| 1 May 2015
Dear Interested Readers,
Inside This Letter
This week’s letter arises from an obituary and my attempts to answer questions that have been recently addressed to me. Not long ago I was asked about the approach of ACOs and IDNs to the management of the obesity epidemic. My faltering attempts to answer a straightforward question revealed to me a deficit in my own thinking and perhaps opened a door through which we should peer, if not walk.
A note from a previous practice partner from my “Shared Medical Appointment” experience came along a few days later. She asked a question about a quote from Oliver Wendell Holmes that she had heard me use in our shared visits with patients. Her question reinforced my thinking about the opportunities that are still unrealized from more collaborative efforts with patients as we better learn how to help them improve their self-management of their chronic medical concerns.
The second discussion was triggered by another note and a query about the pros and cons of a single payer medical economy that combines nicely with the further review of Professor Michael Chernow’s medical economics presentation at GPIN a week ago.
Watching As the Obesity Problem Gets Worse
Perhaps you saw the obituary of Jean Nidetch yesterday in the New York Times or the Boston Globe. Ms. Nidetch died at ninety-one in comfortable surroundings at her home in Florida after becoming a millionaire many times over as the genius behind Weight Watchers. At the IHI meetings last December I heard Robin Roberts of ABC say that her mother’s advice was to “make your mess your mission.” That is exactly what Jean Nidetch did. She also seemed to anticipate by over fifty years the message that I reported in last week’s letter from Stanford’s Kelly McGonigal, a PhD. psychologist and author of The Willpower Instinct: How Self-Control Works, Why it Matters and What You Can Do to Get More of It. What she really did was more like what Tom Sawyer did when he got his friends to help him whitewash Aunt Polly’s fence. So what happened that allowed Jean Nidetch to lose over seventy pounds and start Weight Watchers?
It is a good story. Jean Evelyn Slutsky was born in Brooklyn in 1923 and raised in a family where the answer to every problem or disappointment was a cookie or a bowl of ice cream. She came from a pretty typical background. Her dad was a hard working cab driver and her mother was a manicurist. Jean is quoted in the obit as having said, “I don’t really remember, but I’m positive that whenever I cried my mother gave me something to eat. I am sure that whenever I had a fight with the little girl next door, or it was raining and I couldn’t go out, or I wasn’t invited to a birthday party, my mother gave me a piece of candy to make me feel better.”
Jean was an extrovert and “popular in an overweight set of friends”. By the time she was in high school both Jean and her sister were struggling mentally and physically with their weight problems. She married Mortimer Nidetch who also shared her love of food and after a few years in the Midwest they returned to live in Queens with their two boys. Mortimer drove a bus while Jean tried to manage her weight by visiting public clinics and trying various diets, hypnosis, and pills without success. She was a compulsive eater and seemed to have an addiction for chocolate-coated marshmallow cookies that she hid in a clothes hamper so she could binge at night. In 1960 at age thirty-seven she was five feet seven inches tall, weighed 214 pounds and had a forty-one inch waist. An acquaintance saw her in the grocery store and asked when her baby was due. That was the last straw.
Jean had not read Dr. McGonigal’s book about supports to will power but she was no dummy and she did make her mess her mission and she did organize a little help from her friends. She did not want to be obese and she knew that she could not solve the problem by herself so she invited six of her overweight friends to a party at her house. The party became the first Weight Watchers meeting and it was complete with personal confessions and pledges of support to one another. They swore off sweets and alcohol and adopted together the diet that she had gotten at the hospital obesity clinic. They met regularly to support one another and by October 1962 Jean was down 72 pounds and had reached her weight goal of 142. She died at that same weight 53 years later despite an occasional piece of cake.
The meeting in her living room did grow and by 1963 Weight Watchers was incorporated and by 1968 had 5 million members. Mortimer gave up driving the bus. In a few years the vivacious Jean was a regular on talk shows with Johnny Carson and Merv Griffin. She was a natural motivational speaker and the author of several books who convinced millions that if she could do it so could they. She believed that over eating was an emotional problem that could be fixed with emotional support.
In 1973 16,000 people showed up at Madison Square Garden to celebrate the 10th anniversary of Weight Watchers and see a show with Bob Hope, Pearl Bailey and Roberta Peters. The company had gone public in 1968 and she and her partners were already multimillionaires. In 1978 H.J. Heinz Corporation bought Weight Watchers so they get us coming or going with ketchup for our burgers and fries and then a profit from Weight Watchers as we curtail our consumption of their products.
