PCMHs Don’t Work–Or Do They? Insights From Two Recent Studies (Of the Same Program)

This post was originally published on Project Millennial.

A month ago, a JAMA study rocked the health wonk world by showing provocative evidence that Patient-Centered Medical Homes do not work. Evaluating 32 practices in the PA Chronic Care Initiative over a three-year period (2008-2011), the authors found that achieving NCQA PCMH recognition did not statistically reduce utilization or costs, and only improved one of 11 quality measures (nephropathy screening for diabetes). Aaron Carroll summarized the study and accompanying editorial over at The Incidental EconomistMainstream media and health wonk blogs alike declared the death of the “touted medical homes model”.

That’s why I was surprised to read this headline last week:

Study: Medical homes cut costs for chronically ill members

The punch line: these two studies evaluated the same PA pilot project over the same time period (albeit with different practices and patient populations).

Medical Homes Work—But Only for High-Risk Patients

A close read of the studies reveals that their conclusions are not incongruous. Indeed, the more recent AJMC study found no significant decrease in utilization or costs across all patients, just as the JAMA study did. However, when the authors limited their analysis to the top 10% highest risk patients (defined by DxCG risk scores), they found significant decreases in inpatient utilization in all three program years, and significant decreases in costs in the first two.

We can’t discern if the JAMA study would’ve found the same significant effects if they did a sub-analysis of the highest risk patients. (Interestingly, they state in the Methods section, “we repeated our utilization and cost models among only patients with diabetes,” but the results of that analysis are nowhere to be found.)

These results underscore an insight that’s becoming increasingly clear: cost savings from care management are concentrated in the highest risk individuals.

But we can go one step further.

Cost Savings Came ONLY From High-Risk Patients

Among the 654 high-risk patients, the PCMH produced adjusted savings of $107 PMPM in the first year. That roughly comes out to an estimated $69,978 in overall savings. Almost all of this (and then some) came from an estimated 40 avoided hospitalizations (654 patients x 61 adjusted avoided hospitalizations / 1000 patients).

Among 6940 patients overall, the PCMH produced (statistically insignificant) adjusted savings of $10 PMPM in the first year—an estimated $69,400 in overall savings. Across this entire patient group there were an estimated 41-42 avoided hospitalizations.

In other words, this study didn’t just find that savings are concentrated among high-risk patients. Essentially all of the cost savings and avoided hospitalizations came from the top 10% high-risk patient cohort.

This doesn’t mean that other PCMH models couldn’t squeeze savings out of lower risk patients. It just means that this and many existing models haven’t found out how to.

How to Achieve “Risk-Targeted Population Health”?

That finding raises a broader question that these studies can’t answer: What prevented the hospitalizations among the high-risk patients, and more importantly, were those key interventions limited to only the high-risk patients?

For example, were the crucial interventions ones that were only used for high-risk patients, such as a dedicated care manager, targeted outreach messages, and special appointments for high-risk patients?

Or were they interventions that were indiscriminately used on all patients, such as standard patient education or practice-level infrastructure that all patients enjoyed (even if only high-risk patients “benefited” in terms of reduced hospitalizations)?

This question is important because all interventions (and the infrastructure to support them) have a cost. Developing patient registries, expanding EHR capabilities, maintaining after-hours access, and investing in new training all represent substantial financial investments. Less than $70,000 in savings among high-risk patients—while extremely meaningful and significant—would be wiped out by the $20,000 “practice support” and average $92,000 bonuses paid out to each PCP by the medical home program.

If all of the benefits and savings are coming from the high-risk patients, we need to devise ways to concentrate our costs as well. Implementing such “risk-targeted population health” may be the only way to make the financials work.

Some practices are trying to do this by using dedicated care managers for high-risk patients within their existing patient panels. Others are trying to create separate clinics entirely dedicated to high-risk patients—which would allow them to limit fixed costs to high-risk patients as well. In fact, the NHS in England announced this January they are piloting this latter approach, creating “complex care practices” of 400-500 high-risk patients drawn from surrounding practices.

Whichever approach proves most effective, one thing is clear from these two studies: we need to rethink our current PCMH model.

New Year’s Resolution? Let’s Make it about Cost

This post was first published on Project Millennial.

2013 has been the year of the (botched) insurance expansion. But if the experience of other countries is any lesson, we should hope for political attention in 2014 to be devoted to another looming issue.

