No, Obesity is Not Driving Health Care Inflation –Part 1

Summary: A report from the Congressional Budget Office (CBO) that came out last week spurred a flurry of headlines suggesting that fat people are responsible for the high cost of health care in America. “CBO– Obesity Will Decimate Future Health Costs and Care,” blared one headline. The story began: “While our nation’s obesity problem has trashed health care and insurance rates, the worst is yet to come.” In other words: forget about reform. Folks who eat too much will wipe out any savings.

It is true that obesity has become epidemic. As the CBO study points out, “From 1987 to 2007 the share of adult Americans who are obese has more than doubled –from 13 percent to 28 percent.” Over the same span, the amount that we spend on health problems associated with obesity has soared: “health care spending per adult grew substantially in all weight categories between 1987 and 2007,” the researchers write, but “the rate of growth was much more rapid among the obese. Spending per capita for obese adults exceeded spending for adults of normal weight by about 8 percent in 1987 and by about 38% in 2007.”

It is easy to assume this means that the rise in the percentage of Americans who sport a body-mass index (BMI) equal to or greater than 30, accounts for roughly one-third of the rise in health care spending. But that is not what the report says.

The CBO study explains that for more than two decades the cost of care has been spiraling for Americans of all sizes. Rising obesity is not a major force pushing health care costs higher. As I have discussed in past posts, research shows that advances in medical technology is the most powerful factor behind health care inflation.

Each and every year, our health care industry invents new drugs, devices, tests and treatments. As a result, virtually each year, we pop more pills and undergo more tests and procedures.  Sometimes the “new, new thing” is more effective. Sometimes it isn’t. But it is always more expensive.

Because new technology accounts for so much of the rise in health care spending, “Even if there is no growth in the prevalence of obesity between now and 2020” last week’s CBO report observes “per capita spending on health care for adults would rise by 65 percent—from $4,550 in 2007 to $7,500 in 2020 . . .  largely as a result of the continuation of underlying trends in health care that have led to rapidly increasing spending for all adults regardless of weight.”[These numbers are adjusted for inflation; all are in 2009 dollars.]

We are investing more in treatments for obesity and diseases aggravated by obesity, just as we are laying out more dollars for cancer patients, because in each case, we have many more potential cures than we had in 1987. 

Obesity itself is not driving medical spending.. Indeed, even if, by some miracle, we suddenly understood the multiple causes of obesity, and as a result, the share of adults who are seriously overweight plummeted from 28 percent to 20 percent over the next decade , CBO researchers calculate that per capita spending still “would increase to $7,230 in 2020—[only] about 4 percent less than spending in the first scenario”– which assumes that the percentage of American who are obese remains at 28 percent.   

Finally, it is worth noting that the obese don’t live as long as the rest of us, another reason not to blame them for the cost of medical care. A 2008 study, published in the Public Library of Science Journal, shows that slim and healthy adults consume $417,000 worth of heath care over the course of a lifetime, while the bill for obese adults averages $371,000.
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Who or what is responsible for health care inflation—Insurers? Medicare? Doctors? Patients? Everyone would like to know, and last week the Congressional Budget Office (CBO) released a report that led some pundits to conclude that the answer can be summed up in just two words: “Fat Americans.” Today, roughly 28 percent of the adult population is obese. If the trend continues, and “obesity rates rise to 37 percent by 2020, per capita health care spending for adults will rise to $7,760, up from $4,550 in 2007,” the Boston Globe reported in an article titled “Obesity’s Punch to the Gut.”

Except that’s not what the CBO report said. The Boston Globe lopped off the final four words of the sentence. Here is the quote, verbatim, and in context:  “if recent trends in adults’ body weight continue, by 2020, the share of obese adults would reach 37 percent.  Projected spending per capita would be $7,760—about 3 percent higher” than it would be if obesity rates remain where they are today.

In other words if the percent of Americans reporting a body-mass index (BMI) of 30 or higher climbs  from 28 percent to a startling 37 percent over the next decade, this would add just 3 percent to the cost of medical care in the U.S. To save 3 percent over ten years would be nice, but it’s hardly the answer to a national health care bill that, in recent years, has been rising by 6 percent to 7 percent annually.

                   Why Does the U.S. Outspend Other Countries?

Obese Americans are easy scapegoats, but they are not the reason U.S. health care bills are levitating, says the McKinsey Global Institute (MGI). In a report titled, “Accounting for the Cost of Health Care in the United States,” McKinsey observes that many studies have tried to explain why the U.S. lays out so much more for medical care than other developed nations, but in the past, , researchers have tended to hone in on just one part of the system: administrative costs, obesity, the high cost of drugs in the U.S. . . .  Few take a “holistic” view, using “analysts who have direct experience working across all parts of the U.S. health system.” That is precisely what MGI does.  (Hat tip to Aaron Carroll who highlighted this study in a post on The Incidental Economist.)

