Consumer/Patient Behavior…
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Barbara asked about consumer/patient behavior in the back and forth on health care costs. Several other people did, too. There is simply no doubt that we — as individuals, as patients and as consumers — have a huge role to play in the cost and quality of health care, but figuring out how to factor that into the larger discussion is very, very hard.
Harvard Pilgrim has been preaching education, outreach, prevention and health maintenance since we were founded some 38 years ago. Others have been, too. In fact, it would not be unreasonable to say that over the past 40 years there’s been a bigger, broader, more intense focus on prevention, public health and primary care than at any time in our nation’s history. Think about it. We’ve had anti-smoking campaigns, anti-drinking and driving campaigns, significant investments in public health and nutrition, the creation and expansion of the Medicaid program, tons of outreach and education on physical fitness and diet —entire industries and mountains of literature — both academic and popular — sprung up around why it’s important to take care of yourself, and “lite” versions of many common products — beer, milk, cereals, bread, soft drinks, sugar and butter, to name just a few. At the same time, it’s not too hard to look around at the data on diet, exercise, health status and other morbidity and mortality measures and wonder what went wrong.
Truth is, I don’t know what went wrong, but it’s pretty clear to me that as consumers/patients/custodians of our own health, we’ve done a pretty mediocre job of keeping it together. And while it’s easy to blame it on others — the food and soft drink industries seem to be the two most favorite targets, right up there with the TV and the PC — this seems kind of odd. No one forces anyone to ignore their weight or their health status, and there’s so much material out there these days about the “right” things to do, that ignorance seems like a bit of a stretch, too.
My unscientific and uninformed speculation is that four social forces collided, and our health status has been the collateral damage. First of all, people are busy — busier than they’ve ever been — and their schedules have made the traditional reliance on three meals a day prepared by a parent and delivered and eaten at a particular time each day a novelty for many Americans — kids and adults. Second, the dominant position of television in American households, and the impact it’s had on people’s lifestyles generally and their level of exercise in particular, cannot be underestimated. There’s simply no doubt in my mind that we watch far more TV as a nation today than we did ten, twenty or thirty years ago, and the fact that we don’t even have to stand up to change the channel is both appalling and amazing. Third, technology and customer service — the great enablers — have made much of this possible. Microwave ovens gave new meaning to processed, convenient, ready to serve meals and snacks — rider lawnmowers, snowblowers, PCs, DVDs, video games, laptops, drive-through windows — each and every advancement that’s made entertaining and/or working less physical and/or easier to do — has made us less oriented toward physical fitness. And finally, parents have had enormus difficulty, for many, very good reasons, permitting their children to engage in unorganized, unsupervised play for the better part of twenty years — fear, timing, job requirements and the like have made it almost impossible for many kids to simply run out the back door and play — anywhere in the neighborhood — for an extended period of time. Most opportunities these days for play are structured and organized, and nowhere near the work-out being a kid used to be.
Are there other factors? Sure! School lunches aren’t what they once were, I never saw a vending machine in a school when I was a kid, and the proliferation of “eating out” as the primary option for many families have all played roles in where we are today — heavier than we’ve ever been, out of shape, and in some cases, for the first time ever, unlikely to live as long as our parents.
So when people talk about prevention, which I think we can all agree is a very good thing, I have trouble seeing past our collective inability to manage our diet and our weight, and to exercise regularly. When I graduated from college, I was 6′6″ and weighed 215 pounds. I was a big boy — in good shape. Over time, as I worked, got married, helped raise three children — and got caught up in the swirl of life as we all know it — I gained weight — about a pound a year over almost thirty years. When I was 48, I weighed 245 pounds — which on a 6′6″ frame was noticeable, but not disastrous. But I was terribly out of shape.
Then one day, I was getting my second or third cup of coffee, and I put in my usual two teaspoons of sugar. I looked into the cup and thought, “How much sugar am I absorbing a week,” and I sat there and added spoonfuls of sugar to that cup — until I needed a bigger one — and kept on counting until I’d completed a week’s worth of spoonfuls. It was amazing. I decided, then and there, that I would no longer use sugar in my coffee, and switched to a sweet and low equivalent. Then I stopped eating ice cream, which I love. Then I told myself, no more meals after 8:30 at night — which meant simply going without on some nights, as I often didn’t get home until around then. And I started managing my portions.
Then I started exercising — almost exclusively on the week-ends — usually for about an hour — not too much more — but I exercised hard.