Over dinner with a few panelists at the Lown Conference, I learned about their involvement with the World Bank’s Universal Health Coverage (UNICO) Study Series, a comparative analysis of efforts to achieve universal coverage in 22 countries and Massachusetts (“the People’s Republic of Massachusetts”, as one panelist fondly called it).

And Then Came the Cost Issue

Befittingly, this People’s Republic was recently profiled in Health Affairs for lessons learned from its experience with cost containment, an issue it has been grappling with since achieving near-universal coverage in 2006.

Lesson number one?

“The first lesson is that the implementation of near-universal coverage triggered a new political resolve to address the difficult challenges of cost containment.”

In other words, achieving near-universal coverage subsequently made the cost issue too dire to ignore. While there is debate over whether insurance expansion accelerated cost growth (some say yes, others no), the facts are that Massachusetts’ per capita health spending is 15% higher than the national average, and that it has the highest individual market premiums in the country.

(Update: Medicaid expansion increased ER use by 40% in Oregon, so it’s not an inconceivable hypothesis.)

Interestingly, the same sequence of events is playing out halfway across the world.

Taiwan’s Looming Health Budget Challenge

After returning from Boston, I had the opportunity to grab lunch with an individual who was involved with Taiwan’s health sector for a number of years. Through that, I learned that Taiwan is facing a remarkably similar cost challenge.

Taiwan’s National Health Insurance (NHI) system has been lauded as a model for developed nations. Established in 1995, it expanded coverage from 57% to 97% within a year. But as might be expected, this coverage expansion unleashed a surge in utilization, nearly doubling outpatient visits, hospital admissions, and use of ED services among the previously uninsured. Since then, growth in outpatient visits, ED visits, and surgeries has vastly outpaced overall population growth.

To date, Taiwan has addressed the cost containment problem partly through aggressive price setting—sometimes below the cost of providing those services. Yet ironically, this has pushed providers to rely on increasing utilization as their only survival lever. This supply side-induced demand, along with low co-pays, no gatekeepers, and the political difficulty of raising premiums has created a financial situation where NHI expenditures have outpaced revenues almost every year since 1998.

Price controls will likely only work in the short term. In the long term, the NHI will need to alter its incentives to reign in over-utilization while encouraging greater provider efficiency, much as BCBS has done in Massachusetts. Shifting to a DRG-based payment system by 2015 is a good first step.

We concluded our conversation with a pronouncement that struck me: “China’s health system is about 20 years behind Taiwan’s in its evolution, so I think it can learn a lot from Taiwan’s experience.”

Marching Toward Cost Escalation in China

There’s a lot of wisdom in that statement. To date, most reform efforts in China have focused on expanding access, particularly in rural areas. As described in this UNICO report, insurance coverage in rural China had plummeted from 90% of the population to less than 10% with the collapse of the commune system in the 1980s. In the last decade, through a series of programs and reforms, China achieved 93% insurance coverage nationally, and just announced this past August that it had achieved 99% rural insurance coverage. While the accuracy of the numbers can be disputed, there’s no doubt that a lot more people now have access to health care services.

Which raises the specter of cost escalation in China’s not too distant future. Alarmingly, insurance expansion in urban China has been found to lead to such supply-side demand inducement (e.g. unnecessary treatments, expensive technology) that getting insured can actually increase one’s financial risk. Furthermore, China’s current insurance schemes have been criticized for being too narrow in scope (not enough procedures covered) and depth (not enough reimbursement). If China deepens the value of its existing benefits (as is much needed), we could expect demand to surge even higher.

Seek Truth from Facts

I’ve breezed through a lot of details to keep this post manageable, and for those who are interested, there’s a wealth of information in these papers on the reforms in Massachusetts, Taiwan, and China.

But the experience of all three shows that upon achieving near-universal coverage, cost containment issues are sure to follow. It would therefore seem like a prime opportunity to seek truth from the facts of the trial-and-error already happening in other countries. As our nation’s health care marches toward a costly ruin, perhaps the time is ripe for a UNICO-like study series on cost containment.

How to Eliminate $226 Billion of Overuse in Health Care

This post was first published on Project Millennial.

This past weekend, I had the opportunity to attend the 2013 Lown Institute conference in Boston. The Lown Institute is an organization founded by Dr. Bernard Lown in 1973 that promotes a humanistic, patient-centered practice of medicine. A major topic covered during this conference, as well as during last year’s inaugural conference, was that of overuse in health care.

