Resuscitating Health Care Reform

Health reform is in danger of failing because the focus has been too much on who is covered and not enough on what is covered. Health care reform is primarily about health insurance reform, with the main battle being over coverage and the payment system.

Of course, we need to provide coverage for the 48 million Americans who do not have health insurance. It is morally indefensible that we have not already done so.

But we also need to transform what is covered. If we want to make affordable health care available to the 48 million Americans who do not have health insurance, then the fundamental causes of many chronic diseases need to be addressed -- which are primarily the lifestyle choices we make each day -- rather than only literally or figuratively bypassing them.

If we just cover bypass surgery, angioplasty, stents, and other interventions that are dangerous, invasive, expensive, and largely ineffective on 48 million more people, then costs are likely to increase significantly at a time when resources are limited. As a result, painful choices are being discussed -- rationing, raising taxes, and/or increasing the deficit -- and these are threatening the public acceptance and thus the viability of health reform.

Meaningful health reform needs to provide incentives for physicians and other health professionals to teach their patients healthy ways of living rather than reimbursing primarily drugs and surgical interventions. If lifestyle interventions proven to reverse as well as prevent many chronic diseases are reimbursed along with other strategies for improving cost-effectiveness across the U.S. healthcare system, then it may be possible to provide universal coverage at significantly lower cost without making painful choices, and the only side-effects are good ones.

The U.S. "health-care system" is primarily what Senator Harkin [D-Iowa] calls "a sick-care system." Last year, $2.1 trillion dollars were spent in this country on medical care, or 16.5% of the gross national product, and 95 cents of every dollar were spent to treat disease after it had already occurred.

Heart disease, diabetes, prostate/breast cancer, and obesity account for up to 75% of these health care costs, and yet these are largely preventable and even reversible by changing diet and lifestyle. Here's some very good news: last Thursday, Senator Ron Wyden [D-Ore] introduced new legislation, the "Take Back Your Health Act" (S. 1640) that will pay for intensive lifestyle changes as treatments, not just prevention, for these conditions as a complement to regular medical care. This legislation was co-sponsored by Senator John Cornyn (R-Tex) and Senator Tom Harkin (D-Iowa). Dr. Mark Hyman, Dr. Mike Roizen, and I consulted on this legislative language.

"This is a groundbreaking bill, based on the proven idea that lifestyle changes can improve the health of those with chronic disease if people stick with a program that has that goal in mind," said Senator Wyden. "The Take Back Your Health Act gets doctors and patients invested in the success of treatment, since doctors won't be paid unless their patients actually get better."

"This legislation will provide seniors who have chronic diseases with the care coordination, training, and support necessary to make and sustain intensive lifestyle changes that have been clinically proven to beneficially affect or even reverse the progression of many chronic diseases," said Senator Cornyn. "I'm pleased to join with my colleagues in a bipartisan fashion and will continue pushing for common-sense solutions to our health care system."

"The health reform debate is not about continuing the status quo, but about changing our health care system and the medicine we do," Senator Harkin said. "This legislation will change the medicine Medicare does by reimbursing health care professionals for proven programs to address disease, including coronary heart disease, diabetes, and some forms of cancer, through intensive lifestyle change. Health reform is about giving individuals more choices and individuals should be given the option to engage in a lifestyle treatment program instead of surgery and pills."

Our research, and the work of many others, have shown that our bodies often have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. Medicine today focuses primarily on drugs and surgery, genes and germs, microbes and molecules, but we are so much more than that.

Many people tend to think of breakthroughs in medicine as a new drug, laser, or high-tech surgical procedure. They often have a hard time believing that the simple choices that we make in our lifestyle -- what we eat, how we respond to stress, whether or not we smoke cigarettes, how much exercise we get, and the quality of our relationships and social support -- can be as powerful as drugs and surgery, but they often are. Often, even better.

These choices are especially clear in cardiology as an example of this larger issue. Large-scale studies have shown that changing lifestyle could prevent at least 90-95% of all heart disease.¹ Thus, the disease that accounts for more premature deaths and costs Americans more than any other illness is almost completely preventable, and even reversible, simply by changing lifestyle.

In contrast, many people are surprised to learn that bypass surgery and angioplasty don't work very well. In 2006, for example, according to the American Heart Association,² 1.3 million angioplasties and stents were performed at an average cost of $48,399 each, or more than $60 billion. In addition, 448,000 coronary bypass operations were performed at a cost of $99,743 each, or more than $44 billion -- i.e., more than $100 billion for these two operations.

