Think Tank Newsletters

The HERO Think Tank e-newsletter is a complimentary, national publication that allows communication with thousands of individuals around the world who have common interests in employee health management. The intent of the HERO Think Tank e-newsletter is to be an authoritative and useful instrument of interaction for those with specific interests in employee health, prevention and health care cost control. As such, we provide concise information, data and recommendations from guest authorities who are on the cutting edge of worksite prevention efforts. Each issue features an article on employee health management best practice. Often you will find information describing what employers expect from prevention investment in human capital. Always, the HERO Think Tank e-newsletter is a catalyst that helps focus on-going attention on the fact that 50% to 70% of all diseases are associated with modifiable health risks, and are therefore preventable.

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HERO Think Tank

e-newsletter

Issue number 3

 The HERO Think Tank is a group of employer and provider members who have taken

the lead to create and disseminate national employee health management

It is recommended this e-newsletter be printed and reviewed at your leisure

The HERO Forum is honored to be the venue for the respected and coveted C. Everett Koop National Health Awards. Last September at the 2008 HERO Forum, Dr. Koop delivered a lecture titled, “When Acute Disease Becomes Chronic.” We are pleased to offer his comments as part of the HERO Think Tank e-newsletter

 When Acute Disease Becomes Chronic

C. Everett Koop, MD, ScD

Delivered at the C. Everett Kop National Health Award Ceremony

2008 HERO Forum for Employee Health Management Solutions

New Orleans, LA

September 24, 2008 

Last year when I addressed you I said, "The greatest factor shaping healthcare will be a surprise".  This is to remind you that I kept my prophetic word - with the help of the Republican Party and the Governor of Alaska.  But we can't cover the future of all healthcare in 30 minutes.  So, I will present what I see as an unsolved problem.  I will do so by suggesting the problem and discuss 2 medical advances that fuel it.

I would like to speak to you today on the issues that I see driving the American healthcare system in the first part of the 21st century.  My perspective on these issues will combine our common concerns and my experience as a practicing member of the American healthcare system for over 60 years.  But I will also speak to you in a more avuncular way, sharing with you the singular perspective of someone whose experience and age differs from that of most of you.

 I'm old.

I am I presume the oldest person in this room.  These days, no matter what room I'm in, I'm usually the oldest person in there.  My medical career started before there were antibiotics.  In my summer job in medical school, I used maggots to clean infected tissue on osteomyelitis patients (and did my first surgical amputation of a leg when I was a teenager) A story for another time...  I speak to you this evening as an example of the great success of American medicine, the success of American medicine as exemplified in what I was able to do in my surgical career, and the success of American medicine in what it has been able to do to ME.  And I will share a few thoughts on the unsolved problem that lies before us, the problem that stems from the great success of American medicine.

 You have the prospect and problem of knowing far sooner than ever before what serious might afflict you.  And then the related prospect and problem of not dying from that disease, but living with it.  For millennia, medicine has sought to know SOONER what is wrong with people and how to make them live longer.  We've succeeded particularly in both these issues, to the great benefit of millions of people.  But not without creating some new problems: the issues of EARLY detection of disease and of the epidemic of chronic disease.  Medical progress has meant that more Americans than ever will find out sooner than ever what severe disease will threaten their life, and more Americans than ever will live longer with disease. 

 It has been my great privilege to live through this golden age of medicine, to be part of its accomplishments as a pediatric surgeon, to reap its benefits as a patient.  It was my great honor to be among the handful of surgeons who pioneered the field of pediatric surgery, and I count it my greatest surgical pleasure to be able to devote many years to what we called "Congenital Anomalies incompatible with life but amendable to surgical correction".  In the 4 decades in which I was involved in pediatric surgery we saw the mortality rate for many conditions of, say, 95%, be transformed into a survival rate of 95%.  That's a lot of lives saved, a lot of years lived.

 These have been medicine's wonder years, not just for me, as a physician, but also as a patient.  I am here today because of what medicine can do.  As I stand here on my 2 artificial knees, as a stint keeps my coronary arteries open, and as my daily regimen of 13 pills keeps at bay a host of medical problems that otherwise would have long since cut short my life.  I am also a post-operative recovered and restored quadriplegic.  And, more dramatically, just a matter of months ago, an episode of Flash Pulmonary Edema sent me into respiratory arrest, and the skill of our local EMT's, physicians, and nurses in using life saving intubation, ventilation, and medication brought me back from the brink to be with you today.  Since then, all systems seem to be working because I came through some serious spinal surgery for the relief of pain - with the help of 2 Pacemakers.