Just How Much Overuse Is There in the U.S.?

Dr. Don Berwick, who gave the keynote address, estimated the cost of overuse in the U.S. to be $158-$226 billion in 2011. Interestingly, the methods of the four studies cited for the $158-226 billion figure were primarily based on macro-level economic approximations (e.g. comparison of DRG intensity between U.S. and Canada)—not on micro-level analyses of overuse in violation of widely-accepted standards.

Which makes sense, given that for many questions of what constitutes overuse, the science may simply not be clear. In 2012, Dr. Deborah Korenstein and colleagues published a review of the literature on overuse in the U.S. The study’s subtitle (“An Understudied Problem”) reveals the punch line. While they were able to document overuse rates for specific treatments that have clear standards (e.g. antibiotics for upper respiratory infection), they concluded that “the overuse literature includes relatively few procedures and diagnostic tests.” And they attributed that to the uncertainty of our science:

“The limited overuse literature is understandable given the challenges of developing standards to measure overuse. […] the process of defining appropriateness for many services remains incomplete owing to both gaps in the evidence and failure to translate evidence into appropriateness criteria.” –Korenstein et al., 2012

Which puts us as (aspiring) providers in a bit of a quandary.

Eliminating Overuse May Take More Than a Checklist

For providers (especially in a profession susceptible to paternalism), the most straightforward solution might seem to be to direct patients away from those wasteful, inappropriate treatments, shaving 7-8% off of our $2.7 trillion and growing health care expenditures. But for the majority of cases, there may not be enough evidence to clearly support a treat or don’t treat decision. And even when evidence-based recommendations exist, they are likely based on population-level analyses, which may conflict with the desires of the individual patient.

As Jessie Gruman argues, there is a coming conflict between clinicians pressured to adhere to a burgeoning number of quality measures and patients who are becoming increasingly engaged in their treatment decisions. Dr. Gruman was at the Lown conference, and she described her experience choosing a new doctor when her old one refused to give her a treatment that he deemed was “not worth it” (despite a 20% success rate). Dr. Gruman belongs to a growing chorus of advocates calling for increased patient engagement in their care decisions. Have the provider lay out the treatment options, with each option’s risk and chance of success, and let the patient decide.

At the same time, I kept hearing my former Swarthmore professor Dr. Barry Schwartz whispering three words in my ear: “paradox of choice”. Presenting people with 24 varieties of jam was enough to confuse them into inaction. Present patients with too many treatment options under actual life-or-death situations, and you could create a lot of (unwarranted?) stress and anxiety.

It seems to me that while some patients may be ready to be empowered consumers choosing from among a menu of options their provider lays out, others may not be there (yet). As Dr. Ranjana Srivastava, another panelist, aptly described, “Even with a menu of options, patients expect their doctor to take charge of their treatment.”

Overcoming the Culture of Overuse

Therefore, I believe the role of providers in reducing overuse will be much more complex than simply adhering to evidence-based recommendations to root out overuse. It will require engaging with each individual patient, intuiting that patient’s preferences for autonomy vs. provider advice, and having a conversation about the value of each treatment option (see Teaching Value Project)—including being willing to argue that the most aggressive option may not always be the best (though it certainly might be for that patient).

These are all skills that are often overlooked in our current medical education system. But the alternative—sticking with an ingrained culture to overtreat—may soon become unsustainable.

P.S. If you are interested in the issue of overuse, I strongly encourage you to check out the Lown Institute’s Right Care Declaration and sign if you so choose.

China’s Third Plenum: Reform is Coming

This past week, Washington was gripped with President Obama’s surprise announcement that you can really keep your health care plan, period. Halfway across the world, China and China-watchers were gripped with another set of announcements:

The results of the Third Plenum of the 18th Central Committee of the Chinese Communist Party (CCP).

So What in the World is a “Third Plenum”?

The Plenary Sessions are meetings of the Central Committee, a subgroup of the National Congress. The Third Plenary Session (“Third Plenum”), which occurs once every five years, is the meeting during which leaders introduce new economic and political reforms. This year’s Third Plenum opened one week ago (Nov 9) and ended last Tuesday (Nov 12).

(For more details, here’s a great explanation of the Plenary Sessions, complete with infographic.)