Despite these costs, a major randomized controlled trial found that angioplasties and stents do not significantly prolong life or even prevent heart attacks in stable patients (i.e., in most patients who receive them).³ Earlier randomized controlled trials of coronary bypass surgery found that this procedure prolongs life in only a small fraction of patients -- those with left main coronary artery disease or equivalent and left ventricular dysfunction (ejection fraction less than 30%). A recent randomized controlled trial in diabetics found that neither bypass surgery nor angioplasty prolonged life or prevented heart attacks.⁴

Lifestyle changes also can be reframed not only as preventing chronic diseases but also as reversing the progression of these illnesses -- i.e., as intensive non-surgical, non-pharmacologic interventions.

What we eat, how we respond to stress, whether or not we smoke cigarettes, how much exercise we get, and the quality of our relationships and social support may be as powerful as drugs and surgery in treating (not just preventing) many chronic diseases.

Our studies showed that people with severe coronary heart disease were able to stop or reverse it by making intensive lifestyle changes, without drugs or surgery, and these findings have now been replicated by several others.⁵ There was some reversal of heart disease after one year and even more improvement after five years, and there were 2.5 times fewer cardiac events when compared to a randomized control group.⁶

Almost 80% of patients eligible for bypass surgery or angioplasty were able to safely avoid it by making comprehensive lifestyle changes instead, saving almost $30,000 per patient in the first year when compared to a matched control group.⁷ In a second demonstration project with Highmark Blue Cross Blue Shield, these comprehensive lifestyle changes reduced total health care costs in those with coronary heart disease by 50% after only one year and by an additional 20-30% in years two and three when compared to a matched control group.

Thus, the disease that accounts for more premature deaths and costs Americans more than any other illness is almost completely preventable, and even reversible, simply by changing lifestyle. We don't have to wait for a new breakthrough in drugs or surgery; we just need to put into practice what we already know.

Reimbursement is a major determinant of how medicine is practiced. When reimbursement changes, so do medical practice and medical education.

Some question whether or not prevention saves money, asking whether these approaches actually prevent or only delay the onset of disease. Part of the reason that preventive approaches are usually scored by the Congressional Budget Office (which estimates the overall costs of any legislation) as significantly increasing costs is that lifestyle changes are viewed only as primary prevention -- paying money today in hopes of saving money later.

But even primary prevention saves money, although the cost savings per person are not as high as when intensive lifestyle changes are offered as treatment to those who are already sick. For example, three years ago, Steve Burd (CEO of Safeway) realized that health care costs for his employees were exceeding Safeway's net income -- clearly, not sustainable. I consulted with him in redesigning the corporate health plan for his employees in ways that emphasized prevention and wellness, provided incentives for healthful behaviors, and paid 100% of the costs of preventive care.

Overall health care costs decreased by 15% in the first year and have remained flat since then. Many other worksite wellness programs have shown cost savings as well as a happier and more productive workforce. This approach is bringing together Democrats and Republicans, labor and management.

In each of these studies, significant savings occurred in the first year -- medically effective and cost effective. Why? Because there is a growing body of scientific evidence showing how much more dynamic our bodies are than had previously been believed.

The same intensive lifestyle changes that may reverse the progression of coronary heart disease may also slow, stop, or even reverse the progression of early-stage prostate cancer,⁸ whereas conventional treatments such as radical prostatectomy and radiation may not prolong life except in the small percentage of patients who have the most aggressive disease.⁹

These lifestyle changes also may beneficially affect gene expression in only three months, turning on genes that prevent disease and turning off genes that promote heart disease, prostate cancer, breast cancer, and other illnesses.¹⁰ Often, people say, "Oh, it's all in my genes, there's not much I can do about it." For many people, it captures their imagination to know that changing lifestyle changes their genes for the better.

Last year, my colleagues and I published the first study showing that these intensive lifestyle changes significantly increase telomerase, and thus telomere length, in only three months.¹¹ (Even drugs have not been shown to do this.) Telomeres are the ends of your chromosomes that help control aging -- as your telomeres get longer, your life gets longer. (Like all research, these relatively small studies need to be replicated in larger randomized controlled trials.)

Lifestyle changes are not only as good as drugs but often even better. For example, a major study showed that lifestyle changes are even more effective than diabetes drugs such as metformin in reducing the incidence of diabetes in persons at high risk, with lower costs and fewer side-effects.¹²

"Prevention" often conjures up false choices -- "Is it fun for me or is it good for me? Am I going to live longer or is it just going to seem longer if I eat and live healthier?" Because these mechanisms are so dynamic, most people find that they feel so much better, so quickly, it reframes the reason for making these changes from fear of dying (which is too scary) or risk factor modification (which is too boring) to feeling better.