McKinsey’s researchers began with the common-sense proposition that there are two likely explanations for this nation’s astronomical health care bill:  Either the U.S. population is less healthy that the citizens of other nations–or the U.S. system is intrinsically more expensive, independent of the relative health of the population.  Researchers then compared the prevalence of some 130 diseases in the U.S., including the most common disease groups, with their prevalence in Japan, Germany, France, Italy, Spain and the United Kingdom.)

What they discovered will surprise many: While Americans are fatter than their counterparts in many other countries, they are not significantly sicker. “The differential impact of the 130 diseases studied is less than $130 billion in treatment costs,” the researchers observe. Obesity was one of the diseases studied, along with conditions related to obesity such as congestive heart failure, diabetes, anxiety and various types of cancer.  [One caveat: it seems to me possible that, overall, Americans are, in fact, sicker than adults in Western Europe and Japan. But in the U.S., chronically ill adults also tend to be poorer, and research shows that they don’t receive as much care as other Americans. This could be why a less healthy population is not costing us more. Other developed countries offer universal access to care.  Nevertheless, this post is about cost, and the McKinsey study makes it clear that neither obesity nor other diseases are responsible for the huge differential in how much we lay out for medical care when compared to other nations.)

Aaron Carroll, writing on the Incidental Economist, turns McKinsey’s data into a brilliantly clear graphic.

Carrolchart

“Yes, obesity is more prevalent in the US, and yes, caring for it costs real money,” says Carroll. “But even if we get obesity down to the levels in other countries, it’s not going to magically erase the problem.  There is no simple fix here.                                 

                     Breaking Down “Additional” Spending in the U.S.

When McKinsey’s researchers analyzed health care spending in different countries they adjusted for the fact that more prosperous countries will invariably spend more on medical care. But even after taking higher per-capita income in the U.S. into account, they found “additional” (or excess) spending in the U.S. concentrated in five areas: hospital inpatient care; outpatient care, drugs, administration, and insurance (in that order), with inpatient care and outpatient care accounting for 80 percent of additional spending. (Keep in mind that the pricey drugs administered in a hospital or outpatient setting, along with any devices used during inpatient or outpatient surgery, show up on hospital bills, so drugs and devices should remain high on the list of factors responsible for climbing medical costs).

Taking a close look at the major components of our health care system, MGI analysts found the main sources of higher spending: “Input costs—including doctors’ and nurses’ salaries, drugs, devices, and other supplies, the profits of participants in the system–explain the highest proportion of additional spending –or $281 billion.” (Note, these are 2005 numbers.) “Inefficiencies and complexities in the system’s operational processes” add another $147 billion. Finally, administration, regulation and intermediation cost another $98 billion of excess spending.” 

The report goes on to note that our fee-for-service payments to physicians encourage them to do more and see more patients. U.S. doctors see, on average, 1.6 times more patients than physicians in other countries. They also are paid more: in other developed countries specialists earn an average of 4 times GDP per capita, while generalists earn 3.2 times GDP; in the U.S. these numbers rise to 6.6 and 4.2 respectively. (Of course most U.S. doctors also pay for their own medical education. As I have suggested in the past, we would be better off subsidizing the education, as other countries do, rather than paying some specialists exorbitant salaries for 35 or 40 years.) 

In addition, McKinsey observes, in our for-profit system, “physicians frequently co-own facilities, such as ambulatory surgical centers, diagnostic imaging centers and diagnostic testing and procedure laboratories, and receive a share of their profits. The profit sharing counts for another . . .  $8 billion of higher spending.”

In our hospitals, the cost per day is 2.6 times higher than the OECD average, largely because we emphasize “acute care,” and “complex surgeries.” Many U.S. patients receive far more aggressive, intensive care than their counterparts abroad: One in five is likely to die in an intensive care unit (even though 90 percent say they would prefer to die at home.)  Yet, McKinsey confirms what we know: on average, the quality of care is no better, and we don’t live as long as the citizens of many other nations.

Outpatient centers “have grown rapidly by capturing high-margin procedures from hospitals,” the report adds. “The high profitability of these centers has driven physicians and investors to fund a rapid expansion in the number of these facilities, which has resulted in sub-standard operations and redundancy. For example, in a hospital a CT scanner will perform approximately 20 or 30 scans a day. In an outpatient diagnostic imaging center, “this same equipment will complete many less, since they tend to be open for fewer hours each day, and the breakeven number of scans can be as low as six to eight scans per day. Yet these scanners still require largely the same staff and maintenance as in a hospital setting.” Finally, physician ownership encourages doctors to self-refer; when they own the equipment, they refer “two to eight times more tests than their peers without equity interest.”  (Under reform, Medicare is beginning to address these issues, paying less when doctors use diagnostic equipment that they own or lease for their offices, and discouraging physician ownership of surgical centers.)

Ultimately, MGI concludes that “the overriding cause of high U.S. health care costs is the failure of the  . . . system . . . to regulate the necessary incentives to promote rational use by providers and suppliers.” By “rational use,” McKinsey doesn’t mean rationing. But it does mean stemming the waste—and this is what reform legislation sets out to do.