To underscore the importance of this past week, it’s important to understand what’s happened during prior Third Plenums (Plena?):

  • In the 1978 Third Plenum, Chairman Deng Xiaoping consolidated power, introduced radical economic reforms that propelled China’s remarkable economic growth, and implicitly attacked the cult of Mao, repudiating the Cultural Revolution.
  • In the 1993 Third Plenum, Premier Zhu Rongqi announced the socialist market economy (no contradiction there) and loosened China’s state-owned sector.

So it’s no surprise that analysts excitedly awaited the results of this year’s Third Plenum, especially notable for being timed with the first year of Chairman Xi Jinping’s rule.

They Were Disappointed…Prematurely?

Shortly following the conclusion of the Third Plenum, the CCP released a vaguely-worded communiqué through Xinhua, its state news agency. It was immediately attacked for being heavy on jargon and short on specifics, tempering its promises of economic and political reforms with repeated nods to the “leading role of the state-owned economy”.

Notably, what the communiqué did not mention included:

  • No mention of financial sector liberalization (the Swattie in me wonders if this is necessarily a bad thing)
  • No push for further urbanization (likely because this would require overhauling the age-old hukou system)
  • No indication that President Xi would take on the state-owned enterprises (which dominate China’s oil, aluminum, coal, banking, telecommunications, electricity, transportation and other fields)

Immediately following the release of the vague communiqué, global stocks dipped, headlines called the Third Plenum “disappointing” and “a dud”, and analysts called previously optimistic expectations “sanguine and naïve”, claiming they overestimated Xi and Beijing’s actual power over the rest of the country.

But in the best post-communique analysis I’ve seen, Zachary Keck at The Diplomat argues that disappointment with the Third Plenum is premature. And precisely because it lays the groundwork for helping Xi consolidate enough power to drive through subsequent reforms.

Specifically, the communiqué created two new political bodies that helps Xi consolidate power:

  1. A new state security committee, analogous to the U.S.’s National Security Council. As Keck argues, this new committee is likely meant to “ensure stability as the reforms progress”, which bodes poorly for human rights, but signals the CCP is serious about implementing reforms.
  2. A central leading group reporting directly to top leadership, rather than to the government. This would assist Xi in pushing through reforms by sidestepping the bureaucratic red tape—precisely addressing the problem of limited central power that Beijing faces.

Hot off the Presses: A Blueprint for Reform

And right on cue, the CCP released a new blueprint for reform yesterday, with many more details on specific reforms. These include:

  1. Loosening of the one-child policy. Urban parents can now have two children if either spouse is an only child (previously, both had to be only children).
  2. Abolishment of labor camps, which have been used to imprison people for up to four years without formal arrest or trial. (Unclear how heavily this will be enforced in practice.)
  3. Strengthened rural property rights, allowing farmers to gain more profit from land sales to local governments (hopefully resulting in fewer of these).
  4. Loosening of the hukou system, which may eventually alleviate social and health care access issues for migrants.
  5. Economic liberalization and reforms. A system for insuring back deposits, fewer restrictions on offshore securities investments and M&As, looser pricing controls for energy, water, and telecommunications, and other financial changes I’m not well-versed enough to understand.
  6. Environmental protection-based growth incentives. Specifically, local governments wouldn’t be judged on economic performance alone, but also on environmental protection efforts. That’s cool.

And finally…accelerated health reform. Overhaul of public hospital system, more community hospitals, changes in doc pay, and catastrophic health insurance. I hope to explore the details more in a later post, but for now, this great interview with Shanghai’s former mayor Shen Xiaoming about health reform in Shanghai may provide some indication of where China’s health system is headed.

What the Stock Market Crash Reveals About Medical Errors

This post was first published on Project Millennial.

Proponents of high-deductible health plans want to give patients more skin in the game, to solve our system’s problem of escalating costs. Should our system have more skin in the game to do right by our patients?

The Best Risk-Management Rule Ever?

It is not only economically efficient, but morally imperative, to have “skin in the game”. That’s what Nassim Taleb, author of Fooled by Randomness (2001) and The Black Swan (2007), argues in a recent paper and interview on EconTalk.

Dr. Taleb opens by recounting the “eye for an eye” philosophy of Hammurabi’s code—or, in his opinion, “the best risk-management rule ever.” Three thousand years later, Immanuel Kant posed it in a slightly less morbid way through his notion of a “categorical imperative”: “Act only according to that maxim whereby you can, at the same time, will that it should become a universal law.” Or put more simply, do unto others as you would have them do unto you.

