Life Planning Fail

In preparing for battle I have always found that plans are useless, but planning is indispensable. Dwight D. Eisenhower

Life happens, but that’s no excuse for not knowing where you want to go. That’s a particular issue in healthcare.

People don’t like to think about negative events that are going to happen in the future. They’ll still happen, just the same. For Americans, the difference between life expectancy and “healthy life expectancy” is nine years.  They won’t necessarily come as a block toward the end of life. If fact, you don’t know when they’ll come.

A new study points out that people are often faced with making snap decisions about healthcare without adequate information. (1) That’s due to the failure to anticipate something that’s actually rather likely to happen.

People get hurt and sick. The roughly 320 million Americans generated 130.4 million visits to Emergency Rooms in 2016.(3) What are the odds you’re going to need one?

If you don’t know where you want to go in an emergency, you may get stuck someplace you don’t want to be.

Even if you’ve never had an illness in your life, you will. Nothing on this planet is immortal.

Like it or not, here are some questions for which you need to have answers.

• Financial
  • How do I cover sudden and potentially large medical bills? What does my insurance not cover that I’m going to have to pay?
  • How do I cover normal bills if I’m out of work for a few months? Or longer?
• Medical
  • In an emergency, where do I want to go for care? (Related: is my doctor affiliated with where I want to go?)
  • If I’m hurt and need rehab therapy, where do I want to go for care?
  • Does someone have access to my Living Will if I can’t speak for myself? (Having one isn’t a question.)
  • Who will advocate for me with medical personnel if I can’t speak for myself?
• Living
  • Whose going to care for me if (temporarily or permanently) I can’t care for myself?

Seriously, this matters. We have several local hospitals, two of which are problems.

• The ER department at one of them has misdiagnosed my wife twice out of two visits. That’s a 100% rate of being wrong. Do we want to test them a third time?
• The nurses at another consistently ignore a severe allergy that causes anaphylatic shock. Breathing is really nice, but you don’t really appreciate it until you can’t do it. It turns out, the nurses don’t pay attention to wristbands. (One nurse at that facility told us that they assume the allergy bands refer to drugs and not to more mundane and potentially lethal issues like iodine and latex allergies.) Going to that facility is like going to a casino. You might get fixed and you might die. How lucky are you?

As you age, where you go matters more. With seniors, for example, if taken to an ER for a serious fall, there’s a 50% chance of additional problems within six months of the initial injury, including death. Some of that risk is the result of decisions doctors make about medication.(4)

There’s no need to overthink this. Do your homework, ask questions, make decisions, and then get on with the rest of your life. Just get it done.

Aristotle was  right. Anything taken to excess turns bad. That includes both planning and lack of planning.

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Sources:

1. Emily A. Gadbois, Denise A. Tyler, Vincent Mor. Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives. Journal of the American Geriatrics Society, 2017; DOI: 10.1111/jgs.14988
2. American Geriatrics Society. “Hospitalized older adults may need more help selecting skilled nursing facilities.” ScienceDaily. ScienceDaily, 7 July 2017. <www.sciencedaily.com/releases/2017/07/170707211128.htm>.
3. Centers for Disease Control and Prevention, “Emergency Department Visits.” https://www.cdc.gov/nchs/fastats/emergency-department.htm
4. Jiraporn Sri-on, Gregory P. Tirrell, Jonathan F. Bean, Lewis A. Lipsitz, Shan W. Liu. Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients. Annals of Emergency Medicine, 2017; DOI: 10.1016/j.annemergmed.2017.05.023

US Immigration: the Curiosity of Numbers that Don’t Add Up

The chart below shows data for population growth pulled from the Census Wonder data system. A positive number in the “Missing” column means that the population grew by more than the net of births, naturalizations and deaths. A negative number means it grew by less than the combination of births, naturalizations and deaths.

Here’s the problem. Say you want to assume that there are 1 million illegal immigrants entering the US in 2015. To make the numbers work, you have to have more than 800,000 people living in the US leaving.

• Possible explanation 1: That’s the American Diaspora, and it appears to be quite real.
• Possible explanation 2: There’s less illegal immigration than most people think.

In 2011 and 2012, we appear to have had more people leaving the US than entering.

In fact, if Explanation 1 is true, then were we to stop illegal immigration, we would have a steady population drain and slower economic growth. Without major changes in productivity, economic growth is directly linked to the size of the workforce. 

