Five Out-of-the-Box Ideas For Turning Around Falling US Life Expectancy Rates

By JEFF GOLDSMITH Ph.D.

The Miniature Coffins via The National Museum of Scotland

After last Thanksgiving, the US Centers for Disease Control reported that US life expectancy declined again in 2017, after falling in 2015. The last time the US experienced a two-year decline in life expectancy was during the early 1960’s, before Medicare and Medicaid, and before much of modern medicine! The last three-year decline was a century ago- a result of the Spanish flu epidemic in the aftermath of World War I. Spread over a population of 327 million, the drop of 0.3 years in American life expectancy since 2014 represents a loss of almost 100 million life years! For a country with a nearly $20 trillion economy and that is spending more than $3.5 trillion annually on healthcare, this is both a disgrace and an international embarrassment.

Health analysts pointed to the epidemic of drug deaths as the principal cause. (And it wasn’t just opiates that did the damage; more than 24 thousand of the more than 70 thousand overdose deaths in 2017 were from methamphetamine and cocaine, problems that many lay observers may believe we put in the rear-view mirror years ago). Suicides claimed 47 thousand Americans in 2017, a 33% increase since the turn of the millennium! So between suicides and drug overdoses, which are really a form of suicide, American lost 117 thousand people in 2017.

However, in the background, a more ominous development was the end of a more than forty-year trend in declining deaths from strokes and heart disease, almost certainly due to obesity. Add all these causes together and they are evidence of a slow brewing multi-factor public health crisis. A rising number of Americans are slowly or rapidly killing themselves.

This slow-motion carnage is not randomly distributed among the generations. Life expectancy of children and teens has improved since 2014, as has health of older Americans. The deterioration in health status is concentrated in midlife Americans (most of Generation X and the younger edge of the boomers) and is more pronounced among men of all racial backgrounds than among women. And thanks to overdose deaths, Millennials, that is young people aged 25–34, saw their risk of dying rise ten percent from 2015 to 2017!

The death rate changes are also not randomly distributed geographically. There is a six-year gap between states with the highest and lowest life expectancy. Though the most recent (e.g. 2017) report did not break out individual states’ performance, states with most significant long term rise in death rates have been in greater Appalachia and the deep South, areas with persistent long-term economic problems. There are also hot spots in the near and far West, concentrated in native American reservations and mining communities.

It is time for an honest societal conversation about what to do about this spreading humanitarian catastrophe, a significant challenge given our polarized, blame-infested political climate. Both political parties’ “experts” on health policy decry the rise in health spending. Both wings of the community seem to gravitate toward moral failure as the main driver.

If the population is getting sicker, as appears to be the case, blaming doctors and hospitals, as has been the fashion recently among many of healthcare’s progressive policy experts, is not productive. If we just found the right “operant conditioning schedule” for hospital and physician payment, the argument runs, the care system could take care of this problem.

Conservative policy experts blame moral failure of individuals for rising healthcare use and costs. If only people, particularly the poor, just had more “skin in the game”, they would take better care of themselves, and “shop” for the care they need. The cure, analogous to prescribing bleeding for cancer, is to shift more of health costs to individuals and families, on the unproven assumption that more exposure to the cost of care will lead to better health habits and more responsible consumer behavior.

While behavioral factors certainly play a role in rising mortality- lack of exercise and hypertension are the strongest proximate predictors of rising death rates- the root cause appears to be poverty — and the despair that finds root in it. Indeed, the percentage of a county’s population in poverty was the most powerful demographic predictor of a given county’s death rate . This makes intuitive sense. As an astute colleague, Alexandra Drane, said once, “If your marriage is failing, and you are losing your job and are four months behind on your mortgage, lowering your hemoglobin A1c score may not be your number one priority.”

The societal conversation about how to reverse this trend begins by answering some tough questions. Here is only a sample:

  • Can we do a more effective job of stimulating economic development in struggling areas than laying on large corporate tax cuts and pining for a resurgence of 1940’s industries like coal mining, tobacco and dairy, and steel manufacturing? Or does it make sense to pay people who presently live in those areas to relocate to areas where there are more economic opportunities and shortages of workers?
  • Can we rapidly retool low skill workers who did not attend college to address a growing skilled labor shortage?
  • What role can more generous and more effective mental health coverage play in reversing what Angus Deaton has called the rise in “deaths of despair”- particularly suicide and drug overdoses?
  • Can we do a more effective job of supporting families, and sustaining marriages, which appear to be protective both from suicide and drug deaths?
  • What risk factors can the care system most productively address on its own (hint: hypertension appears to be the leading candidate, followed closely by diabetes)?