Corporate managers, academics, predictors, warmongers, and politicians, Dr. Taleb argues, are exempt from this moral imperative. They take risks and stand to benefit from the upside of those risks, but are shielded from the downside.

The Moral Hazard of “Fat-Tailed” Phenomenon

In fact, this problem is particularly severe for phenomena Dr. Taleb defines as “fat tailed domains”. A fat-tailed phenomenon is one in which an extremely rare but high-impact event dominates the effect of all other events. Repeated instances of a fat-tailed phenomenon (such as stock market outcomes every year) might look like this (source):

fat tail

A problem exists in that the reputation of market forecasters is based on how often they correctly predict the direction of the market movement, and not by how accurately they predict the final value of the market. (More technically, they are judged by a “binary metric” for what is actually a very skewed distribution.) A forecaster who is frequently right wins widespread admiration, even as people who follow that forecaster’s predictions ultimately see their savings wiped out by that rare, “blow-up” event. The forecaster, meanwhile, is insulated from the full pain of the investment loss.

The more skewed the phenomenon, the easier it is to hide the true impact of a mistake behind a façade of “pretty good performance”.

“Forecasters with steady strings of successes become gods.” –Taleb and Sandis, 2013

Skin in the Game for Patient Safety

Medical errors are a prime example of a fat-tailed phenomenon. For 98.6-99.4% of hospitalizations in the U.S., the patient is discharged without a lethal adverse event. But for the family of the patient who falls into that 0.6-1.4% of hospitalizations, getting killed due to medical error is an extremely “high-impact event”. I would imagine that the physician and care team—if they were aware that their error had caused the patient’s death—would feel very terrible. I’m sure even the hospital administrator would feel pretty bad as he/she looks over their adverse event reports. But will their suffering come close to what the patient’s family feels from the loss?

I’ve previously written about why we haven’t eliminated medical errorsNews flash: hospital errors don’t cause 44,000-98,000 deaths each year, as we previously thought. They cause 210,000-440,000 deaths per year. That makes hospital error the number three killer in the U.S., after heart disease and cancer.

Slow innovation is arguably one of the most effective ways to spur adoption of safer practices. But it is, by its very nature—well, slow. The nation’s third leading cause of death may warrant a bit more urgency. And that brings us back to the moral imperative of skin in the game. Today, individual hospitals and clinicians are rarely judged by the impact of their medical errors. When they are, they are evaluated based on the frequency of their medical errors—a binary metric (error vs. no error) for a very skewed phenomenon (the magnitude of suffering to the patient and family). Given the immense suffering caused by medical errors, it would seem that providers should share the burden in some way—perhaps not literally by Hammurabi’s standards, but, as Dr. Roberts suggests, “substitut[ing] the physical eye for the economic value of the eye”. And yet, the vast majority of public and private payers today are still paying hospitals (even rewarding them) for medical errors.

Dr. Ashish Jha recently wrote an article arguing that incentivizing hospitals for patient satisfaction more than patient safety has led them to invest in lavish amenities over patient safety improvements. To be fair, Medicare finalized a rule this August that will penalize hospitals in the lowest quartile for medical errors or hospital-acquired infections by withholding 1% of their overall payment. But that may not be a strong enough incentive to catch hospital executives’ attention, as Dr. Jha points out in this blog post. If we believe that market forecasters should invest in the same stocks they predict, and that warmongers should be subject to the draft themselves, then why shouldn’t health care providers have some skin in the game when it comes to patient safety?

Geniuses and Hard Work

“Success is a lousy teacher. It seduces smart people into thinking they can’t lose.” -Bill Gates

“You’re Going to Lose More Often Than You Win”

In a recent New York Times op-ed, Ashley Merryman, co-author of NurtureShock: New Thinking About Children and Top Dog: The Science of Winning and Losing, rails against the use of “participation awards”. That is, awards which are given out to all children simply for showing up, regardless of performance. (I’ve got a bunch of participation awards strewn around my basement from my early Tae-Kwon Do years.) It turns out that the science is on her side; Ms. Merryman cites research that shows:

  • Nonstop praise can cause students to collapse at the first sign of difficulty
  • Praising a student for having innate talent can lead them to fixate more on their mistakes
  • Excessive praise can create an expectation of success without real effort

In life, “you’re going to lose more often than you win, even if you’re good at something,” says Jean Twenge, author of Generation Me. “You’ve got to get used to that to keep going.”