                        How Technology Propels Health Care Inflation

The McKinsey Report’s emphasis on inpatient and outpatient medical care, acute care and physician ownership of surgical centers and imaging centers where our doctors “do more,” reminds me of CBO Director Peter Orszag’s central insight into health care inflation:  “the single most important factor driving the long-term increase in health care costs involves medical technology.”

Orszag also took on the false claim that obesity was driving health care inflation: Spending per capita on Americans of all sizes rose by 34.6 percent from 1987 to 2001, Orszag reported in 2008.  Over the same span, he noted, the rise in the share of Americans who are obese accounted for only “4 percent” of all spending growth.

 The most recent CBO report confirms Orzag’s statement, pointing out that even if we suddenly won the war on obesity, and the share of U.S. adults with a body-mass index (BMI) of 30 or more shrank from 28 percent to 20 percent over the next ten years, per capita spending still “would increase to $7,230 in 2020—[only] about 4 percent less than the projected bill if 28 percent remain obese. Winning the war against obesity would shave just a few points off per capita health care spending over the course of a decade or more. (There are other, urgent reasons to try to win the battle, but reducing the deficit is not one of them.)

Yes, we are spending more on obese patients—just as we’re spending more on cancer patients.  But this is because we have many more treatments for obesity than we had twenty years ago, ranging from widely advertised weight-loss supplements to bariatric surgery. We also have more cancer drugs. And each year, the proliferation of new “technology” (which in the world of medicine refers not just to equipment, but to “breakthrough” drugs, new diagnostic tests and innovations in surgical procedures) means that Americans are taking more pills and signing up for more tests and surgeries. Physicians have more weapons in their arsenal, and they’re using them.

But, here’s the rub: “While technological advances on average have brought major health improvements,” Orszag observed, “they often then get applied in settings where their benefits seem much less obvious."

Many of those brave new inventions will help some people, but once they become popular, often they are over-used on patients who will not benefit.  And some new entries to the marketplace provide little or no benefit to anyone. They are no more effective than older products and treatments, though often they are riskier, because we know less about them. And, almost always, what is new flaunts a higher price tag, often much higher.

In other industries, the price of innovative technologies comes down over time. But this is not true in the healthcare market. Competition does not reduce prices. This is because the patient has far less leverage than consumers in other markets. We spend the bulk of our health care dollars on serious, chronic illnesses. Unlike someone who is thinking about buying a flat-screen TV, a very sick patient does not have the luxury of deciding to postpone the purchase until prices fall.  Moreover, when you are in pain—or afraid of dying—you are not hunting for a bargain. You are looking for first-class care. Most Americans believe that the costliest care is probably better care.

And while consumers can assess the quality of the picture on a flat-screen TV, they’re not in a position to judge which health care product or service is superior.  They haven’t gone to medical school—and comparing the effectiveness of two treatments is extraordinarily complicated, even for medical researchers. There are many variables to take into account. How sick were the patients? How many failed to follow the doctor’s instructions? How many were suffering from more than one illness? Did age or genetic differences play a role in how they responded to the procedure? The majority of laymen don’t have the time or the training to wade through the risk adjustment data, and figure out what might be the best treatment for someone who fits his or her medical profile. This is why we ask doctors to explain the pros and cons of various options, and how they might apply to our situation.

Meanwhile, drug manufacturers, device manufactures, and medical equipment companies –along with the hospitals that buy their products–know that most patients, and even a great many doctors, will simply assume that higher prices signal top-drawer medicine. Thus, when it comes to the big-ticket items that drive the nation’s health care bill, particularly “ground-breaking” technologies, sellers rarely compete on price. They just keep on adding more bells and whistles—which sometimes means innovation simply for the sake of innovation. The newest imaging equipment gives you a sharper image, but does it really lead to more life-savings diagnoses and treatments? Often, no one knows. The FDA doesn’t require that the manufacturer show that their new product is better than older rivals.

In other developed countries, governments regulate prices in various ways, and more questions are asked before exposing unsuspecting patients to new technologies. In the U.S. we are quicker to embrace what Michael Lewis once dubbed the “New, new thing.”  We love innovation. We also pay more for virtually every product and service, and each year, there are more new things to pay for.

In Part 2 of this post, I’ll explain why thinner Americans cost the health care system more than their overweight brethren—even on an annual basis. (In other words, it’s not just because they live longer.) One can’t help but wonder: doesn’t anyone blame the skinny people for health care inflation?
I’ll also discuss how much of the money that third-party payers and patients themselves lay out to fight obesity is squandered on “medications that produce only marginal benefits in the long-term.”  Bariatric surgery remains the one extreme, but effective answer—for the truly obese. Yet the side effects can be cruel. And we can’t perform bariatric surgery on one-third of the population. The procedure is a stopgap, not a final solution

I’ll also report what physicians studying obesity say about this terribly complex disease. Simply eating less and exercising is not the answer. Even when obese patients are completely compliant, and work hard under a physician’s supervision, more than 95% put back on any pounds that they shed. One can only imagine how discouraging this must be. 