This is just a preliminary analysis. I’m looking for additional data.

You may also notice from the table that the death rate is edging upward. That’s probably just the natural result of the aging US population.

 

How Americans Drive Up Their Own Health Insurance Costs (UPDATE)

This is not a defense or excuse for the exorbitant pricing or profits in the health insurance industry in the US.  As with most social issues, there is no single cause of a problem. The industry owns part of the issue, Congress owns a major part, but consumers also own a piece. It’s time to recognize that and do what you can do about it.

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I grew up in an advertising era touting “rugged individualism.” The icons of that era included John Wayne, the TV character Palladin, and the advertising “Marlboro Man,” all part of a mythology that people could cut their own path regardless of others.

Unfortunately, that’s not how life works. If your reading this, someone else probably had provided the electricity for  you. If you also write, the court system protects your intellectual property. If you have a retirment account, you depend on financial regulators to protect your assets. If you eat (and you’d better be doing that), there’s the farmers and fishermen who provide what you consume. We are a connected network of people, whether on the grid or not. Whether you like it or not.

That’s blatantly the case in health insurance. There was a time when health insurance didn’t exist and didn’t matter. There were relatively few doctors in the 1850s, medical knowledge was relatively crude, and life expectancy was short.

• In the Americans, life expectancy from birth was only 35.1 years in 1850. Life expectancy for slaves was less, with estimates ranging from 22 to 30 years of age.
• The shortness was due to childhood deaths. If one could make it to age 10, there was a reasonable prospect to live to age 60.

Life expectancy has  increased dramatically in the last two years, as you can see from the chart above, from an excellent article by Max Roser. (1)

In most geographies, the major gain in life expectancy came after World War II.

However, the increase in life expectancy comes at a substantial cost. One estimate says that each day of additional life expectancy adds $1.6 billion to medical costs just in the US. (2) However, living longer is just one component of the story of rising health costs.

Behavior matters. Certain things some of us do add substantially to medical costs for each and every one of us. How does that work? It’s in built into the concept of insurance as conceived by Benjamin Franklin.

• People — healthy and sick — pay into a fund that in turn pays people in their time of need.
• The required size of the fund is determined by the number of claims and the size of claims. The required size of the fund determines what people who participate have to pay.

That might seem unfair to healthy people, but we have to remember that no one stays healthy forever. Everyone dies. Everyone gets a turn with illness, sometimes more than one turn.

What might be considered unfair is when people do things or allow things to happen that cause illness. For example,

• The CDC estimates that 36.5 million Americans smoke cigarettes, and 16 million currently have a smoking-related illness. Not everyone who smokes gets sick, but a larger percentage do, and that adds $170 billion to total medical expenses in the US. (3, 4)
  • According to a recent Gallup survey, more than 28% of adults in Ft. Smith, Arkansas, Layfayette, Louisiana, Erie, Pennsylvania and Bristol, Tennessee smoke. The national incidence is 18.2%, down from more than 40% in the 1960s. (9)
• Obesity is estimated to add $147 billion to national healthcare spending (2008 dollars). (5) That figure may be low due to the large number of undiagnosed diabetics in the US.
• Alcohol and drug abuse adds another $64 billion to healthcare spending (7)
• Distracted driving (there are no separate estimates of direct medical costs), but medical bills have been rising even as the severity of injuries has been declining. (6)

The medical expenses that result from these behaviors hit every consumer:

• Rising healthcare charges (remember the principle of “supply and demand”?)
• Rising insurance premiums to cover the rising healthcare costs
• Rising taxes to cover the proportion of expenses the government pays

High spending doesn’t mean better medical results.

With development, health outcomes generally improve, but the U.S. is an anomaly. The U.S. and the U.K. are both high-income, highly developed countries. The U.K. spends less per person ($3,749) on health care than the U.S. ($9,237). Despite its high spending, the U.S. does not have the best health outcomes. [Life expectancy, for example, is 79.1 years in the U.S. and 80.9 years in the U.K. And while the U.S. spends more on health care than any country in the world, it ranks 12th in life expectancy among the 12 wealthiest industrialized countries, according to the Kaiser Family Foundation, a non-profit organization focusing on health issues.] (8)

Europeans and the Chinese government understand the impact of individual behavior on costs. Americans have been more reluctant to understand and accept personal responsibility for how their behavior affects themselves and everyone else. It’s time to grow up and put the myth of rugged individualism away.

