Good post, great topic. JD's comments were thoughtful, as was your response. A key piece missing though, is a general misunderstanding of health drivers-- specifically, a culture focused on "fixes" such as drugs, and differences in access based on income. There's no question that our culture has a preoccupation with income inequality as well as the promise of new innovation-- Health care access meshes very well with this type of thinking. Food policy, public health unquestionably are more important drivers of health outcomes, yet not discussed-- it doesn't have either the income inequality nor the promise of new innovation-- its just detailed, boring, wonkish policy discussion. This dynamic then pervades our political discouse, where politicians rail on drug companies, but put Vilsack in charge of the Dept of Agriculture. Altogether, I think we have a chicken and egg problem-- medical technology companies have strong lobbies-- but I'd suggest as a result of a focus on health care access, not the other way around. I think our culture, politicians and media are the primary reasons we overly focus on access in health reform discussions.

Great post. i would like to see the bar chart separated by payor. That would likely show the burden falling more heavily on Medicaid, Medicare, IHS, etc.

As for employers and their incentive for wellness, there is a real mixed bag out there. Wellness tends to have a longer run payoff. Many employers have turnover high enough that to invest in the wellness of a given employee, only to see him/her leave, is a poor economic choice. Also, for those willing to invest, many of the "disease management" programs do not show significant positive ROI.

As to your comment on access, you are right in that we spend too much time talking about access rather than reducing the need for treatment. But first things first. We have to deal with the fractured system and the 46m uninsured.

According to some evidence based medicine people (see Nortin Hadler), type 2 diabetes is being grossly ovber diagnosed. And that does make money for the healthcare industry.

http://junkfoodscience.blogspot.com/2009/01/what-do-healthy-eating-and-lifestyles.html
Trial evidence to date

Perhaps, it’s little wonder, then, that the results of every major randomized, controlled clinical trial of healthy eating and lifestyles to date have been ignored, downplayed, or explained away... or their benefits greatly overstated. As incredible as it seems, they have failed to demonstrate significant benefit in preventing chronic diseases of old age, like the big three diabetes, heart disease or cancers, or in living longer. Nor has any healthy eating intervention been credibly shown to give everyone a government-approved BMI.

http://junkfoodscience.blogspot.com/2008/10/costly-truism-thats-not-true-obesity.html

All of these large population studies have consistently shown that rates of type 2 diabetes among children and adolescents at the population level have remained unchanged. There is no epidemic of childhood diabetes. In fact, type 2 diabetes remains extremely rare among pediatric populations.

http://mqup.typepad.com/mcgill_queens_university_/nortin_m_hadler_the_last_well_person/

Excerpt:

Drugs to Treat Adult Onset, Type 2 Diabetes
Avandia is one of a newer class of drugs designed to lower the blood sugar of adults whose blood sugar is higher than is said to be good for them.

As we age, our own insulin is less effective in helping our blood sugar enter our cells to provide an energy source. Some of us have this tendency earlier than others, particularly if we have a big gut-to-butt ratio and/or we're poor.

This higher blood sugar and its fellow-travelers (higher blood pressure, higher cholesterol, and lesser wealth) are associated with earlier death, but only if any or all are particularly severe.

For over 50 years medicine has recruited the pharmaceutical industry to smite each of these "risk factors" a mighty blow in order to spare us grief. Avandia is another attempt to tackle persistently elevated blood sugar.

It works. It lowers the blood sugar. Furthermore, the earlier generations of drugs designed to do this also lower the blood sugar. They work too.

However, no one feels better for a lower blood sugar. Some feel worse or get fatter depending on the drug. And no one feels worse for a high blood sugar, except for the rare patient with adult onset type 2 diabetes who can mobilize an extremely high blood sugar.

It isn't just a question of living with a lower blood sugar- it's a question of the onset of long-term complications from uncontrolled diabetes. Retinopathy, peripheral vascular disease, renal failure, gastroporesis- resulting in cardiac disease, amputations, blindness, etc that results in millions of health care dollars spent. And Type 1 diabetes typically affects a much younger population.

I was a nurse on a Diabetes in-patient unit that lost it's institional support due to diabetes not being seen as a money-maker for the hospital. they would rather focus on the interventional care that cardiac medicine involves.

Thanks for the shout out, Ezra.

The case of Medicare is complicated. On the one hand, if people live longer almost all of that extra longevity will be covered by Medicare and costs will go up accordingly. At the same time, there is evidence that those who eat well and have a decent amount of physical exercise have fewer chronic diseases even late in life, and thus they tend to be healthy until closer to death (which tends to be more sudden). This would mitigate the effect of increased costs from increased longevity, but as far as I know it has not been shown whether these things roughly cancel.

Your points about Medicaid and the taxpayer are spot on, and I forgot about that.

As for Scott's post about wellness being a mixed bag for employers, he is right as long as you focus only on corporate wellness programs and not on behavior modification initiated beyond the employer (cultural changes, changes in government incentives and policies). When you bring the bigger picture to bear, then there can be massive savings for employers.

According to some evidence based medicine people (see Nortin Hadler), type 2 diabetes is being grossly ovber diagnosed. And that does make money for the healthcare industry.

I call BS on this. Diabetes is diagnosed via very clear criteria:

1) Oral glucose tolerance test

2) Fasting serum glucose > 127

Diabetes is not one of those diseases like "chronic fatigue syndrome" or IBS in which its 100% subjective. DM is a very objectively based diagnosis to make, and we have readily available simple lab tests that do it.

The last "Anonymous" and Kathy are perfectly correct. There is a very precise way of diagnosing diabetes, and the effects of not managing it are very clear: your circulatory and nervous systems, especially, go to hell, with many unpleasant consequences.

Diabetes is indeed a very serious disease, however it is acquired. There is at present no cure for it; it can only be managed. And I think (I don't have the statistics at hand) that most type 2 diabetics, however successful they may be at managing it with diet and exercise at first, find that eventually they need oral medications and insulin. Sorry, but that's the way it is.

Worth mentioning that, though it is somewhat easy to diagnose, if you've got 10 endocrinologists in the room and you ask them what lab values correlate to well-managed diabetes you'll get 10 different answers.

Many large, well-done studies have documented that (1) type 2 diabetes can be stopped in its tracks, via diet and exercise. Ask any patient who has been diagnosed, and then lost weight and made the decision to exercise daily, and then was told by their doc to stop medication. As for it being 'grossly overdiagnosed' - may I politely disagree? Generally speaking, people have diabetes for an average of 7 years before adequate diagnosis. Once the patient gets the diagnosis and that prevention and treatment work, the results are staggeringly great.

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