True Grit

Incidentally, the reason this article caught my eye was because that same day, the MacArthur Foundation announced its 2013 MacArthur Fellows (journalists love calling them the “Genius Grants“, although the Foundation is loath to do so for reasons that will soon become clear). Among them was Dr. Angela Duckworth, Associate Professor of Psychology at the University of Pennsylvania, whose research focuses on grit: “sticking with things over the very long term until you master them.” Consider some of her lab’s findings:

  • Among cadets at West Point, grit was a better predictor of performance in a rigorous summer training program than intelligence, leadership ability, or physical fitness.
  • Among Scripps National Spelling Bee contestants, grit was a better predictor of advancing to the finals than intelligence.
  • Among Penn students (the perennial test subjects of Penn researchers), grit was a better predictor of GPA than IQ. In fact, those with higher IQs actually had less grit than their peers with lower IQ.

This last point suggests an interesting phenomenon: innate talent–and the frequent early success that comes with it–may reduce the opportunities for an individual to develop his or her grit. This means two things. First, that grit is something that is malleable and can be developed over time (while theories abound over ways to maintain self-control in the short-term, evidence on ways to build grit over the long term has been much harder to find). And second: Bill Gates was right.

A Patient Grit Measure?

And of course, since I’m a health care nerd, I can’t close without connecting this all back to health care in some way. And what got me thinking was the “Grit Scale”, an 8-12 item questionnaire developed by Dr. Duckworth and colleagues that assesses your grit. It’s freely available, and you can take the 12-item version here. I haven’t heard of the Grit Scale being used in health care, but there are other questionnaires that are regularly used. The Patient Health Questionnaire (PHQ-2 and PHQ-9), for example, which has been validated for screening for depression in a primary care setting. Or the Patient Activation Measure (PAM), which gauges a patient’s knowledge, skills, and confidence in managing his or her own health.

I’m venturing into the realm of speculation, but I wonder if the Grit Scale–or some component of it incorporated into existing health questionnaires–can give us a useful measure of which patients are likely to succeed in sticking to a treatment regimen and which patients need extra support. Given that behavior change may be one of the most promising ways to address the coming chronic disease crisis, I think it’s certainly worth exploring.

In the closing minutes of her MacArthur Foundation video, Dr. Duckworth describes the next two areas of her research:

  1. Exploring better ways to measure grit–in particular, “objective measures that don’t require people to measure questionnaires…but looking at their behavior.”
  2. Evaluating interventions to improve grit.

I greatly look forward to seeing what her team finds.

Meanwhile, halfway down their FAQ page, the MacArthur Foundation explains its rationale for avoiding the term, “genius grant”:

“We avoid using the term ‘genius’ to describe MacArthur Fellows because it connotes a singular characteristic of intellectual prowess. The people we seek to support express many other important qualities: ability to transcend traditional boundaries, willingness to take risks, persistence in the face of personal and conceptual obstacles, capacity to synthesize disparate ideas and approaches.” (emphasis mine)

Maybe they should have called them “Grit Grants”.

What If We’ve Been Wrong? Implications of an Imperfect Science

Watch this. If you are pre-med, in medical school, in the health care field, or have ever felt a twinge of disdain for someone who was obese, watch this:

Back in April, as thousands of thinkers, innovators, and TED junkies descended upon DC for the 2013 TEDMED conference, I tweeted about my excitement to see the full talk by Dr. Peter Attia, a surgeon, researcher, and co-founder of the Nutrition Science Initiative (NuSI).

The full talk is finally out. And, man, is it powerful.

A Medical Establishment of Treating Bruises

Dr. Attia raises a provocative suggestion: What if we’ve been wrong about the causation behind obesity and diabetes? What if instead of obesity causing diabetes, obesity is actually a symptom of insulin resistance and other metabolic malfunctions?

Dr. Attia gives the somewhat comical yet strikingly apropos analogy of bruises and banging into coffee tables: Imagine a world in which we thought bruises were the problem. We would evolve “a giant medical establishment and a culture around treating bruises: masking creams, painkillers, you name it, all the while ignoring the fact that people are still banging their shins into coffee tables.” (emphasis mine)

It’s funny until you remember that less than two months ago, the AMA officially classified obesity as a disease. While the decision is unlikely to have much impact on currently research or public health efforts against obesity, I see one area where it could have a marked impact: spurring insurance payments for medical treatment of obesity, i.e. weight loss drugs and bariatric surgery.

