy options in their own neighborhoods. "Many rural Americans and urban Americans have the same problem: they don't have any supermarkets that sell fresh produce where they live," she said.
"When you can't buy fresh produce, it's hard to eat healthy," she said. One study found that the amount of fruits and vegetables eaten in African American neighborhoods actually went up by a third for each supermarket that was added.
"This isn't rocket science. People want to eat healthy diets, but they tend to eat whatever's convenient and affordable, Sebelius said. "If we want to reduce obesity, we need to make eating fruits and vegetables convenient and affordable for all Americans."
Sebelius' comments came on the second day of the conference. The day before, CDC Director Thomas Frieden, MD, told the audience that the average American adult is now 23 pounds overweight—representing about 4.5 billion pounds of excess weight nationally.
He also stated that the incidence of childhood obesity has tripled in one generation. To tackle obesity, the country will probably have to take notes from the earlier national campaign to reduce tobacco use—taking aim at food costs, exposure to food ads, and availability of junk food.
Former President Bill Clinton said on Monday that the issue of childhood obesity "cannot be dealt with entirely within the confines of a medical office."
To change this, "we have to change what goes on at home and in the community and in the neighborhood and in the schools," Clinton said. He noted how his foundation has been involved with getting vendors in some schools to stop selling high-caloric and heavily sugared drinks to children attending those schools.
More patients who sought medical care at a declining number of California emergency rooms are a lot sicker, and slightly more of them required admission in 2007 than they did five years earlier, according to an analysis of facility discharge data from 10 of the state's largest counties.
The July report from the California HealthCare Foundation found that patients classified in the two most serious categories of illness rose from 25% to 34%. "California's EDs are facing a changing patient mix that may be putting pressure on their resources," the report's authors wrote. Not only are the patients requiring more emergency room evaluation and services, more of them need to be admitted.
Those in critical condition (defined as that which poses an immediate significant threat to life or physiologic function) rose from 9% of visits to 12%, while those in severe condition (requiring urgent evaluation, but not of immediate significant threat to life of physiologic function) rose from 16% to 22%.
"Severely ill ED patients, especially those who are admitted, require more resources and time to treat and may take up more ED bed capacity than a 'treat and discharge' patient," according to the report entitled "Is California's Hospital-Based ED System Eroding?"
Contrary to common belief that the bulk of people coming to hospital emergency rooms are uninsured, the report found that in 2007, private-pay patients with insurance used the emergency department the most. The study reported that 34% of all ED visits were by privately insured patients, while Medicaid (Medi-Cal) patients accounted for 24%, and Medicare 19%. Self-pay patients used the smallest proportion of ED visits, 16%.
Another finding is the steep increase in emergency room visits by people who did not have true emergencies, the report said. "Hospital EDs are becoming a source of primary care for a growing share of the population, leading to an increase in non-emergency ED visits from 578,000 in 2002 to 891,000 by 2007," the report said.
Also, more patients are leaving the ED without treatment "often after long waits."
Against this trend is the backdrop of a decline in the number of hospitals supporting emergency room services. Between 1996 and 2007, the number of hospitals declined from 481 to 436 while the number of emergency departments went from 388 to 344.
The majority of those EDs that closed were in urban areas. Overall, the report said, since 2001, the average travel distance to the nearest ED across the state changed little.
However, many of those hospitals that maintained emergency services increased their number of ED treatment bays. There were 4,994 ED beds statewide in 1996, but 6,310 ED beds in 2007, an increase greater than that of the population (15%) in that period. Hospitals that did not close expanded their emergency bed capacity to help meet the increased demand.
"Overall, there was an 8% rise in ED beds between 1996 and 2001and a 17% rise between 2001 and 2007," the report said, adding that this suggests EDs "are considered an essential service and that most hospitals have been able to manage external pressures in order to continue to offer ED services."
The report also found wide regional variation in emergency department capacity versus need throughout the state. For San Francisco, Fresno, Santa Clara, and Contra Costa counties, ED capacity outpaced demand for emergency care. In Sacramento, Los Angeles, and Kern counties, capacity kept up with demand. However, in San Bernardino, Riverside, and San Diego counties, demand exceeded increases in capacity.
Robbin Gaines, who is California HealthCare Foundation program officer, could not speculate on why there was so much variation between the counties, saying a more detailed analysis was necessary to determine if reimbursement or a mix of patients might be influential.
However, she noted, the lesson from the report is that "Emergency care is not 'one size fits all.' While statewide the number of ED beds has increased, there is substantial variation in ED systems across counties."
An emerging consensus among a bipartisan group of senators is poised to shift the dynamic in the congressional debate over healthcare reform. The finance panel's legislation is expected to include incentives for employers to provide health insurance for their workers, rather than a more punitive coverage mandate. The committee is also likely to endorse narrowly targeted tax increases, rejecting a controversial tax surcharge on wealthy households that the House adopted.
Members of Congress said the have been deluged with calls from constituents worried that their Medicare benefits might be cut to help finance coverage for the uninsured. The concern over Medicare came as House Democratic leaders tried to assuage the concerns of fiscally conservative House Democrats who have held up action on healthcare legislation while they press for changes to reduce the cost of the bill.
Liberals are growing anxious that a final healthcare reform deal will negotiate away their top priority: a public plan to compete with private insurers. Some Democrats are threatening to oppose any bill that excludes this option, and sympathetic outside groups are pressuring wavering lawmakers. Health Care for America Now, a liberal group, and the American Federation of State, County and Municipal Employees spent $800,000 on television ads targeting moderate Democrats, citing their opposition to a public option.
Boston Medical Center chief Elaine Ullian has announced that she will retire, amid what could be the hospital's worst financial crisis in years. Earlier this month, Boston Medical Center sued Massachusetts officials, accusing them of illegally cutting payments for treating thousands of poor patients and plunging the hospital into fiscal uncertainty. The hospital estimates that it will lose $175 million in the fiscal year starting Oct. 1 and $38 million by the end of this fiscal year.