I’ll also discuss what some of the latest research on prevention suggests could have a real impact on the population’s health. If we are committed to tackling the obesity epidemic, we should stop blaming the victims, expose the snake-oil cures,  and invest that money into serious research on the causes of the disease, while subsidizing bariatric surgery where truly needed. Finally, and perhaps most importantly, we need to take close look at the U.S. food industry. One way to make unhealthy food less attractive is to make it more expensive. But then we have to make sure that affordable, nutritious food is available.

28 thoughts on “No, Obesity is Not Driving Health Care Inflation –Part 1

  1. Hi Maggie
    Nice post.
    A interesting, but difft take on international disease prevalence below (link, and then quote). I am not making any opposing arguments–just putting it out there.
    Also, the PLoS study on obesity is controversial, and one of many contradictatory citations in the literature. The evidence on that one is still out.
    Brad
    http://content.healthaffairs.org/cgi/content/full/26/6/w678
    “Our tabulations show that for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004 (the most recent year for which data are available). The high U.S. prevalence of these costly conditions, such as heart disease, cancer, and diabetes, suggests that measures designed to prevent these conditions could yield lower spending in the United States.22 Indeed, estimates from the Centers for Disease Control and Prevention (CDC) indicate that 80 percent of diabetes, heart disease, and stroke could be eliminated through reductions in smoking and obesity.23 Based on differences in obesity rates between the United States and Europe (33 percent versus 17 percent), it would seem that at least part of the difference in prevalence rates is attributable to poorer underlying population health status in the United States.
    A voluminous literature exists highlighting the association between obesity, smoking, and several chronic conditions.24 Obesity has been linked to diabetes, hypertension, hyperlipidemia, heart disease, depression, back problems, asthma, arthritis, and some forms of cancer. Standardized (for age and sex) rates of total diabetes among obese adults are 14 percent, compared with 4 percent among normal-weight adults. Rates of hypertension are more than double those found in normal-weight adults.25 A recent comparison of disease rates and physiological measures between Americans and Britons found that Americans are more obese, are more diseased, and have elevated levels of disease markers such as systolic blood pressure, cholesterol, and HbA1c levels.26 These differences highlight the increased policy rationale for broader, more effective policies aimed at prevention.”