Many patients say that there is no point in giving up something that they enjoy unless they get something back that's even better -- not years later, but days or weeks later. Then, the choices become clearer and, for many patients, worth making. They often experience that something beneficial and meaningful is quickly happening.

The benefit of feeling better quickly is a powerful motivator and reframes therapeutic goals from prevention or risk factor modification to improvement in the quality of life. Concepts such as "risk factor modification" and "prevention" are often considered boring and they may not initiate or sustain the levels of motivation needed to make and maintain comprehensive lifestyle changes.

In our experience, it is not enough to focus only on patient behaviors such as diet and exercise; we often need to work at a deeper level. Depression, loneliness, and lack of social support are also epidemic in our culture. These affect not only quality of life but also survival. Several studies has shown that people who are lonely, depressed, and isolated are many times more likely to get sick and die prematurely than those who are not. In part, this is mediated by the fact that they are more likely to engage in self-destructive behaviors when they feel this way, but also via mechanisms that are not well-understood. For example, many people smoke or overeat when they are stressed, lonely, or depressed.

What is sustainable is joy, pleasure, and freedom, not deprivation and austerity.¹³ When you eat a healthier diet, quit smoking, exercise, meditate, and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. The latest studies have shown that your brain may grow so many new neurons that it may get measurably bigger in only a few months -- this was thought to be impossible only a few years ago. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent -- the same way that drugs like Viagra work. For many people, these are choices worth making -- not just to live longer, but also to live better.

In other words, the debate on prevention often misses the point: the mortality rate is still 100%, one per person. So, it's not just how long we live but also how well we live. Making comprehensive lifestyle changes significantly improves the quality of life very quickly, which is what makes these changes sustainable and meaningful.

Unfortunately, anything involving lifestyle changes gets held to a different standard. Drugs and surgery are not required to show that they save money in order to be covered, only that they work. Lifestyle changes often work even better, and at lower cost.

Finally, it's worth pointing out that what's good for your personal health is good for the planet's health; what's personally sustainable is globally sustainable. For example, eating a diet high in red meat increases the risk of heart disease and many forms of cancer. It also increases global warming: livestock cause more global warming than all forms of transportation combined due to methane production, which is 21 times more powerful a greenhouse gas than carbon dioxide.¹⁴

As Senator Harkin said, "To date, prevention and public health have been the missing pieces in the national conversation about health care reform. It's time to make them the centerpiece of that conversation. Not an asterisk. Not a footnote. But the centerpiece of health care reform."

If we don't, then the escalating costs and resulting painful choices -- rationing, raising taxes, and/or increasing the deficit -- are threatening the public acceptance and thus the viability of health reform.

References:

1. Yusuf S, Hawken S, Ôunpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Lancet. 2004; 364: 937-52.
2. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics 2009 update. A report from the American Heart Association statistics committee and stroke statistics committee. Circulation. 2009;119:e1-e161.
3. Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1-14.
4. The BARI 2D study group. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503-15.
5. Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. Lancet. 1990; 336:129-133.
6. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-2007.
7. Ornish D. Avoiding Revascularization with Lifestyle Changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998;82:72T-76T.
8. Ornish D, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. J Urol 2005;174:1065-1070.
9. Barry MJ. Screening for Prostate Cancer -- The Controversy That Refuses to Die. N Engl J Med. 2009;360:1351-4.
10. Ornish D, Magbanua MJ, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008;105:8369-8374.
11. Ornish D, Lin J, Daubenmier J, et al. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. Lancet Oncol 2008;9:1048-1057.
12. Diabetes Prevention Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
13. Ornish D. The Spectrum. New York: Random House/Ballantine Books, 2008.
14. United Nations Food and Agriculture Organization's report, Livestock's Long Shadow. Accessed on April 16th, 2007.

Comments

[Chironomid]

And, if we're going to have a health care system where physical activity is central to it, we are going to need a whole new cadre of PT's and manual therapists to guide people through inevitable musculoskeletal issues. You take a body that's been on a couch for 40 years and put it in motion and you are going to have minor but temporarily disabling and VERY discouraging injuries. Nothing will take the starch out of a budding walker or runner than a bout of Achilles tendonitis or plantar fascitis.