 Early on in the last century, we found ourselves at an ironic moment in the history of disease, disability, and death.  Throughout most of history, most people have died from things they didn't choose: Infectious disease, or war, or famine, or work related accidents.  But by the end of the 20th century, most Americans were dying from choices THEY made, BAD choices about lifestyles that included tobacco, obesity, alcohol abuse, not wearing seatbelts, and the like.  Nearly a million lives are cut short each year by preventable causes.  And we have not calculated the numbers afflicted by chronic disease attributable to lifestyle decisions.  That statistic is a national tragedy, but it also a national opportunity.  We Americans do a better job of preventive maintenance on our cars than on ourselves.  As a society, we need to debunk the myths that aging is illness and old bodies can't be improved.  It has now been conclusively demonstrated that even modest lifestyle changes in diet and exercise have a beneficial effect in elderly people.  Among these are quitting smoking...always at the top of the list of things to do to prolong life...a heart healthy diet: fewer fatty foods, losing a few pounds, dietary supplements like Vitamin E, Calcium, and aspirin...and regular exercise...all this can help make life even better for older Americans not only living longer, but also better.  And while many seniors join special exercise programs, you don't need to join a posh health club or invest in expensive sports clothes to get the benefit of exercise.  Just walking around the block or doing arm exercises with cans of soup, or pulling on a bungee cord...all this can strengthen muscles and bone in order to avert incapacitating falls, it can deter incontinence, and of course, the right diet and exercise can help prevent heart disease and stroke.

 One of the great achievements of health science in the last decade is the dramatic increase in the methods of early disease detection.  A number of the most dreaded diseases, especially several forms of cancer, can now be detected in very early stages, and, of course, this means we can initiate treatment far sooner than before, and that means we will be able to extend thousands of lives tens of years.  Our progress for detection and diagnosis makes it possible for us to diagnose early, not just a disease here and a disease there, in people who decide to go to a physician, but more important, early detection means we can enact appropriately targeted population screening, so that we can pick up and then treat cancers, for example, in individuals who otherwise would not have come near a doctor until it was too late, until many treatment options were no longer viable.  In addition to a new battery of tests for early detection, we are also standing in the dawn of a new day of genetic testing.  The information provided by new screening modalities and by genetic testing will greatly increase our ability to prevent and to treat disease.  They are the advances I mentioned that fuel the unsolved problem.  But, screening and genetic testing also raise some complicating questions and even dilemmas, logistical, economic, and ethical.

 Logistically, we'll need to sort out the role of the primary care physician  in this new world of screening and genetic testing to make sure the primary care physician has the information she or he needs to coordinate prevention and patient care, but we can't have the primary care physician's day swamped in screening, especially patient-demanded screening.  Once again, we come to the vexing irony that while prevention often costs the least and accomplishes the most, it is also the most difficult to achieve.  But with screening and genetic testing the economic issues become complicated or at least enlarged because the target population for screening and testing can be defined as, not just certain at-risk groups, but the entire population of the nation.  Not everyone is a candidate for disease, but everyone is a candidate for prevention, so the potential cost of prevention screening and testing can loom very large indeed.

 In addition to the logistical and economic quandaries that screening and genetic testing will bring to our health care system and our society, it seems there are even more serious ethical problems.  Many screening tests yield a positive diagnosis for a disease that cannot be treated, or a disease where early detection or early treatment offer no real benefit.  But a positive diagnosis can bring great anxiety to the patient, and family, and for that matter, to the physician as well.  But our ability to detect earlier and smaller means that more and more Americans are going to be told, "You have cancer," words that always change that life.  And many of those people have cancers that wisdom says are too small or too quiet to treat, and yet they must live each of the rest of their days worrying about the cancer inside of them. 

As our detection efforts became increasingly sophisticated, we may find out more and more about diseases that pose little real physical threat, but cause great emotional stress.  We’ve all heard it said that far more men die with prostate cancer than die of prostate cancer.  Do all people with cancer that will not kill them need to know as early as possible that they have cancer?  True, early detection will enable us to save many lives.  But at the same time we need to develop the medical and counseling skills to deal with the folks who will live with cancer as well as for those who may die from cancer.

These issues are multiplied when we turn to genetic testing.  We really need to question the wisdom of genetic testing for diseases for which there is now neither cure, not treatment.  There are over 400 diseases that can be detected, or predicted, by genetic testing, but will society know what to do with that information?  In some cases it seems to offer a real benefit.  Genetic indications for a tendency to colon cancer might be sufficient reason for a patient to schedule more colonoscopies, while a negative result should lead to fewer of these intrusive procedures.

But it is ethical to test a 40-something for indicators for Alzheimer’s disease when we have nothing to offer that person?  What about the possible abuses of genetic testing by insurance companies?…or employers?... Or college admissions offices? …or fiancés, or maybe I should say, prospective fiancés?