 

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Sources:

1. Max Roser, “Life Expectancy,” Our World in Data, undated. https://ourworldindata.org/life-expectancy/
2. Sean Davis, “8 Charts that Explain the Explosive Growth of U. S. Health Care Costs,” Media Trackers, 1 October 2013. http://mediatrackers.org/national/2013/10/01/8-charts-explain-explosive-growth-u-s-health-care-costs
3. US Centers for Disease Control and Prevention, “Economic Trends in Tobacco,” last updated 17 June 2017. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm
4. US Centers for Disease Control and Prevention, “Current Cigarette Smoking Among Adults in the United States,” last updated 1 December 2016. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
5. US Centers for Disease Control and Prevention, “Adult Obesity Causes and Consequences,” last updated 15 August 2016. https://www.cdc.gov/obesity/adult/causes.html
6. Rocky Mountain Insurance Information Association, “Cost of Auto Crashes and Statistics,” undated. http://www.rmiia.org/auto/traffic_safety/Cost_of_crashes.asp
7. National Institute of Drug Abuse, “Trends and Statistics,” last updated April 2017. https://www.drugabuse.gov/related-topics/trends-statistics
8. NPR, “What Country Spends The Most (And Least) On Health Care Per Person?” 20 April 2017. http://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what-country-spends-the-most-and-least-on-health-care-per-person
9. Samuel Stebbins, “Cities with the Most Smokers,” 24/7 Wall Street, 22 JUne 2017. http://247wallst.com/special-report/2017/06/22/cities-with-the-highest-smoking-rates/?utm_source=247WallStDailyNewsletter&utm_medium=email&utm_content=JUN232017A&utm_campaign=DailyNewsletter
   

Tai Chi and Depression

My wife and I started classes in tai chi some months ago, so I was curious about a new study about the impact of tai chi on depression.

The pilot study, conducted at Mass General in Boston, focused on Chinese-Americans. This group is just as subject to depression as the rest of the population, but tends to be skeptical regarding western therapeutic techniques.

The key finding of the study is that a twelve-week course of instruction in tai chi could lift depression symptoms, and could be used as the primary course of treatment for depression among Chinese-Americans.

The researchers made an assumption that there are cultural factors that make tai chi effective among Chinese-Americans that might make it ineffective with individuals from other backgrounds. Thus they limited the study just to Chinese-Americans, and even more narrowly, to those speaking Cantonese or Mandarin.

I’m not sure that limitation is appropriate.

• First, while tai chi is a form of martial art, it is also exercise. Exercise is known to lift depression symptoms. (2) There’s no compelling reason to limit tai chi to those of Chinese descent.
• Second, I’ve noticed that I feel better emotionally after an hour of tai chi.

Tai chi may be a virtually universal therapy. It has several forms, and there’s a low impact version that can be done easily by seniors.

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Sources:

1. Albert S. Yeung, Run Feng, Daniel Ju Hyung Kim, Peter M. Wayne, Gloria Y. Yeh, Lee Baer, Othelia E. Lee, John W. Denninger, Herbert Benson, Gregory L. Fricchione, Jonathan Alpert, Maurizio Fava. A Pilot, Randomized Controlled Study of Tai Chi With Passive and Active Controls in the Treatment of Depressed Chinese Americans. The Journal of Clinical Psychiatry, 2017; 78 (5): e522 DOI: 10.4088/JCP.16m10772
2. Mayo Clinic, “Depression and Exercise: exercise eases symptoms.” http://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression-and-exercise/art-20046495

 

Your Health: The Right to Life?

The US was founded on the promise of “the Right to Life, Liberty and the Pursuit of Happiness” in Jefferson’s Declaration of Independence.

From the start, the relationship between the country and this promise has been at best inconsistent and sometimes ironic. After all, the principal writer of the Declaration, Jefferson, was a slave-owner.  So for whom was this promise made? Everyone? Or the wealthy, the planters, the slave-owners and the merchants? (Remember, there were no factories — that was before the industrial revolution.)

The inconsistency continues to this day.

