PAUL D HAIN, MD, FAAP NORTH TEXAS MARKET PRESIDENT Lifesty tyle Choice oices and nd Impa Impact on on Claim ims Why Healthcare is so Expensive and How to Live Healthier @drpdhain A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Audience Participation: Americans are sicker than Europeans. False. @drpdhain A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Audience Participation: Higher prices are the #1 reason America’s healthcare spending is increasingly more than Europe’s. True. @drpdhain A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
After Adjustment for Wealth, U.S. Still Spends More Than Other Countries
But the U.S. is Not as Sick as Europe
Spending in the U.S. Increased $930 Billion 1996-2013 $583 $600 $500 $400 $300 $269 $200 $136 $100 $0 -$28 -$27 -$100 Disease Prevalence Utilization Aging Population Size Price Increases “Factors Associated With Increases in US Health Care Spending, 1996-2013.” November 7, 2017. JAMA.
Cumulative Change in Price, Utilization and Spending 2012-2016 Health Care Cost Institute: 2016 Health Care Cost and Utilization Report
A recent driver of higher facility prices is hospital consolidation . Physicians control costs much more effectively when they are independent. @drpdhain
Robert Wood Johnson Foundation Study: SUMMARY OF KEY FINDINGS The Impact Of Hospital Consolidation Hospital consolidation generally results in higher prices Hospital competition improves quality of care Physician-hospital consolidation has not led to either improved quality or reduced costs
“ Increases in physician- hospital integration from 2008 through 2012 were associated with increased spending and prices for outpatient services, with no accompanying changes in utilization that would suggest more efficient care from better care coordination and economies of scale.” JAMA Intern Med. Doi: 10.1001/jamainternmed.2015.4610 Published online October 19, 2015.
“The most definitive finding is that hospital ownership of physician practices leads to higher prices and higher levels of hospital spending .” “Vertical Integration: Hospital Ownership of Physician Practices Is Associated With Higher Prices and Spending.” Health Affairs, May 2014.
A Texas Problem: Freestanding Emergency Rooms • 75% of all patients seen at FSERs can be seen in urgent care • $2,200 vs $168 average cost • Deliberate confusion of patients (As seen on the website of an out-of-network FSER) Comparing Utilization and Costs of Care in Freestanding Emergency Departments, Hospital Emergency Departments, and Urgent Care Centers Vivian Ho, PhD*; Leanne Metcalfe, PhD; Cedric Dark, MD, MPH; Lan Vu, BS; Ellerie Weber, PhD; George Shelton, Jr., MD, MPP; Howard R. Underwood, MD, FSA
OECD Expenditure on Pharmaceuticals Per capita, 2013 (or nearest year) 1. Includes medical non-durables (resulting in an over-estimation of around 5-10%). 2. Excludes spending on over-the-counter medicines. Source: OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en.
Costly New Specialty Drugs Are Major Driver of Increased Health Spending
National Trends in Pharmaceutical Spending (per capita, 1980-2015) Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier? The Commonwealth Fund, October 2017
Summary — Healthcare Costs • The #1 cause of high healthcare costs in the U.S. is prices. • Hospital Consolidation raises costs and prices. • Freestanding Emergency Rooms are very expensive and raise the cost of healthcare. • Pharmaceuticals are already 10% of our spending, and the fastest growing part of the increase in healthcare costs. • The U.S. pays far more for the same drugs than any other country in the world. @drpdhain 17
How to Stay Healthy @drpdhain A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Relative Mortality Risk for Conditions 3 2.8 2.6 Smoker Relative Risk of Mortality Lowest Fitness 2.5 High BMI 2 1.7 1.5 Recommended BMI Middle Fitness 1 1 1 Non Smoker 1 0.5 0 1 2 3 Smoking Fitness Obesity Sources: 1. “21st-Century Hazards of Smoking and Benefits of Cessation in the United States” N Engl J Med 2013;368:341-50. DOI: 10.1056/NEJMsa1211128 2. “ Physical fitness and all-cause mortality. A prospective study of healthy men and women .” JAMA. 1989 Nov 3;262(17):2395-401. 3. “Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies” Lancet 2009; 373: 1083–96 19
Quit Smoking “There is a significant drop in the rate of acute myocardial infarction hospital admissions associated with the implementation of strong smoke-free legislation.”