Obesity has many origins but emotional management and support is core to any program of chronic disease management. The problem is that we really do not manage obesity with the same focus or any focus that resembles our approach to other chronic diseases. We all know that there is an epidemic and it is not confined to children. We are accustomed to seeing more and more overweight neighbors and family members at social gatherings, in shopping centers, at church, in the airport and in our offices.
We talk a lot about losing weight. We advocate diets and exercise. We send referrals to nutrition. We treat their blood pressure, their hypertension, their diabetes and their growing list of musculoskeletal issues and feel hopeless. We send a very small number to bariatric surgery compared to the denominator of those with BMIs even in the forties. Many of our patients find their way to Weight Watchers, Jenny Craig and other diets but tens of millions just get heavier and solve their problems by buying larger clothes and having more medical expenses because we have no standard approaches that come anything close to what we have developed for diabetes, hypertension, hypercholesterolemia and asthma.
At the level of the patient, the community or from the perspective of cost, our lack of focus on solutions for obesity makes no sense. A study published in 2012 reported that people with obesity used more medical resources than smokers.
https://acoem.org/CostsObesityvsSmoking.aspx
Getting our minds around the data and the true cost of obesity is high because it is associated with both direct and indirect costs and there is a fear of double counting with other associated chronic diseases but there is no doubt that obesity adds thousands of dollars on a yearly basis for every patient who meets the definition of BMI greater than 30 without co morbidities. There are about 80 million adults who meet the definition of obesity. The CDC predicts that 86 % of adults will be obese by 2030. The CDC, the Harvard School of Public Health and the Robert Wood Johnson Foundation offer a lot of data and projections but few recommendations about potential solutions. The data also shows that the problem is worse as a function of socioeconomics, geography and race. If you are affluent, white and live in the Northeast your chances of being overweight are much lower than if you are black or Hispanic and live in the South or Southwest.
http://www.cdc.gov/obesity/data/adult.html
http://www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/economic/
Some authorities suggest that the rates of adult obesity are stabilizing at a very high level but I am not so sure.
http://stateofobesity.org/obesity-rates-trends-overview/
The projected medical costs generated by obesity are going to increase by multiples over the next few years so the question that again comes to mind is what in an age of population based health and value based reimbursement are ACOs, Integrated Delivery Systems, and large health systems doing to responsibly address the issues of obesity? Are they applying to the management of obesity with or without its comorbidities to the lessons learned from models of care like the Wagner Chronic Disease Management process that has been successful in diabetes? Is it possible to find easy to access multidisciplinary programs that stress patient self-management with or without medications or other support and guidance in a process of shared decision making?
I went to more than ten websites of organizations like Atrius Health, Partners Healthcare, BIDMC, Mayo Clinic, Cleveland Clinic, Geisinger Health System, Intermountain Health, Kaiser, Group Health and a few others and did not find much until I asked about bariatric surgery. As much as bariatric surgery is a popular revenue generating options for hospitals it does not appear to make much of a dent in the problem of obesity from a population management point of view.
There was an interesting discussion of management steps on the Group Health website but it seemed to be directed to PCPs that probably would not have the time to use it effectively. Mayo has a great evaluation of the risks and benefits of the new meds that are available to assist in the management of obesity. Even though most systems do have bariatric surgical programs and there are some programs for preparation for surgery and post surgical management I never found what I was looking for which was a multidisciplinary team based program with structure, collaboration of medical clinicians, surgeons, nutritionists, psychologists, and coaches.
Nothing I found looked capable of making a measurable difference in the problem for the population. I hope that I am wrong and would be delighted to be corrected. I did ask Tom Graff at the GPIN meetings what Geisinger is doing. They do have a small program for their employees and some other employer groups that directly contract with Geisinger. That is a start. I also discovered from Mike Sheehy at Reliant Medical Group that they are generating some data about their use of medical and surgical management of obesity. Neither is available to the whole population at risk. They appear to be more like pilot programs that are small scale and neither program sounded anything like the more robust programs that either of these groups have for other chronic diseases.
