Spokesman-Review (Spokane, WA)
April 22--Americans spend boatloads of money on medical care -- roughly twice as much, per capita, as other industrialized democracies. And what do they get in return?
Shorter lives and poorer health.
According to a recent study by the National Academy of Sciences, when the United States is compared to 16 peer countries, Americans have the lowest probability of surviving to age 50. What's more, "Americans who do reach age 50 generally arrive at this age in poorer health than their counterparts in other high-income countries, and as older adults, they face greater morbidity and mortality from chronic diseases."
But the times, they are a-changing.
And the changes mean baby boomers still have an opportunity to revitalize aging bodies.
A new generation of physicians is making its way through medical school, where the latest public health research is urging less emphasis on whiz-bang technologies, and more emphasis on guiding patients toward healthier ways of living.
The Affordable Care Act of 2010 is adding impetus to the trend. It requires health insurance, including Medicare, to begin paying for prevention -- with no deductibles to deter patients from going ahead with a potentially lifesaving test, such as a mammogram or colonoscopy.
What's more, it funds medical coverage for those who couldn't afford it before. And it improves reimbursement rates to primary care physicians who treat Medicaid clients -- making it more likely that low-income Americans can find a clinician willing to help them when disease is in an early stage and costs less to treat.
Dr. Matt Hollon applauds the move toward expanded coverage and prevention. At a clinic in Spokane, he practices internal medicine and teaches third-and fourth-year medical students from the University of Washington School of Medicine.
"About a third of what we spend on health care is probably just waste," Hollon said. Some Americans get little care, until it's too late. Others get too much care, he said, sometimes using medicines and undergoing procedures that feature high cost, risky side effects and questionable value.
Professional organizations, such as the American Board of Internal Medicine, he said, have begun to tackle this problem; that organization's "choosing wisely" program urges medical specialties to identify treatments that are overused or unjustified by outcomes research.
Meanwhile, some of the most effective treatments are also the simplest.
"All of us have stories. An ounce of prevention is worth life," Hollon said.
Screenings catch skin cancer when it's a removable speck; sunscreen stops it sooner. Immunizations block flu, pneumonia and the agony of shingles. For diabetics whose nerves have deteriorated, daily foot checks are essential.
Dr. Glen Stream, a family physician at Rockwood Clinic in the Spokane Valley, remembers a diabetic patient who accidentally stepped on an insulin syringe at home. The needle broke off in his foot, unfelt due to the nerve damage diabetes can cause. By the time it was discovered, the simple injury had become a crisis.
Hollon, too, recalls a patient with diabetes. Fifty pounds overweight, the man faced serious risks including kidney disease and heart disease. He needed medication, but the medication came with side effects.
Instead of taking the medicine, he chose to change his lifestyle. He started walking to work -- and it was a long walk, every day. "He lost the weight and cured himself of his diabetes. Just by walking."
Asked if he could offer a list of most effective techniques to prevent disease, Hollon said: "Exercise. Exercise. Exercise. Exercise. And exercise."
"And it doesn't have to be high intensity exercise, that's the amazing thing," he said.
Skip the elevator and take the stairs. Walk just 30 minutes a day, he said.
Research has found exercise more effective than drugs at preventing diabetes, he said. For patients with arthritis in their knees, research found that a walking program reduced pain, led to better daily function and reduced long-term disability. For those suffering from depression, research has found that an exercise program can work as well as talk therapy or medication.
"As it turns out, there actually is one fountain of youth," he said. "Exercise."
In addition, he talks with patients about diet. And on that front, there's pleasant news. Recent medical research recommends the Mediterranean diet -- a tasty cuisine based on cooking styles in countries bordering the Mediterranean Sea.
One 2009 study published by the British Medical Journal examined the relative health benefit of each component in Mediterranean cuisine: moderate wine consumption led the list in benefits, followed by low meat consumption, and high consumption of vegetables, fruit, nuts, olive oil and legumes.
