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A Plausible Future of Health
The sub-title to this piece is “Patient-Advocates as Harbringers of Hope in the Health Care System.”
Disclaimer: I am a Libertarian-Progressive. I generally trust markets more than I trust government, primarily because I think it’s easier to inspire real change and harder to make massive mistakes in the free market — however I think government must harness the power of markets and put bumper-rails in to protect the masses from greed overdoses. I supported Barack Obama in the 2008 election and continue to do so. In advance of his healthcare speech, and at the tail-end of a lengthy vacation where I discussed my views, I decided to pen the following missive.\n
This post is about 1250 words, if, like most, you are far too lazy to read something of that length, here’s a good summary:\n
Today, doctors are manipulated by the fear of malpractice into recommending unnecessary procedures that individuals accept because of an information disadvantage. We have little compulsion to overcome this disadvantage because we are not the primary buyers of our own health care. The current position is untenable, and it’s in our interest to influence change with the free market. There are models we can build off, and in the future, it seems likely that patient-advocates will possess the medical knowledge and fiduciary responsibility to allow their clients to decrease their personal costs and increase their quality of life despite a broken system, beating the path down good health reform. I’ve called this new industry “FutureHealth” in my own thinking, but I don’t like the way that sounds. Can you suggest a better name in the comments?\n
OK, that wraps up the word sushi, on with the more gluttonous show…\n
I backed Obama for his strength in foreign policy and the economy, on those fronts he’s made careful and reasonable decision –curbing a massive economic decline while positioning the US well abroad (specifically regarding War in the Middle East and the Iran Election). He’s done us one better and placed his political chips on the table of the most pressing economic issue today: health care.\n
People often take issue with framing health care as an economic issue — at it’s core it deals with the life and well-being (or lack there-of) of human beings, so it’s clearly a social issue, and yet — 20% of total government spending is on medicaid/medicare and both government and personal health spending are rising at rapacious rates (2 to 3 percent faster than inflation). If we don’t fix health care, it will bankrupt well before it kills.\n
There have been a series of fascinating articles this summer exposing the perverse economics of health care — two stand out: Atul Gawande’s watershed piece in The New Yorker, “McAllen, Texas and the high cost of health care” and, more recently, David Goldhill’s piece in the Atlantic Monthly, “How American Health Care Killed My Father.” Both conclude the incentive structure of the medical system is broken. The Doctors, fearing malpractice suits, recommend unnecessary procedures. Patients, at a severe information disadvantage and with little skin in the game perceived when it comes to payment, accept this recommendation. Insurance foots the bill and in search of greater profits tries to shirk as many payouts as possible and, if faced with an inability to do so, raises rates (making it harder for individuals to maintain health insurance).\n
The heart of the health care problem therefore seems to be unnecessary procedures (estimated at 30% of annual medical costs) and lack of innovation in the patient experience.\n
To solve both issues, patients must become the central focus of the system. By creating strong financial incentives for patients to judiciously use health care you would create a health services industry that must curb costs and cater to the patient’s experience, improving care, along with an information industry that will eliminate the information disadvantage that allows patients to be easily manipulated today.\n
Unfortunately, a quick, sweeping change (legislative or otherwise), requiring individuals to foot more medical bills is unlikely (at best) to happen when one of the largest industries is involved, people’s pocketbooks are at stake and there’s no existing use to defend that this system will be preferable in the long-run. Our brains are bad at evaluating risk-reward when the status quo is an option (for however briefly) and the risk involves our health and our savings account.\n
This means the change must happen gradually, and likely (at least initially) through market forces rather than legislation.\n
Luckily, there is already a subset of early adopters that care aggressively about health and patient experience and have been spurring innovation on both fronts: the wealthy.\n