Today, I weigh in at about 225. It’s still not my college graduation weight, but twenty pounds less than I weighed two years ago, and I’m in much better physical condition than I was in then. And while everyone’s situation and circumstances are different, we all own some piece, maybe a significant piece, of the “prevention” equation. I’m trying to make the most positive commitment to prevention that I can think of. I’m watching what I eat, exercising, and trying to stay “healthy.” It’s meant some changes in my lifestyle overall — and believe me, giving up ice cream was not one of my happier moments — but on balance, the choices I’ve made have been good ones.
On a grander scale, Harvard Pilgrim worked with John Hancock to develop and implement a “Healthy Returns” program for Hancock employees, which included, among other things, a weight loss goal for those employees who wanted to give it a try. Over a year and a half, we helped Hancock employees lose over 2 tons of weight, using fairly manageable goals, a regular check-in process to measure progress, and some nice, but not stupendous, rewards for people who achieved their objectives. Today, we joke together about how our collective efforts have ensured that the Hancock Tower won’t sink any deeper into Back Bay, because the tower’s so much lighter than it was before!
We’re proud of the Healthy Returns programs we’ve put in place for many of our employer accounts and their employees, and I’m all for prevention and education and support. But it takes two to tango, and it seems to me that we have a long way to go in this area if we believe that high percentages of the population would benefit from a more aggressive and more sustained focus on health promotion and prevention.
Way to lead by example, Charlie! Good for you (though Ben & Jerry’s might take exception to this post). My weakness is cookies… but I’m considering giving them up. It’s that or run several miles/day… ugh.
I eliminated cookies from the snacks served at our weekly meeting of Chiefs of Service — leaving only fruit. I did this because of my personal weakness and, for the first time in 5 years, made a unilateral decision without academic peer review.
Some grumblings ensued, but no one had the nerve to complain to me directly. People adjusted. (Yes, I know fruit has calories, too, but you have to eat a lot of fruit to get the equivalent of two cookies — especially the cookies at our place!)
I agree that health education information has been available to the public for a very long time, and for one reason or another it isn’t hitting home with a large percentage of the population. There are so many factors involved; however, I think we can agree that walking for most people is a doable activity.
Towns need to think of ways to expand and maintain their sidewalk systems. This would serve to increase physical activity and connect people within their communities. While I have seen some great new walking paths (in Northern Vermont towns), there seems to be a lack of attention to maintaining a sidewalk system throughout the Boston suburbs. There are many beautiful wooded, winding streets between towns, and most of them are narrow with no shoulder or sidewalk. Every town wants to maintain their own character; a sidewalk system can only be a benefit. Naturally, this is an expensive endeavor. Rather than increasing taxes further, how about another bike/walk to raise money for walks/paths statewide? Or maybe a type of “Healthy Returns” program for town/state workers which can show actual monetary savings. This savings could then be used for sidewalk funding.
Speaking of Vermont, I know that the ice cream moguls do work out (with treadmills, not just spoons). The wellness message has been heard by all, yet we all maintain our own priorities!!
While the points you raise about factors in our society that drive people toward worse diets and less exercise are all valid, I can identify two problems but cannot offer solutions for either. First, with respect to healthcare, personal responsibility doesn’t seem to count for nearly as much as I think it should.
Our history of comprehensive health insurance nominally paid for by employers (for the most part) makes people less willing to see a doctor if they have to pay more than a nominal share of the cost out of their own pocket. At the same time, they are perfectly capable of maintaining their homes and cars without the benefit of third party insurance payments. Go figure. Conceptually, at least for the upper half of the income distribution, they should find high deductible health insurance plans attractive, but most don’t. We keep hearing that people will wait until they are really sick before they see a doctor if they have to pay more than $10 or $20 out of pocket.
The other factor is what I would characterize as generally much higher expectations as to what constitutes a middle class or upper middle class lifestyle today. From the 1950’s to the 1970’s, a house that would be considered solidly middle class would be woefully inadequate today – not enough space, too few bathrooms, no family room, only a one car garage, etc. Everyone seems to need two or three cars now instead of one. It’s no wonder that both the husband and wife have to work to pay for all of this. Add in the cost of all of the structured activities for kids, expensive summer camp and vacations, the prospect of trying to save for both college and retirement, and it’s no wonder that people feel stressed out. Maybe if lifestyle related expectations weren’t so high, more families could let one spouse stay home (if that were their preference) and provide a calmer, simpler, less stressful and probably healthier lifestyle for the entire family.
My bottom line take on this is: We’ve met the enemy and it’s us!
BC - Very good post. And Al Capp, who was, I think, the guy who originated your closing line through one of his comic strip characters (Pogo?) - would be pleased to see his work living on long past his death.