One thing seems likely. Last year, 2018, and next year 2019, will probably bring America yet more life expectancy reductions. The issue seems almost certain to raise its ugly head in the 2020 Presidential campaign, which is not shaping up to be an exercise in substantive, real world type health policy discussion, but rather a war among dueling “bumper stickers” (“Single payer”! “Socialized Medicine!”, etc.) Not clear yet is how many combatants will mention the niggling $85 billion a year that we are spending on public health in the midst of a public health crisis. It would be great for prospective Presidential candidates to bring us some real answers.

Jeff Goldsmith Ph.D. is a veteran health industry analyst. He is National Advisor to Navigant Healthcare, and President of Health Futures, Inc, a strategic consultancy.

The Death of Specialization

By NIRAN AL-AGBA, MD

George Orwell undated BBC photo, via Wikimedia Commons / Penguin India

“If you control the language, you control the argument
If you control the argument, you control information, 
If you control information, you control history, 
If you control history, you control the past. 
He who controls the past controls the future.”
— Big Brother, 1984. (George Orwell)

Allow me to submit to you: a physician should be called a “physician.” A nurse practitioner should be identified as “nurse practitioner.” Please call a physician assistant, “physician assistant.” These are accurate titles, reflective of their specialized education, training, and expertise. They are all venerated professions which share a mutual goal of improving patient’s lives, yet the vocations are fundamentally different.

“But if thought corrupts language, language can also corrupt thought.”
   — George Orwell

A central message of 1984 is that language shapes thought by structuring ideals and limiting ideas. Imprecise syntax spreads by imitation and tradition, even among those people – like physicians–who should know better. Some young physicians do not realize that the word “provider” undermines their profession by devaluing their specialized education and training. 

My request:  Stop calling physicians “providers.” It is insulting, personally and professionally.

Language is a powerful tool.  It doesn’t just allow us to communicate; it is a way to change culture and control people. History has shown us that every oppressive regime to come into power, did so by shifting language and influencing thoughts in order to alter perception and then, form a new reality. There is a word for this weaponization of language.

Propaganda.

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Open Source / Software As Medicine

By MARCUS BAW, MD

I believe that closed-source, proprietary clinical software is fundamentally unethical, going beyond even the pharmaceutical industry in how closed source clinical software subverts the duty to share medical knowledge, and protects intellectual property to the detriment of patients.

The Chamberlen Forceps via Wikipedia.org

When developing healthcare software it is important to recognise the additional ethical dimension that medicine brings with it. Medicine affects all human life in such profound ways that we need to consider the moral dimensions of its technological developments in a completely different way to that of other industries:

In other areas of human endeavour, for example, there is usually more choice available to the consumer — including, often, the choice to opt out of use of that technology. People cannot ‘choose’ not to need healthcare.

Further, the consequences to an individual of being denied access to the best available treatment may well include physical harm, early death, unnecessary pain, avoidable disability, and many other unpleasant and potentially permanent disadvantages.

Medical Software now IS Medicine

Not long ago, clinical software consisted of simple systems for patient administration, databases for recording clinical information, and messaging. Nothing particularly exciting, and nothing particularly likely to make huge differences to clinical outcomes. One can easily see how these dull systems weren’t considered to be ‘part of medicine’ and not thereby subject to the scientific process and moral obligations of a medical innovation.

Now, however, we have a range of complex interactive clinical systems which have become so integral to the delivery of care that it’s likely that a good system could positively influence clinical outcomes (and conversely, a bad system could cause harm!). We have disease-specific scoring systems, clinical algorithm implementations, clinical decision support, patient-facing and clinician-facing mobile apps, triage engines and much more. These things can certainly influence clinical outcome. Yet they are in most cases closed-source, proprietary, non-peer-reviewed, and not independently testable.