The wealthy have developed a tool that helps them navigate the complexities of health care, enjoy a better patient experience, and obtain the information and access required for better preventive care: concierge doctors. Concierge (also known as “boutique”) doctors require extra cost from a more limited subset of patients who receive expiriential perks like same-day appointments and higher levels of access to their doctor. These can range from the expensive MD2 (24K/year for a family) to the relatively inexpensive (I pay $150/yr to a concierge practice in San Francisco), but access and benefit tends to flow linearly across that range (at the end of the day you’re buying time from highly skilled, valuable people).\n
Boutique medicine puts the patient in the buyer’s seat and creates an opportunity for the patient to take much more control of their health and utilize preventive care to decrease health needs. Once the patients health costs are more predictable (and probably far below the average), the concierge relationship helps the patient gain information advantage to increase confidence in making alternative purchasing decisions, perhaps self- or co-operative insuring.\n
So, there’s a clear path to improving health care, and the first hurdle in our way is visible and defined. A company that can accomplish the same (or similar) effect as boutique doctors for the rest of us will create the passage point to the future of health care.\n
At the highest level, this new class of doctors need not be doctors at all, but rather “patient-advocates” that maintain enough medical knowledge to ensure proper care and are capable of supporting and helping patients through both simple and complex medical situations. At the lowest levels, this function may be a game or service that encourages more healthful activity (think DailyMile, tweetwhatyoueat, FourSquare, or others).\n
There are many people in this FutureHealth industry, but one seems particularly well-placed to bring about the next step in the industry’s evolution, a small company called HelloHealth (disclaimer: Jay Parkinson, CEO of HelloHealth, is a friend). They are creating a platform where doctors can interact with patients in a more traditional primary-care role: hands-on, preventive care administered in a personal fashion. To the extent that HelloHealth can create technical tools that help their doctors save time (like automated paperwork, electronic patient interactions, and more), they can lower the cost of access for patients into a realm affordable for the average joe (they seem to have already gotten into the high-end of this range).\n
Finally, I’ve dubbed this new industry “FutureHealth” in my head, but I don’t like the way that sounds. Can you suggest a better name in the comments?\n\n
Edit Notification: I published the first draft of this on my blackberry without review; I have sense gone back and fixed any typos and lack of links I could find. I have sent this to a few knowledgeable friends for feedback. I may edit again for clarity based on their suggestions.\n
The COVID-19 pandemic is making health disparities in the United States crystal clear. It is a clarion call for health care systems to double their efforts in vulnerable communities.
- The COVID-19 pandemic has exacerbated America's health disparities, widening the divide between the haves and have nots.
- Studies show disparities in wealth, race, and online access have disproportionately harmed underserved U.S. communities during the pandemic.
- To begin curing this social aliment, health systems like Northwell Health are establishing relationships of trust in these communities so that the post-COVID world looks different than the pre-COVID one.
COVID-19 deepens U.S. health disparities<p>Communities on the pernicious side of America's health disparities have their unique histories, environments, and social structures. They are spread across the United States, but they all have one thing in common.</p><p>"There is one common divide in American communities, and that is poverty," said <a href="https://www.northwell.edu/about/leadership/debbie-salas-lopez" target="_blank">Debbie Salas-Lopez, MD, MPH</a>, senior vice president of community and population health at Northwell Health. "That is the undercurrent that manifests poor health, poor health outcomes, or poor health prognoses for future wellbeing."</p><p>Social determinants have far-reaching effects on health, and poor communities have unfavorable social determinants. To pick one of many examples, <a href="https://www.npr.org/2020/09/27/913612554/a-crisis-within-a-crisis-food-insecurity-and-covid-19" target="_blank" rel="noopener noreferrer">food insecurity</a> reduces access to quality food, leading to poor health and communal endemics of chronic medical conditions. The U.S. Centers for Disease Control and Prevention has identified some of these conditions, such as obesity and Type 2 diabetes, as increasing the risk of developing a severe case of coronavirus.</p><p>The pandemic didn't create poverty or food insecurity, but it exacerbated both, and the results have been catastrophic. A study published this summer in the <em><a href="https://link.springer.com/article/10.1007/s11606-020-05971-3" target="_blank">Journal of General Internal Medicine</a></em> suggested that "social factors such as income inequality may explain why some parts of the USA are hit harder by the COVID-19 pandemic than others."