The issue isn’t really complicated. The more we provide free healthcare to the uninsured, the more we shift costs to the payers, those that are insured. That explains the unreasonable escalation of costs. Let’s be pragmatic, our national policy of healthcare falls short of serving all Americans, especially the poor, and increasingly the middle class. We are on a downward spiral of cost shifting that will ultimately break the private insurers. Let’s wake up!
Charlie,
I am switching back to Harvard after a near 20-year absence as a GIC retiree. I have an idea for creating an incentive for cutting prescription drug costs for health plans, by encouraging consumers/members to comparison shop.
Just as health plans offer incentives for insureds to shop around for “more efficient” doctors and hospitals, you might consider implementing a reward system for filling prescriptions at less expensive pharmacies.
A recent Wall Street Journal article showed, for example, that generic Zocor (simvastatin) costs between $80 and $109 at CVS, while it is only $7 at Sam’s Club and only $12 at Costco. While I pay the same co-pay of $10 no matter where I shop under current rules, this prescription will cost the insurance company $70 at CVS but only $2 at Costco.
Big savings could be reaped, but I have no incentive to shop for the best price. In fact, I have a disincentive to save the insurance company $68 by shopping at Costco. I will then be footing 83% of the total cost of the drug out of my own pocket, and will feel I am not getting value for my insurance premium dollar.
So, to encourage consumers to care about the cost of filling prescriptions, why not offer them a reduction or elimination of the co-pay, or some type of banked savings credits if they shop at less expensive pharmacies? This should NOT be viewed as an opportunity to surcharge those who shop at CVS or Walgreens. Rather, this is to encourage comparison shopping by sharing real savings with members who shop smartly.
Let me know what you think!
Edgar
Charlie- It was nice eating dinner with you last night at the Elite Broker Dinner at the Fairmont Copley Plaza Hotel. Per your recommendation, I read your blog and see a lot of similarities to what my thoughts were 6 months ago at 6′0″, 250lbs.
Before I get into the 3 ingredients removed from my diet (removed as well as they can be removed when eating out a few times per week), it is recommended to purchase men’s business attire at an establishment that provides free lifetime alterations prior to weight loss.
1- Milled sugar is OUT! However, I do not monitor my “natural” sugar intake when it comes to fruit. My morning routine is a big bowl of cereal with skim milk and 1-2 glasses of orange juice. On my way to work, I grab my unnecessarily large cup of coffee at the corner store and a bunch of 5-6 bananas. I’ll eat 1-2 bananas on the way to work, and the rest between meals as snacks. I haven’t done too much research on bananas, but I would imagine they are high in calories and high in natural sugar (both of which I am not overly concerned about).
2- High fructose corn syrup is in a lot of food we eat, and I do my best to avoid it. It surprised me when I grabbed a loaf of whole grain wheat bread in the fall and discovered the third ingredient was High Fructose Corn Syrup. I now eat organic bread without the HFCS.
3- Partially hydrogenated oils have absolutely no business being on any ingredient list in any food we buy at the supermarket, but it’s definitely there. Do the research, there is nothing good about it.
I eat at least 2500-3000 calories per day, exercise only about 30 minutes per day on average, and have lost about 50 lbs in 6 months. I did not want to crash diet, I did not want to lose weight that fast, but it happened. However, I enjoy food and eat a lot of it with no regrets.
My biggest fear this year, because my children and I are involved in town baseball, was the concession stand with all the delicious hot dogs, greasy hamburgers, steak and EXTRA cheese subs, and of course the baseball field staple- fries! And who can turn down a early bacon, egg, and cheese sandwich for only $2? To be honest, I can- now also on the menu are bananas, apples, and watermelon slices, as well as salads. When spectators, my kids used to get a hot dog or popcorn chicken along with a pack of Big League Chew. Now they get a watermelon slice and Big League Chew. I know, milled sugar in Big League Chew- but nobody is perfect.
I’m doing well and eating. My overall recommendation- exercise and stay away from “man made” foods and ingredients.
Edgar - interesting post. I’m going to check it out and let you know if there is a pharmacy shopping opportunity. Thanks for your comments. And JD - I know what you mean about Little League game snacks, and I share your over-arching message that we are what we eat.
And now that I’m 50, what I eat and how I take care of myself matters more than ever. We baby-boomers talk about staying fit and active as our kids grow up - and as we do, too. Well, delivering on that will require some discipline and commitment. Let’s get on it.
Edgar - the answer is, we pay the same price - and therefore our members pay the same price - for drugs, no matter where they get picked up. Our contracts are, for the most part, price neutral from one pharmacy to the next, even if the list price from pharmacy to pharmacy varies. Hope that answers your question.