Exercise (at least a little) Sources: “Sitting too much, not just lack of exercise, is detrimental to cardiovascular health.” UT Southwestern Medical Center. July 7, 2014. “Every Minute Of Exercise Could Lengthen Your Life Seven Minutes.” wbur’s Common Health Reform and Reality. March 15, 2013. “Taking up physical activity in later life and healthy ageing: the English longitudinal study of ageing.” British Journal of Sports Medicine . Jan. 10, 2014. 21
Incidence of Cancer by Midlife Cardiorespiratory Fitness JAMA Oncology. 2015;1(2):231-237. doi:10.1001/jamaoncol.2015.0226 22
Years of Life Expectancy Lost after Age 40 by Physical Activity and Body Mass Index Leisure Time Physical Activity of Moderate to Vigorous Instensity and Mortality: A Large Pooled Cohort Analysis. PLOS Med. Nov. 6, 2012. 23
Annual Costs by Mid Age Fitness Level Cardiorespiratory Fitness in Middle Age and Health Care Costs in Later Life, Journal of the American College of Cardiology , October 2015 24
Changes in Physical Fitness and All-Cause Mortality It’s Never Too Late to Start 122 67.7 39.6 Fit to Fit Unfit to Fit Unfit to Unfit Age-Adjusted All-Cause Mortality/10,000 PY (Five years between exams, on average) Changes in Physical Fitness and All-Cause Mortality: A Prospective Study of Healthy and Unhealthy Men. Journal of American Medical Association . April 12, 1995. 25
20-40 minutes of “Combined together, Brisk walking/day a lack of activity and a high BMI were associated with 7.2 years of life lost relative to meeting recommended activity levels and being normal weight.” For comparison, long term cigarette smoking reduces life expectancy by approximately 10 years. “Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis.” PLOS Medicine . Nov. 6, 2012. 26
What You Eat Is Important Diet and Obesity Still Matter @drpdhain A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 27
“Ultimately, weight loss requires consuming fewer calories than expended. A common misconception of this thermodynamic principle de-emphasizes the importance of dietary composition…an alternative view, the metabolic effects of refined carbohydrate cause the adipocyte to take in, store, and trap too many calories…If so, treatment focused on dietary quality, rather than advice to eat less, could help…” “Increasing adiposity: consequence or cause of overeating?” JAMA. 2014 Jun 4;311(21):2168.
“The Dietary Guidelines Advisory Committee, which convenes every five years, followed the lead of other major health groups like the American Heart Association that in recent years have backed away from dietary cholesterol restrictions and urged people to cut back on added sugars.” -The New York Times 29
Healthy Eating Plate, Harvard Health Publishing, Sept. 2011. Updated June 5, 2017. 30
Just What is Whole Grain? • Whole Grain consists of bran, germ, and endosperm. • Processed flour strips out bran and germ, which can help in making light, fluffy pastries. • Processed grains lose more than half of wheat’s B vitamins, 90 percent of the vitamin E, and virtually all of the fiber. • Bran contains fiber, which slows the absorption of the carbohydrates, and helps keep glucose under control. • Fiber can also lower cholesterol. “The Nutrition Source,” Harvard T.H. Chan School of Public Health. http://www.hsph.harvard.edu/nutritionsource/whole-grains/
Real Food is Key “A diet of minimally processed foods close to nature, predominantly plants, is decisively associated with health promotion and disease prevention and is consistent with the salient components of seemingly distinct dietary approaches.” Sources: Science Compared Every Diet, and the Winner Is Real Food, The Atlantic . March 24, 2014. Can We Say What Diet Is Best for Health? Annual Review of Public Health, March 2014. 35:83-103. 32
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