How many risk factors are too many????

The Wall Street Journal (11/22/11) assembled nearly 100 chief executives of large companies for a day and a half to discuss the policy choices facing the nation, and the effects those choices may have on business and the economy. On the subject of health, they made the following recommendations:

The Top Five:

1. CHANGE DELIVERY INCENTIVES

Reimburse for quality outcomes rather than volume. Incentivize team-based care (including greater use of non-physicians and novel delivery mechanisms such as accountable care organizations and medical homes). Reimbursement should encourage alternative care settings including home and hospice care.

2. MAKE DATA TRANSPARENT

Help employers, insurers, employees and providers easily get public and transparent data on all providers’ performance, measured against nationally accepted standards. Incentivize use of providers with best outcomes/practices. Enable consumers to use data on outcomes to make better choices about health.

3. BEST PREVENTIVE-CARE PRACTICES

Use disease management or prevention programs for major chronic conditions such as hypertension, diabetes, depression. Aggregate information on successful approaches from employer innovators and other countries to serve as best-practices models.

4. ENGAGE/EMPOWER EMPLOYERS

Bring employers’ perspectives, ideas and voices to the health-care realm—including granting them freedom to design innovative benefit plans that include sticks as well as carrots for healthful behaviors. Create workplace wellness programs for issues such as obesity, smoking, disease prevention—emphasizing activity.

5. TORT REFORM

In addition to addressing malpractice, attack larger problem of defensive medicine, the overuse of care solely due to a fear of lawsuits. Rather than focusing only on award caps, overhaul liability laws to create a safe harbor for physicians who follow evidence-based practice guidelines. Explore alternative dispute-resolution mechanisms and venues.

If we look at this data critically, it all pertains to people who have significant illnesses. How are we going to save money while providing adequate care for those who by definition need care?  As you know as a reader of this blog, I am firmly convinced that they only way to save money is to keep people from needing care.  That means keeping  them healthy so they will avoid the health care system. I’d like to share on slide with you from my book that I think will help you understand what I am saying.
When we find out we have “risk factors” for heart disease, we seek medical care and essentially demand medicines to reduce our risk factors. The most recognized of these risk factors are smoking, high blood pressure, high cholesterol, and diabetes. This slide from almost 88,000 adults with known significant heart disease evidenced either by a heart attack or almost heart attack shocked me when I first saw it.  Notice that 19.40% of them have ZERO risk factors and 43.20% have only one of those 4 major risk factors. In other words, almost 2/3rds of all heart attack events occur in people with either zero or one risk factor.  This slide says two things to me:

#1 If you wait until you have multiple risk factors, you waited too long.

#2 If you ignored the critical risk factors (gluttony ~ high saturated fat diet, & sedentary lifestyle), you missed an opportunity to change your ways and prevent this disease without taking medications or having serious heart damage when you have your heart attack.

I have to repeat the main point – almost 2/3rds of those who develop heart attacks have zero or one conventional risk factors.  When a patient with 6 or 7 risk factors says to me that he would get serious about his behavior IF I would guarantee him he would not have a stroke.  “I’d rather die than have a stroke.” All I have to offer him is “Good Luck”.  Don’t totally blame the medical profession for you infirmity and the explosive rise in costs.  Criticize them if you want for not yelling at you loud enough to get you to behave better and not have serious health issues.

Gerald L. Evans, M.D.