</p><p>That's not to say better-off families in the U.S. weren't harmed. A <a href="https://voxeu.org/article/poverty-inequality-and-covid-19-us" target="_blank" rel="noopener noreferrer">paper from the Centre for Economic Policy Research</a> noted that families in counties with a higher median income experienced adjustment costs associated with the pandemic—for example, lowering income-earning interactions to align with social distancing policies. However, the paper found that the costs of social distancing were much greater for poorer families, who cannot easily alter their living circumstances, which often include more individuals living in one home and a reliance on mass transit to reach work and grocery stores. They are also disproportionately represented in essential jobs, such as retail, transportation, and health care, where maintaining physical distance can be all but impossible.</p><p>The paper also cited a positive correlation between higher income inequality and higher rates of coronavirus infection. "Our interpretation is that poorer people are less able to protect themselves, which leads them to different choices—they face a steeper trade-off between their health and their economic welfare in the context of the threats posed by COVID-19," the authors wrote.</p><p>"There are so many pandemics that this pandemic has exacerbated," Dr. Salas-Lopez noted.</p><p>One example is the health-wealth gap. The mental stressors of maintaining a low socioeconomic status, especially in the face of extreme affluence, can have a physically degrading impact on health. <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">Writing on this gap</a>, Robert Sapolsky, professor of biology and neurology at Stanford University, notes that socioeconomic stressors can increase blood pressure, reduce insulin response, increase chronic inflammation, and impair the prefrontal cortex and other brain functions through anxiety, depression, and cognitive load. </p><p>"Thus, from the macro level of entire body systems to the micro level of individual chromosomes, poverty finds a way to produce wear and tear," Sapolsky writes. "It is outrageous that if children are born into the wrong family, they will be predisposed toward poor health by the time they start to learn the alphabet."</p>Research on the economic and mental health fallout of COVID-19 is showing two things: That unemployment is hitting <a href="https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/" target="_blank" rel="noopener noreferrer">low-income and young Americans</a> most during the pandemic, potentially widening the health-wealth gap further; and that the pandemic not only exacerbates mental health stressors, but is doing so at clinically relevant levels. As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413844/" target="_blank" rel="noopener noreferrer">the authors of one review</a> wrote, the pandemic's effects on mental health is itself an international public health priority.
Working to close the health gap<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDc5MDk1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTYyMzQzMn0.KSFpXH7yHYrfVPtfgcxZqAHHYzCnC2bFxwSrJqBbH4I/img.jpg?width=980" id="b40e2" class="rm-shortcode" data-rm-shortcode-id="1b9035370ab7b02a0dc00758e494412b" data-rm-shortcode-name="rebelmouse-image" />
Northwell Health coronavirus testing center at Greater Springfield Community Church.
Credit: Northwell Health<p>Novel coronavirus may spread and infect indiscriminately, but pre-existing conditions, environmental stressors, and a lack of access to care and resources increase the risk of infection. These social determinants make the pandemic more dangerous, and erode communities' and families' abilities to heal from health crises that pre-date the pandemic.</p><p>How do we eliminate these divides? Dr. Salas-Lopez says the first step is recognition. "We have to open our eyes to see the suffering around us," she said. "Northwell has not shied away from that."</p><p>"We are steadfast in improving health outcomes for our vulnerable and underrepresented communities that have suffered because of the prevalence of chronic disease, a problem that led to the disproportionately higher death rate among African-Americans and Latinos during the COVID-19 pandemic," said Michael Dowling, Northwell's president and CEO. "We are committed to using every tool at our disposal—as a provider of health care, employer, purchaser and investor—to combat disparities and ensure the <a href="https://www.northwell.edu/education-and-resources/community-engagement/center-for-equity-of-care" target="_blank" rel="noopener noreferrer">equity of care</a> that everyone deserves." </p><p>With the need recognized, Dr. Salas-Lopez calls for health care systems to travel upstream and be proactive in those hard-hit communities. This requires health care systems to play a strong role, but not a unilateral one. They must build <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank" rel="noopener noreferrer">partnerships with leaders in those communities</a> and utilize those to ensure relationships last beyond the current crisis. </p><p>"We must meet with community leaders and talk to them to get their perspective on what they believe the community needs are and should be for the future. Together, we can co-create a plan to measurably improve [community] health and also to be ready for whatever comes next," she said.