The current body of physicians are essentially untrained and unknowledgable about musculoskeletal injury from physical activity. It's an area of study all its own. I know from experience that this is probably the weakest area of our entire medical system.

[Ametista]

Well after all the crap we have heard about health care I honestly need all those references at the end of an article. I am so sick of the media sabotaging health care! Thank you Dr Ornish, your opinion is worth a million times what most politicians' are.

[DrP]

I recently paid nearly $300 in out-of-pocket expenses for a routine, screening physical, the first I had had in three years due to the cost. And my employer pays $4800/year for just my premiums. Since the premiums are going up for the next plan year, the employer had to chosse to raise the deductibles for all employees. When I saw my doctor, she wanted me to have two other screening tests, but after discussing options with her, she admitted that were alternatives to the tests that would not have any additional costs for me. When my lab work came back, she sent a note to let her know if I want to do something about my cholesterol. Since my HDL is 89 and my ratio to total cholesterol is 2.8 and my triglycerides are 51, which is truly amazing for someone with severe insulin-re­sistance/m­etabolic syndrome, I have no clue why she would ask that. I expect most people would call and agree to be put on dangerous and expensive statin drugs just like they would have agreed to the expensive screening tests. Because I know how to read scientific studies and am proactive about my own health, I questioned my doctor's advice and avoided additional costs, but how many people are able to do that? The preventative care provide by many physicians is inappropriate because too many still subscribe to the fallacy of the low-fat diet and insulin therapy for type II diabetics.

[Chironomid]

I hear you. I have degrees in human performance and biology, and can make sense of the peer-reviewed lit, and this test versus that.

I have a minor hernia I'm having corrected next week. The first Doc (Pres. of our local Medical Society) I saw sent me for a CT scan, which I chose not to get. Why? Because CT is the absolutely wrong scanning technology for musculoskeletal injury. If you do any scanning, its MRI. I later found a real hernia pro who was able to diagnose my problem without ANY scanning technology. He found it through manual palpation, and put his finger right on it (so, we both knew in no uncertain terms where my problem was!).

How many people out there have the education and tenacity to do what I did, and with courage of conviction? And when is my Ins Co going to cut ME a check for the $2500 I just saved them? BTW, I have great insurance by US standards - costs me $4000 a year; my employer picks up another $10K of the total. Still, I'm going to come out of OR on the hook for about $1500.

[DrP]

If physicians would take a course on metabolism and nutrition from the doctors in the first three URLs, read the research (the scientifically sound research, not the bad science sponsored by Big Pharma), watch the video in the second URL posted bellow, etc., then treat their patients appropriately (without statins, insulin, expensive procedures, etc.), the cost of healthcare would plummet. However, the economy would take a huge hit because Coke, Pepsi, McDonald's, Sara Lee, Pepperidge Farm, ConAgra.....on and on...would probably go out of business.

http://nmsociety.org/

http://www.dsolve.com/

http://www.mercola.com/nutritionplan/beginner.htm

http://www.dhslides.org/mgr/mgr060509f/f.htm

[borschtblue]

I wish there were more doctors who believe and have the knowledge that you declare. But this is not the case. Doctors speak in broad statements. For years they never told people to whom they gave antibiotics to replenish with probiotics and healthy flora; people find this out for themselves. Today how many doctors after prescribing statins will tell tell patients to take bioflavanoids, eat more greens, etc. Doctors, in my experience, (with only Medicare finally after not having insurance)treat patients with the prescription pad only. Nutrition information? Never. They just prescribe the latest drug advertised. I could go on and on here Dr. Ornish, but I suspect you know what I am talking about. Changes in health care need to happen at the doctor level AND the insurance level. Doctors have been getting away with spouting medical cliches for much, much too long.

[darkclouds55]

I'm an Independent who voted for Obama this time around because I believed he would actually fight to make a difference. If he bargains away a public option, he has become Carter in my book and I will no longer support him. I still won't vote GOP because there's just no one on that side who is supportable, so I guess I'll just be left out of the loop again for a while. So far, i've been very disappointed with Obamas
handling of the health care debate. He has the upper hand but will sell us out to appear successful instead of daring possible failure to bring real change that will improve the lives of millions in this country. That's what POLITICIANS do. CHANGE WE USED TO BELIEVE IN!

[demfemme]

Here are a few things that will help right away in promoting wellness but will not happen anytime soon:
1) Ban tobacco products outright. No intrinsic value and kill 450,000 people in the US every year.
2) Ban factory farming. Bad for animals and bad for the humans who eat their meat.
3) Ban high fructose corn syrup. Contributes to the high rate of diabetes and metabolic syndrome and obesity.
4)Give people an extra 30 mins at lunch to take a walk after lunch or do some other light exercise. Good for your overall health and good for heart health.