Where would we start if we were going to design such a program. My note up to here is essentially box 1 and box 2 of a design A3. We have looked at the reason for action and the current state. I have hinted at what I would consider an ideal state. Box 4 on the chronic disease management of obesity will be complex and will include issues of insurance company coverage, less than optimal meds, and lack of real data about what works. In box 5 while we are looking for a framework for a solution I would consider using the Wagner Model for Chronic Disease Management. A brief review of its components might be helpful.
http://selfmanagementalliance.org/wpcontent/uploads/2013/08/Wagner-CCM.pdf
It is clear that as we think about problems of chronic disease one of the major objectives should be to enable patients with the knowledge and support necessary to participate in the management of their own disease because their success will be determined by their understanding and ability to make decisions that lead to stability or improvement. And that brings me to the note from my former colleague. She informed me of one potential innovation at the Kenmore Office of Atrius and one clinician’s attempt to fight obesity even though you can’t find it on the website if you type in weight management or obesity. The bolding and italics are my emphasis.
Hi Dr. Lindsey!
It’s Ashley from your shared medical appointments. I think of you often and still share your words of wisdom with clients and patients.
I was telling a client of mine last week about the famous Boston physician you often referred to who said the best way to stay healthy is to have a condition you have to manage. Hearing that was so powerful for this young woman - she’s in her 30’s now but had cancer as an adolescent and they had to remove a muscle from one of her legs. She can easily feel demoralized by the constant PT and exercise it takes to keep herself in balance, so I was telling her the fact that it keeps her doing yoga and pilates could be a real gift as she ages. She would love to know the name of the physician so she can find the quote because she finds that idea so inspiring.
I was glad her request gave me a reason to email you and say hello! I’m still working with 5 physicians on their shared medical appointments. One of them is a weight loss specialist in Kenmore and we do a SMA every Friday afternoon - it’s very rewarding to see people making the lifestyle changes in combination with the medications.
I hope you still look and feel as good as you did at your retirement party!
Regards,
Ashley
Ashley Norwood
Certified Wellness Coach
MBSR Practitioner
ACSM Certified Personal Trainer
I did frequently tell the story that Ashley mentioned to individual patients and to my patients in our shared medical appointments. I did verify it once in a book of quotes but have had difficulty finding it on the Internet. I would use the story in those moments when a patient seemed to need a little lift from the drudgery of their struggle with a chronic medical problem. A situation much like the one Ashley describes.
I would say: Have you ever heard of Oliver Wendell Holmes, Sr.? He was a man of letters and a great Boston physicians of the eighteen hundreds who lived well into his late eighties. His son Oliver, Junior lived even longer. He was on the Supreme Court when he was 90!
One day when Dr. Holmes was well into his eighties, a young newspaper writer interviewed him. The young writer asked many questions but saved the question that he was most interested in having answered until the end of the interview. He asked Dr. Holmes if he would tell him the secret to living a long life. It is likely that the young man was expecting advice about temperance or diet or exercise but after short moment of reflection Dr. Holmes looked up at him and said, “The secret of a long life is to get a chronic medical problem and then take good care of it!”
I would then pause to see if anyone looked confused. Sometimes I would explain the obvious. A person with a chronic medical problem who is engaged in self care makes very good healthcare choices and decisions and I had practiced long enough and with enough patients to be able to verify that many patients that I had known had proven that Dr. Holmes was right! Jean Nidetch had a chronic medical problem that she managed well for 53 years and I think she is a perfect example of the wisdom of Dr. Holmes.
Continuing Concerns About Healthcare Finance
Professor Alan Gaynor is not the typical consumer of healthcare. I wish that there were more like him because he is intensely interested in the future of healthcare for all the personal reasons that any of us should have but Professor Gaynor is also interested in the larger picture of what healthcare should be like. He wrote me recently to ask if I had read Marcia Angell’s (Former Editor NEJM) review of Stephen Brill’s book on healthcare. You might remember that I discussed that book at some length a few months back. I had not read the article but I have now as you may:
http://www.nybooks.com/articles/archives/2015/apr/23/health-right-diagnosis-and-wrong-treatment/
Alan always asks questions that go to the heart of the matter.
Gene,
Sorry for the delay in getting back to you…
I am attaching an article—the gist of which you are all too familiar with—that discusses the deep problems of medicine, yes, but especially of big pharma (e.g., the Orphan Drug Law) Unfortunately, our health system is the most expensive in the world by far—but far from the best. Greed and political corruption, for sure, but would a Single Payer system really be best? What's your take on this?
As always,
A.