  2. Brad —
    Good to hear from yhou. Thanks for the comment and link to study by Thorpe et. al.
    I’m puzzled by one thing near the top of your comment. When you state that “the PLOS study is controversial” I’m not sure what you’re referring to. I’m not wrtiing about a PLOS study. Do you mean the McKinsey study? If so, has someone written about it questioning the data?
    The Thorpe piece that you link to does not suggest that it is contorversial. In fact, it cites the McKinsey study without caveat, saying “Our findings are consistentwith those recently estimated
    by McKinsey and Company.” (footnote to the same McKinsey study that I’m writing about here).
    I admire Ken Thorpe; I interviewed him while writing the book.
    But Thorpe is very focused on the harm caused by smoking and obesity–and the need for preventive care–to the point that he ignores other factors.
    For instance in this article, he dismisses medical technology as a major factor driving health care costs–without evidence.
    Thorpe writes: “Neither system capacity
    nor access to technology appears to account for the higher level of spending in the
    United States compared with these European countries.”
    As evidence for his statement he cites only the 2003 article “It’s the prices stupid!.” It’s a perfectly good piece –I remember it–and at the time, Anderson et. al.were trying to call attention to the fact that we pay more for everything. In 2003, that factor wasn’t not getting the attention it deserved.
    But at this point in time, there is pretty much of a consensus that we spend so much on health care BOTH because we pay more for everything, and because we “do more”to patients.
    Thorpe et. al. slide over the fact that we use far more medical techdnology and that doctors in the U.S. “do more” when they write: “Organization for Economic Cooperation and
    Development (OECD) data shows little difference in capacity—physicians,
    nurses, and hospital beds per capita and hospital days per capita—between the
    United States and OECD countries Thus, the residual (and unmeasured) differences
    in spending are thought to reflect higher payments for services in the
    United States.”
    Here they ignore the fact that even if we have the same number of doctors per capita as some (not all) countries, our doctotors see 1.6 times as many patients (McKinsey). They prescribe more drugs than docs in most countires (except Switzerland), they run many more lab test and diagnostic imaging tests and those tests lead to more aggressive treatments.
    We have a higher ratio of specialists than many countries. We do far more surgeries (I’ve quoted ATul Gawande’s statistic on this in the past.)
    Finally, while hosptial stays in the U.S. are shorter than in some countires, as Elliott Fisher points out “more happens to you when you’re there.” You see more specialists, undergo more tests and procedures.
    And, as you know, when it comes to technology, we have far greater capacity– more scanners (see McKinsey) more equipment the size of a football field designed to treat prostate cancer, more ICUs.
    One in five Americans dies in an ICU
    In addition, while the Thorpe study looks at 10 diseases, McKinsey looks at 130– a more thorough comparison of disease prevalance.
    But, as I say in the post, I’m not convinced that we AREN’t sicker than the citizens of other countries–and that isn’t really what the McKinsey study shows. It shows only that the high COST of health care in the U.S. isn’t driven by higher prevalence of disease. More disease accounts for only $130 billion of what we spend on health care– a tiny fraction of the pie. (See pie chart in post.)
    On the question of whether we are sicker than the citizens of other countries,let me repeat what I wrote in the post: “[One caveat: it seems to me possible that, overall, Americans are, in fact, sicker than adults in Western Europe and Japan. But in the U.S., chronically ill adults also tend to be poorer, and research shows that they don’t receive as much care as other Americans. We don’t spend as much money on them annually or over the course of a lifetime.This could be why a less healthy population is not costing us more. Other developed countries offer universal access to care. Nevertheless, this post is about cost, and the McKinsey study makes it clear that neither obesity nor other diseases are responsible for the huge differential in how much we lay out for medical care when compared to other nations.)
    After writing the post, I found another article which seems to confirm my suspicion. It look at 6 diseases in the U.S. and other countries and concludes that: Americans are less healthy . . . but “Smoking, obesity, physical activity levels, and alcohol consumption explained a fraction of health variations.” http://ajph.aphapublications.org/cgi/content/abstract/99/3/540 According to the article, in the American Journal of Public Health, the big difference is Poverty in the U.S. We’re in poorer health because we have more poor people a they are in much, much poorer health. Greater disparities between rich and poor than in Europe. The psycholgical consequences of being poor–stress, anger, depression– take a huge toll on the body, and lead to self-medication (smoking, drugs,binging etc.)
    Finally, Thorpe et al. claim “Our findings are consistent with those recently estimated
    by McKinsey and Company.”
    In fact, they are Not consistent. McKinsey is saying that poorer health is Not the explanation for why we spend more on health care. In the next sentence Thorpe et. al.,don’t admit that McKinsey says poorer health accoutns for only $130 billion of health care spending, instead Thorpe writes: “Developing precise estimates of the share of
    theU.S.-European difference in spending linked to higher diagnosed (and treated)
    prevalence rates in theUnited States is conceptually difficult.”
    In fact, putting a number to the cost of disease is preicsely the sort of thing that McKinsey does very well. They have the computers, the know how . . . This is why businesses pay them vast sums–they know how to quantify things.
    Finally, at the end of their article, Thorpe et.al. undermine their entire argument by acknowledging that because we do so much testing, we diagnose and treat much more disease than doctors do in Europe, and this could be why prevalance of disease looks so much higher.
    They write: “The case of cancer is illustrative. According to our estimates,
    the prevalence of diagnosed cancer was 12.2 percent in the United States but only
    5.4 percent in Europe in 2004. Are Americans really more likely to develop malignant
    tumors, or are they just screened more intensely than Europeans are? Comparisons
    of breast cancer screening rates and five-year cancer survival rates suggest
    the latter.
    The impact of more aggressive treatment on patient outcomes is important to
    consider as well.”
    The article ends: “Our results suggest that differences
    in both underlying health status and medical practice patterns contribute
    to differences in diagnosed disease, treated prevalence rates, and the higher
    rate of per capita spending in the United States.”
    Sorry to go on at such length, but your comment and the Thorpe paper reminded me how people who focus on obesity tend to exaggerate its importance in $$ terms. Of course, in human terms, obesity is taking a terrible toll.
    But finally, when Thorpe et al talk about “preventing” obesity and saving a huge amount of money, they don’t quite come to terms with the fact that we don’t have any effective cures for obese people except bariatric surgery.,
    Exercise, dieting, taking medication have only a limited and temporary effect for 95% of the obese. The medical literature is very clear on that.(See past posts: “Fat!”–part 1 and 2.
    Of course “preventing” obesity is different from curing it. There is much more hope that at a population level we could prevent kids from becoming obese by improving the food they eat and opportunities for exercise.
    But so far, we haven’t been able to reverse the trend of growing obesity among kids.
    In part 2 I’ll be talking about what might work–

  3. Maybe obese people need to consume less calories than they expend. Maybe they need to get off their butts and move.

  4. We all know there are lots of reasons for the high cost of healthcare and obesity is just one of them. It costs less to treat the obese because they have a shorter life span. Maybe that’s the secret. We should encourage obesity and our healthcare spending will be reduced!!

  5. “Health, Money and Fear” is a 48 minute video, produced by an emergency physician, that objectively and methodically illuminates the multitude of “incentives” that drive up the cost of health care. It is available for viewing at:
    http://www.ourailinghealthcare.com.
    The underlying reason is that we don’t have a health care system. We have a sick care non-system.
    check it out. you will be started at it’s clarity.
    Paul Hochfeld
    (ER Doctor/producer)

  6. Maggie,
    I’ve been a fan for a long time and read your blog religiously. The analysis in this article is very impressive particularly your discussion toward the end regarding the actual incentives which drive up health care costs.
    I would add that not only does the new imaging device with a sharper display cost more than the older device, it may actually be less effective than the older device because it causes physicians to omit or disregard other pertinent aspects of the patient’s overall presentation due to the “wow” factor from the new technological advance.
    I was also surprised to learn the facts regarding just how little the surging obesity crisis actually ads to health care spending.
    I’m looking forward to part 2 of this post. Thanks again.
    C. Onyeije, M.D.