[grooveygrover]

these sound great, unfortunately #1 will never happen

[Tactical Grace]

Sign up for Hill Burton Health care at your local public hospital. The have to provide it under federal mandate and it is free.

[dkliman]

The only reason reform can fail, is if we don't have the votes in the senate. it is as simple as that. Baucus is running a panel with only 3 democrats and 3 republicans, because he has taken millions from the health insurance industry. He is doing his part to help them, not us.

what we need, is to have more democrats in congress.

[ianrthorpe]

I'm just back from visiting Majorca and have been having an e-mail exchange with a friend who lives in Greece. It started off on the Swine Flu scam then we got onto the much praised Mediterranean diet. Which does involve losts of fruit and veg and plenty of fish. What is a lie however is thelow level of red meat. There is little beef it's true, but lots of pork, lamb, mutton, goat. And lots of cream and butter, near lethal levels of alcohol intake and everybody seems to smoke. And yet the people seem to live longer and stay healthy longer.

It seems we in Britain and America are missing something about the Mediterranean diet. Perhaps its the easy pace at which they live life.


http://greenteeth.blog.co.uk/2009/08/16/fighting-back-against-the-food-fascists-6738016/

[alibeamish]

This doctor sounds okay, but his ultimate goal is coersion. He would force the greeks to change their diet and lifestyle, and problably take lipitor. This is the philosophy of Cleveland Clinic. A doctor at Cleveland Clinic says they should not hire people who are overweight

[jumperpin]

It's the red wine.

[maxfax]

Insurance companies don't want this type of change, and neither does Big Pharma, they'll lose money, and they are more about greed than health care.

[CTtransplant]

We cannot let the obstructionists prevent the health care/health insurance reform this country so desperately needs!

Please sign this petition to have paid health care removed from our representatives in Congress until such time as they reform health care - to include a strong public option - for 'we the people' who they are supposed to represent. Then spread the word to anyone and everyone you know!

http://www.petitiononline.com/PubOp676/petition.html

[krocklin]

What is not being discussed is also just plain price gouging of health insurance AND Medicare.
People with insurance get gouged in this country in out of pocket expenses from their deductibles.
The profit motive is the religion of America more than in other developed nation.
Bankers, doctors, health insurance companies, Wall Street, etc. are all equally guilty.
But this is the elephant in the room.

[rudyinbama]

Exactly.
What "reform" is left if the White House has given away negotiating drug prices just as Bush did with Medicare?
Am I grossly mistaken or is all that's left of this so-called reform is that we cover everybody by forcing everyone to pay - not for healthcare - but for insurance?
Was this election about hope and change or just choosing which party gets the lobbyist's money?

[kendraro]

As someone who has struggled with several chronic illnesses over the past 25 years, I have spent a lot of time interfacing with our current model, and it's limitations. What I do not understand is why a panel of thoughtful professionals like yourself has not been convened to address some of these issues. Prevention, alternative medicine, I think there is room for an entirely new health professional - the health coach - someone who could not only advise about nutrition and exercise but assist in coordinating multiple doctors, keeping track of meds and being an advocate.
I have to say, I have been giving a lot of thought to the food issue lately, because I really want to overhaul the way my family eats. But my husband lost his job a while back, so I really can't afford to start shopping at Whole Foods (much less boycott them) and I know that you can cook for yourself just as cheaply...the thing is, I am not a cook and I have two very picky (read: fast food addicted) eaters. Personally, I'd like some more healthy options where I live. What about tax breaks to bring healthy restaurants into areas that don't have them?

[nylibgrrl]

"I think there is room for an entirely new health professional - the health coach - someone who could not only advise about nutrition and exercise but assist in coordinating multiple doctors, keeping track of meds and being an advocate."

The "coordinating multiple doctors, keeping track of meds" part is what a person's primary care physician is supposed to be doing under the current system. I think for the majority of people, if they had proper nutrition and exercise their coach/advocate wouldn't really have to take on that job because multiple doctors and multiple meds would become largely unneccessary.

You should try buying produce from a local farmer's market or roadside produce stand. Even if it's not organic, you'll support your local growers and the food is fresher and usually cheaper than grocery store produce.

[jayraye]

Correction, I mean 30 years ago, usually when I lie about my age, I do it in the other direction!