  1. Weight loss drugs: Two new weight loss drugs, Qsymia and Belviq, entered the market last year. A day after the AMA decision, a group of lawmakers introduced bills in the Senate and House to require Medicare Part D to pay for weight loss drugs. Qsymia costs about $160/month, or $1920/year. Belviq costs about $200/month, or $2400/year. Our history with weight-loss drugs has not been that great, with many being ultimately pulled due to side effects or leading to rapid weight regain after discontinuation.
  2. Bariatric surgery: Currently, bariatric surgery coverage by Medicare or private payers is limited–something that may change given the new classification. However, the cost-effectiveness of bariatric surgery was called into question by a JAMA article published this February. The surgery and 30-day postoperative care cost $29,517. There was no significant reduction in health care costs for surgery patients compared to non-surgery patients in the 6 years following surgery.

Alarmingly, the vote went against the conclusions of the AMA’s Council on Science and Public Health, which studied the issue for a year and concluded that the main measure used to define obesity (BMI) is simplistic and flawed. More specifically: “Some people with a B.M.I. above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.” Which brings us back to Dr. Attia’s provocative suggestion: maybe we have cause and effect backwards.

“So what I’m suggesting is maybe we have the cause and effect wrong on obesity and insulin resistance. [...] What if being obese is just a metabolic response to something much more threatening, an underlying epidemic, the one we ought to be worried about?” – Dr. Peter Attia

Revisiting an Imperfect Science

Intrigued, I went onto NuSI’s website to see what they’re actually doing. After overcoming my initial reaction that I had tripped upon another miracle weight-loss scam company, I dug deeper and realized that NuSI is actually gathering researchers to tackle significant shortcomings in the literature on the cause and effect of obesity.

Dr. Attia goes hard after the idea that carbohydrate restriction, independent of caloric restriction, is the way to reduce incidence of metabolic disorder, which then causes obesity. NuSI provides a great review of nearly 100 studies on diet and obesity and summarizes key points on why the existing research approach is insufficient. For those who want a summary of the summary, here are some key points:

  • The vast majority of dietary trials are “free-living studies“, in which researchers tell ordinary people to stick to a dietary regimen and then evaluate their adherence through questionnaires or food diaries. If people actually listened, we probably would have solved the obesity crisis by now.
  • The more stringent option is to isolate people in metabolic wards to monitor their intake. Any volunteers?
  • Even studies with sufficient sample size and decent adherence fail to parse out the effects of caloric restriction and carbohydrate restriction. This is a crucial nuance, as it precludes us from testing the hypothesis whether restricting a particular micronutrient (e.g. carbs) is more important for preventing obesity than reducing caloric intake overall.
  • A few studies have managed to make this distinction, but they relied on lean individuals. “Similar results might not have been obtained in a group of obese individuals or lean individuals susceptible to obesity.”

This last point is particularly provocative, as it suggests that obesity may be much less a result of “poor self-control” than we are inclined to assume. I had the opportunity to do a little research in the glorious field of gut bacteria research, and there’s rapidly growing evidence that of two perfectly identical people (at least from the outside) who consume the same foods, one may become strikingly more obese because of the gut bacteria in his/her gut. I recently began reading Dr. Eric Topol’s The Creative Destruction of Medicine, and I can easily foresee a world in which individuals have their gut bacteria characterized (which you can do for $80), and then have metabolic therapies tailored for them. But seeing as I’m already pushing 1000 words, that’s a story for another time.

What If We’ve Been Wrong?

Have you watched the video yet? If not, take two minutes and click to 13:30.

I think the power of Dr. Attia’s speech doesn’t come primarily from the provocative nature of his hypothesis, or from the facts he musters to support it. It comes from his tangible humility, and the painful implication that by staking our belief in an imperfect science, we may be letting our patients down.

“We can’t keep blaming our overweight and diabetic patients like I did. Most of them actually want to do the right thing, but they have to know what that is, and it’s got to work. [...] If obesity is nothing more than a proxy for metabolic illness, what good does it do us to punish those with the proxy?” -Dr. Peter Attia