  7. Maggie,
    Thanks so much for refocusing our eyes on reality despite the real US childhood Obesity epidemic which must be addressed.
    But it should NOT divert us from the real mega- drivers of health care cost inflation.
    I’ve been reading Arnold Relman’s papers recently and he seems to echo much of what you believe?
    Dr. Rick Lippin
    Southampton,Pa

  8. Frank,Henry,Dr. Rick, Chukuma O., Paul
    Frank– Maybe you need to learn more about what doctors understand about obesity. There is an excellent documentary titled “Fat” that you can rent or buy. I write about it, plus the medical research in a two-part blog titled “Fat!” (Try Googling it,along with my name and “Fredericks,” the name of the director.” It’s a great documentary–not just educational–you will enjoy it!
    Henry–
    Yes, the obese cost us less over the course of a lifetime, because they die sooner. (Smokers cost us even less because they die even sooner.)
    Dr. Rick-
    Thank you. As you suggest, , obesity–particuarly among young people– is a national tragedy
    But the problem is not that it’s costing us so much. The cost comes in lives that are shortened, and people who are stigmatized by our society.
    You’re right–Relman and I are basically on the same page. I admire his work very much. I wanted to interview him for my book, but at that point no one had heard of me, and so he didn’t return my calls.
    Chuckuma O.–
    Thank you very much.
    It’s always wonderful to hear from my “silent readers”
    The numbers tell me
    that there are a great many of you out there, but I don’t know who you are.
    It helps, when writing the posts, to be able to imagine the audience–your interests and concerns.
    And, yes, I entirely agree that the “Wow factor” of new technology really can overshadow other even more pertinent information–what docs hear when they listen to patients, what they see when they look at patients, what they feel when they lay hands on patients, what they know, intuitively, by having seen so many other patients, and reocognizing something that they have seen, heard or smelled before . .
    Paul–
    Yes, we don’t have “organized medicine.”
    We have “disorganized medicine.”
    Thanks for the link to the documentary–I look forward to looking at it. at it.

  9. Maggie- Alow me one more “high on my moral horse” comment
    I have walked out of meetings in protest of senior health economists publically arguing that prevention “is not cost-effective” because people might live longer.
    I believe that to be a fundamentally immoral argument.
    Dr. Rick Lippin
    Southampton,Pa

  10. “MGI concludes that ‘the overriding cause of high U.S. health care costs is the failure of the . . . system . . . to regulate the necessary incentives to promote rational use by providers and suppliers.'”
    I think this is the first time I’ve seen any mainstream economist (other than the Dartmouth Atlas researchers) admit that “irrational use of the system” is on the part of providers and suppliers. Conservative economists and analysts always blame the “customers” or “consumers” (they used to be called “patients”) for “overusing” the system and demonstrating the “moral hazard” of having insurance because they “want everything”. This is a breath of fresh air. However, as you point out, the “spin” has already begun.

  11. “Indeed, even if, by some miracle, we suddenly understood the multiple causes of obesity…”
    No miracle is needed. The same dietary factors that generate inflammatory responses leading to cancer, heart disease, stroke, diabetes, etc., are responsible for boosting the percentage of fat people among us. The major culprits are excessive fructose and omega-6 intake. Google “1 of 4 Dr. Bill Lands” to learn about the primary prevention of chronic inflammatory diseases.

  12. Rick —
    You say “I believe that to be a fundamentally immoral argument.”
    I may be a little confused by what you are saying, but you seem to be arguing that it is more moral to LIE about the facts concerning preventive care than to tell the truth.
    I believe it is more immoral to allow people to talk about the idea that good health habits can create significant savings in US health care than to face the facts that that is not true and that the high costs in US health care are mostly due to overuse of procedures and treatments that are ineffective. As I have written often before, I believe it is immoral not to face these facts squarely and take appropriate steps to deal with them, since if we do not we will end up depriving most Americans of health care that will have become unaffordable for the country, businesses, and individuals.
    That said, “preventive” care needs to be divided into two categories. One is the encouragement of people to have good health habits, to not smoke, not overeat, and to exercise. That is morally correct but economically not useful. People should do that to lead better and longer lives, but there should be no expectation that it will save money.
    The second type of preventative care is appropriate intervention. That included vaccinations, getting good insurance for all people so that they seek early intervention for treatable conditions rather than allowing them to end up in the ICU, maternal and child care, and so on. These things have been proven to be cost effective.
    However, in the end, to quote Walt Kelly, “we have met the enemy and he is us.” Doctors need to join in the support and practice of rational medicine to avoid useless spending that is bankrupting America.