We have groups concerned with whether babies or born, but not with what happens to them after they are born. How long do they live? What’s their quality of life? As Ed Cara notes, in some areas of the US, children will now have shorter lives than their parents. (2)

A new study in the Journal of the American Medical Association talks about discrepancies in life expectancy. I’ve blogged about this before, but it’s nice to see authoritative sources recognizing the issue.

The new statistical analysis shows that there is a difference in life expectancy of up to 20 years based on the county in which you live. In this analysis, the issues affecting life expectancy are

• Income and poverty
  • The wealthy live longer
• Race/ethnicity
  • Both Native Americans and African Americans have a shorter life expectancy
• Regular exercise
  • Those who do live longer
• Obesity, Diabetes and Hypertension
  • Shorten life expectancy
• Education
  • Each level completed adds to life expectancy
• Quality of health care
  • Higher quality is associated with living longer
• Having health insurance
  • Having health insurance promotes longer life
• Access to physicians
  • Having more physicians in an area helps

These factors translate into differences in life expectancy in the US based on where one lives:

• Residents of central Colorado, coastal California and the New York Metro area live longer
• Residents of eastern Kentucky and much of the Old South, especially along the lower Mississippi River, have a shorter life expectancy
  • The Old South in this case includes Alabama, Arkansas, Georgia (outside of Atlanta), Louisiana, Mississippi, Oklahoma and Tennessee (outside of Nashville)
  • The two metro areas, Nashville and Atlanta, offer much better life expectancy than the rest of their states

The states with the lowest life expectancy are those with the lowest spending on public health and health education.

One limitation of this study is that the analysis is at a county level, and there is only selected data available at that level regarding health. In particular, suicide is now one of the top 10 causes of death in the US. Suicide isn’t reported accurately or consistently, and there is limited data available on the causes of suicide.

A second limitation is the inter-relationships between some of the factors measured. For example, wealth is associated with having health insurance, with less use of cigarettes, and with living in an area with better access to medical professionals. By breaking the analysis into this much detail, does the report understate the role of wealth in life expectancy?

By the way, I use the image of Ben Franklin on some of these posts for the following reasons:

• His brilliance
• His common sense
• His skill at negotiation
• And among the Founding Fathers of the US, he became a profound opponent to slavery

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Sources:

1. Laura Dywer-Lindgren, et. al., “Inequalities in Life Expectancy Among US Counties,1980 to 2014,” JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.0918. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2626194
2. Ed Cara, “Kids Will Die Younger than Their Parents in Some Parts of the US,” Vocativ. 9 May 2017. https://www.aol.com/article/news/2017/05/09/kids-will-die-younger-than-their-parents-in-some-parts-of-us/22077174/

 

 

Alzheimer’s — latest news

This is in an early stage of testing, but is worth knowing.  A Greek research team is experimenting with a virtual reality game that can be used as a self diagnostic tool for detecting early stage mild cognitive impairment (MCI).  MCI is a precursor to Alzheimer’s. Early detection of MCI can allow medical treatment that can either delay or prevent the development of Alzheimer’s.

“MCI patients suffer from cognitive problems and often encounter difficulties in performing complex activities such as financial planning. They are at a high risk for progressing to dementia however early detection of MCI and suitable interventions can stabilize the patients’ condition and prevent further decline.”

The the virtual supermarket remote assessment routine is able to classify individuals with MCI 91.8% of the time, on a par with diagnostic tests administered by professionals.

And that, people, is a remarkable step in dealing with one of the most horrific diseases among humans today.

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Sources:

1. Stelios Zygouris, Konstantinos Ntovas, Dimitrios Giakoumis, Konstantinos Votis, Stefanos Doumpoulakis, Sofia Segkouli, Charalampos Karagiannidis, Dimitrios Tzovaras, Magda Tsolaki. A Preliminary Study on the Feasibility of Using a Virtual Reality Cognitive Training Application for Remote Detection of Mild Cognitive Impairment. Journal of Alzheimer’s Disease, 2017; 56 (2): 619 DOI: 10.3233/JAD-160518
2. IOS Press. “Mild cognitive impairment (MCI) detected with brain training game: A condition that often predates Alzheimer’s disease (AD), can be remotely detected through a self-administered virtual reality brain training game.” ScienceDaily. ScienceDaily, 24 February 2017. <www.sciencedaily.com/releases/2017/02/170224092544.htm>.