Even so, the U.S. obesity rate points to a conflict between American culture, and the attainment of healthy exercise and diet.
According to research cited by the Robert Wood Johnson Foundation, 36 percent of Americans are obese, and 50 percent are on track to be obese within 20 years. In 2012, one in three cancer deaths was related to obesity, poor nutrition or physical inactivity, the foundation said. Obesity currently causes diabetes for 25 million Americans, plus heart disease and stroke for 27 million.
Hollon works with his students on techniques to turn this around. Instead of putting patients on the defensive, the physicians-to-be learn to collaborate with their patients. Encouraging. Supporting. Discussing what frustrates them, and what step-by-step changes they feel they could incorporate into their lives.
Stream, who has practiced medicine for 21 years, emphasizes the medical value of a good, ongoing relationship with a primary care physician. "It's not like I get one shot with somebody. We work on it over time."
If patient and doctor have a good relationship, a patient who has a negative side effect to a new prescription will come back and talk it over instead of just quitting medication and suffering a medical crisis as a result, he said.
That's why there promises to be a huge advance for public health, Stream said, as more Americans get affordable insurance coverage and begin a relationship with a primary care provider.
In years past, he said, "we really invested in this illness infrastructure. Hospitals. Technology. But we underinvested in primary care."
In countries with better health outcomes, 50 percent of physicians are primary care providers, compared to 32 percent in the United States. "We've got more doctors that treat the problem, than prevent the problem," Stream said.
The federal law requiring 100 percent coverage of prevention, such as a mammogram or a colonoscopy, likewise offers a significant advance. "I have had patients who said 'I know I should have that test, but I can't afford that copay,' " Stream said.
In the past, when Medicare required a 20 percent copay on a mammogram, the patient's share could be enough to cover food for the week, and some patients had to choose the food, Stream said.
Mary Selecky, who retired this month after 14 years as Washington's secretary of health, said "prevention can start any day of your life. If you're a smoker it's never too late to quit. Adult immunizations are important. People should get over the myths. Avoid getting the flu by getting a flu shot."
Childhood immunizations do not last forever. Older adults need boosters, Selecky said, for tetanus, whooping cough, diphtheria, measles, mumps, rubella.
"Most of us just say we'll wait until something goes wrong. We need to change our thinking," Selecky said. "If you invest in prevention the payoff comes because you didn't get sick."
Communities have a role to play in disease prevention, she said.
--Smoke-free apartment buildings protect people with asthma from a neighbor's second-hand tobacco smoke.
--Neighborhood grocery stores can offer fresh fruit and vegetables in quantities more appropriate to an elderly person who does not need, or wish to carry, a huge Costco-sized package.
--City and county parks and sidewalks, if maintained with older pedestrians in mind, can offer safe places for a walk. Indeed, the Spokane Regional Health District offers an online set of popular walking routes, at www.srhd.org/topics/walkingmaps.asp
--Employers who invest in wellness programs, such as smoking cessation and fitness, get back $3.27 in medical insurance savings and $2.37 in reduced absenteeism costs, for every dollar spent, according to the Robert Wood Johnson Foundation.
All three health professionals -- Selecky, Stream and Hollon -- acknowledged that even the best efforts at prevention do not exempt us from bad luck, accidents or genes that might predispose us to disease. Which is why there's no substitute for the remedy Stream favors -- insurance coverage, and a good relationship with a trusted physician.
At the same time, they said, prevention goes a long way. Not only for the person we see in the mirror.
Baby boomers have a chance to serve as role models for their grandchildren -- who are suffering epidemic levels of obesity in a culture where people drive instead of walk, and play video games instead of playing in a park.
"Boomers can involve the grandkids in being active," Hollon said. "It's really important."
And, as Selecky pointed out, in the Spokane area, with extraordinary parks and public events such as Bloomsday and Hoopfest, we are well positioned to serve as a model for public health.
(c)2013 The Spokesman-Review (Spokane, Wash.)
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