  13. Good Points Pat S- But my idealism will try to trump you one more time. It is immoral to put a price tag on human flesh and human souls period.
    But it is done every day and probably is necessary.
    Ergo-It must be done with the most rigorous fairness and compassion that we can possibly muster.
    Dr. Rick Lippin
    Southampton,Pa

  14. Dr. Rick, Pat S., A. Carroll, David Brown
    Dr. Rick-I agree that it is immoral to suggest that we shouldn’t invest in effective preventive care because it will not save money.
    But, like Pat, I also think it is immoral to lie to people and pretend that much of what we call preventive care will save money.
    Also, I’m pretty skeptical of many of the “wellness” programs that pretend that they can help people lose weight. People lose some weight, then put it back on. No health benefit, but some middle-men make money.
    Somking cessation programs, providing drugs and nicotine patches, on the other hand, can be very effective. They don’t save money (the former smokers live longer), but they are well worth the investment because they reduce suffering.-That, it is seems to me, is the moral high ground.
    The goal of health care is not to save money; the goal of health care is to reduce human suffering. We need to do it as efficiently as possible, or we won’t be able to afford to do it for everyone, but we need to keep clear on our primary goal.
    Pat. S. I agree that there are two kinds of preventive care. On the whole, I think the U.S. Preventive Services Task Force is a good guide to effective preventive care.
    As I said to Rick I’m skeptical of some (not all) “wellness programs” that involve lecturing people about losing weight, giving them pamphlets, paying for medications that don’t work (or risks outweight benefits) and financially penalizing people who are obese (with higher premiums). Often, this is done by lowering premiums for people who meet certain BMI or weight goals–but people who don’t meet the goals then wind up paying higher premiums to make up for the breaks that thinner people are getting.
    Often, these programs are aimed at discouraging over-weight people from taking a job with a particular employer–or reducing the number of people who sign up for a particular insurance policy. It’s a subtle form of “cherry-picking.”
    I totally agree that lying about the cost-effectivness of much preventive care is immoral.
    ACarroll-
    Yes, I think it is pretty impressive that McKinsey would spell out that the big problem is waste and overutilization, and that providers have to begin to rein in that waste.
    And no one is going to accuse the McKinsey reserachers of being socialists who want to “ration” care.
    David Brown–
    If someone had figured out a cure for obesity, I think we would have heard about it–and seen testimonials from a great many people who lost weight and kept it off for 2 or 3 years.
    Also, someone should tell all of the people having bariatric surgery that they don’t need to do it.
    As I will explain in part 2, there are multiple factors involved.

  15. OK you forced me to play my last card –
    My “prevention program” is JOBS for all!- good,secure,safe jobs with decent wages and benefits
    The rest is probably trivial
    Dr. Rick Lippin
    Southampton,Pa

  16. Thanks for this, Maggie. And re: your statement:
    “And while consumers can assess the quality of the picture on a flat-screen TV, they’re not in a position to judge which health care product or service is superior.”
    The story the NYTimes ran earlier this month about Consumer Reports rating surgical groups included this tell:
    “The society, which has been tracking surgeons’ performance since 1989, gave the information to Consumer Reports. More than 90 percent of the nation’s heart surgery programs participate in the society’s registry.
    The 221 groups in the Consumer Reports ratings, fewer than a quarter of those performing bypass surgery in the United States, are the only ones who permitted their information to be published.”
    So even when we TRY to obtain the information to make informed decisions, the very people being rated control whether we know about them. Surgeons are not refrigerator, and unlike surgeons, buying a bad one won’t kill you.

  17. While obesity certainly can lead to health issues, I think it is unnecessarily correlated with many health issues that can happen to anyone, regardless of weight.

  18. As a sociologist who researches weight stigma, I say this is an excellent well thought out article. Although I would like to point out that one of the reasons so many people are “obese” is pharma’s (via Uncle Sam) redefinition of correct weight to sell more pills. It should also be pointed out that many obese people live as long as thin people. Very obese people have shorter life spans, as do poor people who tend to be fatter. But you will find many fat people live healthy and robust well into their 80s. Our government is clearly highjacked by corporate interests and using obesity as a scapegoat.

  19. And one more thing to Dr Rick who I know from Alternet, prevention for weight does not work because it keeps focusing on the lifestyle when that is only one part of the equation. Until they address things like stress, overwork, pollution, environmental estrogens and a host of other things that cause obesity, all you will get is a part of the population that is perpetually nagged. That is all weight control programs really are. They are based on the scientifically obsolete theory of calories in vs. out, and when patients cant live on reduced calories for the rest of their lives, they are blamed. There is no point to a longer life if one can’t enjoy it.

  20. Obesity isn’t a disease. It’s a weight/height ratio as defined by BMI, and many people with BMIs over 30 are healthy and will live long, full productive lives without weight loss. I don’t know why this fact is so rarely noted.