I will begin with the last couple of paragraphs in the article which sum Dr. Angell’s point of view. You should read at least this much.
The fundamental issue in the US health system is costs. After all, if money were no object, everyone could have all the health care he or she could possibly need or want. But money is an object, and sadly, the Affordable Care Act is a misnomer, because it’s not really affordable except in the short run. Yes, it has expanded access, but the costs will not be sustainable—unless deductibles and copayments are greatly increased and benefits cut. That is happening now, particularly in the private sector, where employers are also capping their contributions to health insurance.
The problem is that Obamacare attempted to reform the system, while retaining the private insurance industry and the profit-driven delivery system with all its distortions and waste. Obamacare even made the private insurance companies the linchpin of the reform, providing them with millions more publicly subsidized customers. At the time Obamacare was enacted, its supporters argued that anything else was politically unrealistic. In view of our industry-friendly politics, that may have been so, but that does not mean that Obamacare can work. It’s unrealistic for different reasons.
Until we begin to treat health care as a social good instead of a market
commodity, there is simply no way to make health care universal,
comprehensive, and affordable. Brill’s book is a superb, even gripping,
description of the American health system and the creation of Obamacare, but he is misguided in his recommendation for reform by turning over the administration of the health care system to hospitals. The last thing we need is more foxes guarding the henhouse.
Alan leaves me nowhere to hide. Yes I would prefer a single payer but I think that is something that may be possible in twenty or mores years that will be of benefit to my children and grandchildren since things move slowly in healthcare. Historically it is about every twenty years that we have a new breakthrough process or effort to improve care. Most attempts fail. This one, like Medicare and Medicaid fifty years ago, seems to be one of the more effective experiments. It was Churchill who said, “You can always count on Americans to do the right thing, after they have tried all of the wrong things!”
I was extremely disappointed when Massachusetts achieved universal coverage by passing chapter 58 as a mandate rather than as a single payer entitlement. I got over it realizing that half a loaf is always better than starvation and to ask people to wait for something that was not going to happen soon is not fair or smart either and having no access to healthcare is close to starvation as a problem to eradicate as soon as possible at any cost. The last few paragraphs of Dr. Angell's article are a description of a point of view that I wish a majority of American shared. So far they do not. Things can change fast but fast is usually at least twenty years in terms of social and political issues. Dr. Angell is right but she is also wrong. Single payer has had little chance since Truman although Ted Kennedy came sort of close in the late seventies.
The ACA is a big business friendly public private partnership that has been decremented by the Supreme Court’s release of states from the Medicaid expansion. Even considering that loss I see it as a continuing compromise in principle that accomplishes something if not everything. The positives can be accentuated with enforcement of market principles as we saw with Judge Sander’s decision about South Shore Hospital’s desire to sell itself to Partners. Laws like Chapter 228 with its direction to keep cost increases in line with economic growth is a start that could be the beginning of an effective gradual improvement in the rate of cost increases. Medicare is a single payer system and it has its imperfections.
Last week I reported on Professor Michael Chernow’s analysis of the ability to lower the cost of care with quality payment incentives. I agree with him that the only thing that will lower cost is a change in the delivery model and innovations. I believe the tools and philosophies like Lean and broader cultural changes similar to the attitudes that Dr. Angell advocates can make a difference together even in a system that retains big business. The first section of this letter is about the potential for improvement in health and in the cost of care by more effectively addressing the complex issues of obesity. The ACA fosters disease management, team based care, innovation and progress through price competition. I agree it was not perfect and I would personally prefer a single payer system that addresses healthcare as a social issue but I still agree with Joe Biden when he leaned into the President and said, “This is a big----deal!”
Here Comes The Sun!…On Some Days
I took a trip to Boston for a few meetings on Wednesday and was delighted to see forsythia in bloom everywhere! What a day! We don’t have many things in bloom in New Hampshire as the picture in the header reveals. All that green is Astro-turf but I have a new joy. I have discovered the gorgeous track at Colby-Sawyer College where I can run around in circles to my heart’s content while I am soaking in the big sky and the mountain scenery. Not bad. I also am armed with my new fishing license and by the time you are reading this I should be on the lake in my pedal kayak looking for that first trout of the year and checking out the loons who have just returned to make their annual attempt at producing loon babies!
I hope that you have a terrific first May weekend and will find someone to enjoy the beauty that is present in your world with you.
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