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The Disruption Distraction

By JEFF GOLDSMITH

               

        Clayton Christensen/World Economic Forum via Wikimedia Commons

Clayton Christiansen’s  1997 classic Innovators Dilemma explored how established businesses are blindsided by lower cost competitors that undermine their core products, and eventually destroy their businesses.   Classic examples of disruption are the displacement of film-based cameras by digital cameras and, now, cell phones, the destruction of retail shopping by Amazon and of video rental outlets by streaming video services. 

Because of the anxiety it generated, Christiansen’s disruption thesis has dominated corporate strategy ever since. However,  I believe this notion of “disruptive innovation, twenty years on,   has reached its “sell-by” date, at least in healthcare,  and is now doing more harm than good.  

The healthcare version of the disruption thesis was found in Christiansen’s “Innovator’s Prescription”, written with health industry maverick Dr. Jerome Grossman, in 2009.  Christiansen and Grossman forecast that innovations such as point-of-care testing, retail clinics and special purpose surgical hospitals threatened to take down healthcare incumbents- physicians and hospitals.  

This book gave rise to a swarm of breathless healthcare disruption forecasts.  Eric Topol predicted that the cell phone and a swarm of diagnostic apps would shortly replace the physician as the patient’s principal source of diagnostic wisdom.  Vinod Khosla said that 80% of physicians would be replaced by AI.  

Are Health Insurers Practicing Medicine Without A License?

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By NIRAN AL-AGBA, MD

It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape—final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Decisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My own nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particular virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under nine are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

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Book Review: Obsessive Measurement Disorder: Etiology of an Epidemic

By KIP SULLIVAN

In the introduction to The Tyranny of Metrics, Jerry Muller urges readers to type “metrics” into Google’s Ngram, a program that searches through books and other material published over the last five centuries. He tells us we will find that the use of “metrics” soared after approximately 1985. I followed his instructions and confirmed his conclusion (see graph below). We see the same pattern for two other buzzwords that activate Muller’s BS antennae – “benchmarks,” and “performance indicators.” [1]

Muller’s purpose in asking us to perform this little exercise is to set the stage for his sweeping review of the history of “metric fixation,” which he defines as an irresistible “aspiration to replace judgment based on personal experience with standardized measurement.” (p. 6)

If You Call Me a Provider, I Will Assume You are a Nazi

By NIRAN AL-AGBA, MD

As a physician, I am proud of the degree I earned. Upon graduation from medical school, my diploma conferred the title of physician and medical doctor, it did not say “provider.” The word “doctor” originates from the Latin “docere”, meaning to teach. I value highly my role as a teacher to patients, students, residents and colleagues. Physicians should accept nothing less than the title we worked hard to obtain through a great deal of personal and professional sacrifice.  It was a small price to pay to join that sacred society of men and women who have devoted their lives to healing.

Calling me a “provider” is a professional insult, no different from that of discriminating based on my race, ethnicity, religion, or gender.  The source of any argument can often be found by looking at the language used to frame it. Something about the word provider has always bothered me. So I decided to investigate and learn a little about the history of the word. As I researched this story, I made a very interesting discovery, which surprised me. It turns out the term “provider” was first utilized by The Third Reich, who embraced it to devalue Jewish physicians as medical professionals.  

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What’s Wrong With Marketing? (The Short Version)

By FRANCINE HARDAWAY

The Future is tastefully curated Source: Peleton, Hat Tip: @clueheywood

The suicide rate in the United States has risen to the 10th leading cause of death, and it is still climbing. In North Dakota, it has gone up something like 57% in the past decade. You might be expected to ask me, what does this have to do with marketing? Unfortunately everything, because theorists think suicide is a disease of civilization, of people whose other needs on Maslow’s hierarchy have already been met. In earlier times, people struggled to stay alive. Hunters and herdsmen didn’t commit suicide. Doctors and engineers do.

Often when someone does commit suicide, those closest to them say “we had no idea he/she was depressed.” Not to claim any special expertise in this realm, I’d venture a guess that the reason for most suicides resides in a lack of human connection, a feeling of isolation

Here’s where marketing may have a responsibility. Not only does marketing often present images of a glorified, unattainable life, especially through advertising and social media, but through the last decade of big data and the approach of AI robots, it has succeeded in atomizing people further and further into individual data points rather than connecting them into communities.