Flatlined

Wasteful Patient behaviors

Doctors are used to patients not taking medications that they prescribe or failing to follow the diet and exercise regimens that they recommend, but no one knows what those behaviors cost in preventable illnesses. Numbers can be attached to two behaviors, however. The consequences of smoking accounted for seven percent of health care costs and obesity nine percent of costs in the US in the mid-nineties.i, ii Added together, the consequences of the two behaviors were responsible for sixteen percent of health care costs, all entirely preventable health care spending.

I could generally tell at surgery if a patient was a chronic smoker--the tissue did not bleed normally when cut, would fall apart when picked up with little tweezers, and the neck bones were often dry and hard. When surgeries required a fusion of bone, the risk that the bones would not fuse, requiring a second operation was doubled because of smoking. I would always discuss this risk in the clinic before surgery, and many patients accepted medication to help stop smoking saying, “I have needed to stop smoking; this sounds like a good time to do it.”

Smoking damages almost every organ in the body--causing heart disease, lung disease, and lung cancer. Smoking is the leading cause of preventable disease in the US, accounting for over 400,000 deaths per year.iii Public education campaigns, physician counseling, and cigarette taxes are credited with reducing the percentage of smoking adults from forty percent in the 1960s to twenty-one percent in 2006.iv, v

The number of smokers that I saw in clinic decreased over the years and, like most doctors, I was unprepared for a new epidemic. I rarely saw an extremely obese patient before 2000, but then I began to see patients weighing over three hundred pounds frequently. The percentage of obese adults has doubled since the 1980s. By 2000 nearly one in three US adults were obese.vi Eleven percent of US children are obese and one-quarter are overweight.vii The cost of health care of an obese child is three times the cost of that for an average child.viii

A number of my practice’s procedures required change. Most of the imaging equipment is not designed for patients weighing over three hundred pounds, and so diagnostic studies have been delayed as we shopped for facilities with equipment to accommodate these individuals. Even then the imaging studies were substandard because the layers of fat distorted the penetration of the magnetic waves or x-rays used to image. During spine surgeries, the patient’s body is often placed face down on a frame that allows the abdomen to hang in the air above the operative table (because pressure on the abdomen causes surgical bleeding). I frequently saw patients in clinic who were so large that the table frames could not withstand their weight, so we could not avoid using a more risky sitting position for their surgeries. The patients were also at more risk for wound problems and stayed in the hospital longer after surgery because their obesity made it difficult for them to get out of bed and move.

But the real cost of obesity is that it produces chronic diseases. Obesity causes diabetes, hypertension, and high cholesterol, and the US is in the midst of an epidemic of them. Seven percent of the US population has diabetes, and eighty percent of diabetics are obese.ix, x Obesity has been estimated to account for as much as twenty-seven percent of the escalation in health care costs over the last twenty years.xi

One argument, however, is that reducing the prevalence of obesity will improve the health of the public but will not reduce health care costs except in the short run. A study based upon data from the Netherlands concluded that health care costs of people who were obese at age 20 were increased until they were age 56 but after that their costs were lower than healthy-living people because the obese died five years younger. Lifetime health care costs were the lowest for smokers because compared to obese, and healthy-livers smokers had the shortest live expectancy.xii

  1. “Medical Care Expenditures Attributable to Cigarette Smoking—United States, 1993, Centers for Disease Control and Prevention. CDC Morbidity and Mortality Weekly Report (MMWR) 43, no. 26 (July 8, 1994): 469-472.
  2. Eric A. Finkelstein, Ian C. Flebelkorn, and Guijing Wang, “National Medical Spending Attributable to Overweight and Obesity. How Much, and Who’s Paying?” Health Affairs Web Exclusive, May 14, 2003.
  3. “Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 1997-2001,” Centers for Disease Control and Prevention. CDC Morbidity and Mortality Weekly Report (MMWR) 54, July 1, 2005.
  4. David P. Hopkins, Peter A. Briss, Connie J. Ricard, et al., “Reviews of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke,” American Journal of Preventive Medicine 20 no. 2S (2001): 16-66.
  5. “Cigarette Smoking Among Adults—United States, 2006,” Centers for Disease Control and Prevention. CDC Morbidity and Mortality Weekly Report (MMWR) 56, no. 44 (November 9, 2007: 1157-1161.
  6. “Statistics Related to Overweight and Obesity,” National Institute of Diabetes and Digestive and Kidney Diseases. Weight-Control Information Network. Updated October 2006.
  7. Mahshid Dehghan, Noori Akhtar-Danesh N, Anwar T. Merchant AT, “Childhood Obesity, Prevalence and Prevention. Nutrition Journal 4, no. 1 (September 2, 2005).
  8. William D. Marder and Stella Chang, “Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions,” Thomson Medstat Research Brief, December 5, 2005.
  9. Ali H. Mokdad, Barbara A. Bowman, Earl S. Ford, et al., “The Continuing Epidemics of Obesity and Diabetes in the United States,” JAMA 286, no. 10 (September 12, 2001).
  10. “Study of Obese Diabetics Explains Why Low-Carb Diets Produce Fast Results,” Science Daily (April 8, 2005). Accessed online 2007: http://www.sciencedaily.com/releases/2005/03/050326095632.htm.
  11. “Study of Obese Diabetics Explains Why Low-Carb Diets Produce Fast Results,” Science Daily (April 8, 2005). Accessed online 2007: http://www.sciencedaily.com/releases/2005/03/050326095632.htm.
  12. Kenneth E. Thorpe, Curtis S. Florence, David H. Howard et al, “The Impact of Obestiy on Rising Medical Spending” Health Affairs Web Exclusive, October, 2004.
  13. Pieter H. M. van Baal, Johan J. Polder, G.Ardine de Wit et al. “Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure, PLoS Medicine 5, Issue 2, (February, 2008): 0001-0008.