</p><p>Northwell has built relationships with local faith-based and community organizations in underserved communities of color. Those partnerships enabled Northwell to test more than 65,000 people across the metro New York region. The health system also offered education on coronavirus and precautions to curb its spread.</p><p>These initiatives began the process of building trust—trust that Northwell has counted on to return to these communities to administer flu vaccines to prepare for what experts fear may be a difficult flu season.</p><p>While Northwell has begun building bridges across the divides of the New York area, much will still need to be done to cure U.S. health care overall. There is hope that the COVID pandemic will awaken us to the deep disparities in the US.</p><p>"COVID has changed our world. We have to seize this opportunity, this pandemic, this crisis to do better," Dr. Salas-Lopez said. "Provide better care. Provide better health. Be better partners. Be better community citizens. And treat each other with respect and dignity.</p><p>"We need to find ways to unify this country because we're all human beings. We're all created equal, and we believe that health is one of those important rights."</p>
What’s Eminem doing in Missouri? Kanye West in Georgia? And Wiz Khalifa in, of all places, North Dakota?
This is a mysterious map. Obviously about music, or more precisely musicians. But what’s Eminem doing in Missouri? Kanye West in Georgia? And Wiz Khalifa in, of all places, North Dakota? None of these musicians are from those states! Everyone knows that! Is this map that stupid, or just looking for a fight? Let’s pause a moment and consider our attention spans, shrinking faster than polar ice caps.
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Vegans and vegetarians often have nutrient deficiencies and lower BMI, which can increase the risk of fractures.
- The study found that vegans were 43% more likely to suffer fractures than meat eaters.
- Similar results were observed for vegetarians and fish eaters, though to a lesser extent.
- It's possible to be healthy on a vegan diet, though it takes some strategic planning to compensate for the nutrients that a plant-based diet can't easily provide.
Comparison of fracture cases by diet group
Credit: Tong et al.<p>The results showed that vegans were especially vulnerable to hip fractures, suffering 2.3 times more cases than meat-eaters. Vegetarians and pescatarians were also more likely to suffer hip fractures, though to a lesser extent.</p><p>One explanation may be that non-meat eaters consume less calcium and protein. Calcium helps the body build strong bones, particularly before age 30, after which the body begins to lose bone mineral density (though consuming enough calcium through diet or supplement can <a href="https://ods.od.nih.gov/factsheets/Calcium-Consumer/" target="_blank">help offset losses</a>). Lower bone mineral density means higher risk of fracture.</p><p>Protein seems to help the body absorb calcium, <a href="https://www.bonejoint.net/blog/did-you-know-that-certain-foods-block-calcium-absorption/#:~:text=Historically%2C%20nutritionists%20have%20warned%20that,may%20increase%20intestinal%20calcium%20absorption." target="_blank" rel="noopener noreferrer">when consumed in normal levels</a>. The recent study, along with past research, shows that people who don't eat meat tend to have lower levels of both protein and calcium. When the researchers accounted for non-meat eaters who supplemented their diets with calcium and protein, fracture risk decreased, but still remained significant.</p>
Credit: Pixabay<p>Another explanation is body mass index (BMI). Non-meat eaters tend to have a lower BMI, which is associated with higher fracture risk, particularly hip fractures. In the new study, vegans with a low BMI were especially likely to suffer hip fractures. That might be because having more body mass provides a cushioning effect when people fall.</p><p>Still, the study has some limitations. For one, White European women were overrepresented in the sample. The researchers also didn't collect precise data on the type of calcium or protein supplementation, diet quality or causes of fractures.</p><p>Another complicating factor: Producers of vegan products, such as plant-based milk, are increasingly fortifying foods with nutrients like calcium and protein, so modern vegans are potentially at lower risk of deficiency.</p><p>The researchers wrote that their findings "suggest that bone health in vegans requires further research."</p>