  21. Sherie,Deidre, Elizabeth,Riggsveda . .
    Sherie– Thank you. Clearly, you know the subject well and people should pay attention to what you say, so I’m going to repeat it here:
    “One of the reasons so many people are ‘obese’ is pharma’s (via Uncle Sam) redefinition of correct weight to sell more pills. It should also be pointed out that many obese people live as long as thin people. Very obese people have shorter life spans, as do poor people who tend to be fatter. . .
    Yes, very obese people die sooner. And poor people die earlier (for many reasons.) But many overweight (or even obese) people can be in good health and live long lives–particularly if they are physically active, and exercise.
    And, yes, businesses selling all sorts of medications, equipment, and diet programs have helped convinced Americans that they need to be slim, Normal weight just isn’t good enough. Many young women feel that they must be a size 6-8–at worst, a 10. Yet larger young women can be both healthy and beautiful.
    Everything is in the eye of the beholder, which depends on time and place. If you one goes back and look at the movie stars of the 40s and 50s . . .By today’s standards, Doris Day would be considered hefty.
    You also point to the many causes of obesity– “like stress, overwork, pollution, environmental estrogens and a host of other things that cause obesity,”
    As you suggest, if we focus only on the simplistic idea that obestiy is about “calories in, calories out” all we will achieve is making sure that “a part of the population is perpetually nagged. That is all weight control programs really are. They are based on the scientifically obsolete theory of calories in vs. out, and when patients cant live on reduced calories for the rest of their lives, they are blamed. There is no point to a longer life if one can’t enjoy it.”
    Deidre–
    Thanks much for your comment.
    Yes,I think you’re entirely right: BMI is over-rated as the be-all, end-all standard for obesity.
    At the same time, I can’t agree that obesity “isn’t a disease.” What doctors call “morbid obesity” is a disease– it causes many health problems and suffering, followed by early death.
    In my view, the big problem is that we blame these patients for the disease–medical science hasn’t been able to find a way to help them, except through bariatric surgery, which is an extreme solution.
    Please see my reply above to Sherie–I think you two would probably agree on the main issues.
    Elizabeth:
    You write: “While obesity certainly can lead to health issues, I think it is unnecessarily correlated with many health issues that can happen to anyone, regardless of weight.”
    Yes. Doctors tell me that often, when patients die in a hospital, if they are overweight, the cause of death is listed as “obesity”–even though hypertension (which led to congestive heart disease) or a separate disease may have led to the person’s death.
    Riggsveda–
    Thanks for commenting.
    Consumers really don’t have the information they need to compare quality–hospitals are relucant to put this info out there But much of the the info also can be hard to interpret.
    If more patients died after underging heart surgery, does that mean that the hopsital takes paients who are older, poorer and sicker?
    Alos, lived/or died is not the only measure of quality. There are othe rquestions to ask: if the patient died, did he receive palliative care, or did he die in great pain? Also, was the surgery necessary in the first place?

  22. I admit that I didn’t read everything here but mainly reacting to some of the comments that were made. I think we have to look at the issue at hand more broadly than just on the cost side. Smokers & the obese may cost less in terms of medical spend over a lifetime due to a shorter lifespan, but a shorter lifespan means a waste of investment in making a human life productive (think education, experiences, etc). A healthier individual is also likely to be more productive and can contribute more to society, while a smoker/obese person is less likely to be healthy (all other things being equal). So once you add in all these other costs there is a huge incentive to lowering smoking and obesity rates, even if doing so may not have a significant impact on reducing health care costs.

    • This person did not read the article but wants to pass judgement on smokers & fat folk that they are not as educated. wow. I guess the media is winning over the masses. Hitler would be so happy to see a pure race.

      • Rocky–

        Yes, you are entirely right: low-income people are far more likely to smoke (it’s one way to respond to the stress of
        being poor) and they’re more likely to be obsese (fewer opportunities to exercise, affordable fresh vegetables and fish not as available in their neighborhoods.

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    • Boots Theory–

      I’m afraid that what you say is true. Too often, people who are thin are very smug –as if their body type was a sign of inner virtue.
      Typically, thiness is a combination of genetics, body chemistry, environment . . . Being overweight is not a sign of a character flaw. And if you’re active– walking, dancing, swimming– you can remain in good health, even though you’re overweight. (Morbid obesity is an extreme that does threaten your health. But most “fat” people are not morbidly obese.)

      The largest share of our health care dollars are spent on people suffering from chronic diseases –particularly when those diseases are not managed well, and they land in the hospital.

      In addition a fair share of our health care dollars (maybe one-third) are squandered on unnecessary operations (back surgery for low–back pain, heart surgery that doesn’t save lives, unnecessary knee replacements because someone wants to improve his tennis game . . )
      Hip and knee replacements are life-savers for people in great pain who cannot find any other way to relieve the pain. But
      physical therapy and exercises recommended by the physical therapist are worth trying first. Hip and knee replacements have become
      too popular and some of replacements that device-makers have been selling (at exorbitant prices) are not that good.

      Bottom line: overweight people are not driving health care inflation.