This may seem like the stuff of a novel by George Orwell or Franz Kafka, but it is lurking in our immediate future, and Americans will need to answer these questions before the possible abuses of genetic testing prove more of a threat to our freedom than any terrorist.  One effort our future demands is prevention against the wrong kind of prevention.

And now, a few words about chronic disease and it’s about time.  By the way, the title of this talk is:”When Acute Disease Becomes Chronic”.  The growth of chronic disease is a real problem for our society… but in some ways it is a good problem to have, at least better than the most obvious alternative.  One of the reasons for the growth of chronic disease is a real success story, the success of American medicine in treating acute disease.  A generation ago, many of the Americans now facing the problems of chronic disease in the elderly would have been long since dead from a heart attack. 

The demands of chronic disease will only grow in the future as each year medicine makes another chronic disease, or really makes another acute disease chronic.  Aids, only 20 years ago, an acute and devastatingly fatal disease, while still fatal has been transformed into a chronic disease from which its sufferers may die, but a disease with which they can live for years.  Similarly, some forms of cancer, once deadly acute, are now regarded as chronic.

In many ways this is a silent crisis, because most chronically ill Americans are not hospitalized nor institutionalized, indeed most are cared for at home by family members.  One in four Americans now provides some kind of care for a person with a chronic condition.  But the increasing unavailability of family members to provide the assistance means that the unmet needs of the chronically ill will skyrocket, and by unmet needs…  I’m talking about simple things such as help bathing or getting out of a chair, or cooking or eating, or walking or shopping… these unmet needs lead directly to the injuries or illnesses that force hospitalization or institutionalization, with all its attendant cost and stress.  By 2005, it is estimated that 3 out of 4 of you will be engaged in care giving for a family or extended-family member.  As a society we aren’t even beginning to address the need for long term nursing care, which even in an average nursing home can consume over $45,000 a year, with living conditions that can range from marginal to criminal.

We also must eventually realize that even the greatest efforts at prevention and healing must acknowledge that medicine’s historic twin objectives of prolonging life and alleviating suffering ultimately reach their limits.  Medicine’s goal is to avoid, not death, but death at the wrong time (too early in life) or for wrong reasons (medically avoidable) or wrong way (with relievable pain).

So acute disease becoming chronic is our problem— made possible by the major advances in screening and genetic testing.

Things You May Like To Know

The Business Roundtable Provides Wellness Program Information – The Business Roundtable (BRT) is a national association of about 160 CEO’s from mostly FORTUNE 200 corporations. The member companies comprise about one-third of the total value of the U.S. stock market. Collectively, these employers have in excess of 10 million employees. Recently, the BRT released a useful and intriguing document entitled “Doing Well Through Wellness: 2006-07 Survey of Wellness Programs at Business Roundtable Companies”. This report provides information for about 70 BRT member employee health management (EHM) programs. Some of these companies are Abbott Laboratories, The Boeing Company, Dow Chemical Company, Eastman Chemical Company, and Prudential Financial. Of these programs, over half have been operational for at least 5 years and about 40% have existed for ten years. The report, which is over 50 pages in length, is available at no cost, and featured on the BRT website home page. Go to www.BRT.org to obtain your copy.

The Cost of Health Care Around the World – The Commonwealth Fund, which is a private foundation that centers on “creating high-performance health systems” (www.commonwealth.org), has provided information on the per capita cost of health care in a number of developed countries: New Zealand - $2,083, Britain - $2,546, Australia - $2,876, Germany - $3,005, Canada - $3,165, and the United States - $6,102. How can it be that in the United States health care cost is 50% to 70% more than these other countries? Is it because the other countries have socialized medicine and the government pays the bills? Is it because the American health care system is that much better? Is it because the American lifestyle is much worse? Is it because the U.S. is not as good in sharing health care medical information? Is it because of over-use in the U.S.? The questions go on and on. The important issue is that conservative estimates indicate the per capita cost in the U.S. for health care in 2016 will be about $12,000. This provides an extraordinary opportunity for EHM to step forward and become the method of choice to reduce modifiable health risks, and there-by, moderate health care cost increases.

Growth of Severe Obesity Passes Moderate Obesity – A study conducted by the Rand Corporation and published in the journal Public Health indicates severe obesity is increasing significantly faster than moderate obesity. The study identifies a severely obese person as having a body mass index (BMI) of 40 or more. A severely obese male weighs about 300 pounds and a severely obese female weighs about 250 pounds. The study reports that from 2000 to 2005, the number of Americans with a BMI of 30 or more increased 24%, while the number with a BMI of 40 or more increased by 50%. The average health care cost for a middle aged person with a BMI of 40 is double the cost of a similar age person with a normal BMI (18.5-24.9)

Source: www.medicalnewstoday.com/healthnews.phd?newsid=67554

“A person who has health has a thousand wishes, a person who doesn’t, has but one.”

Anonymous

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