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Former Surgeon General on a Better Approach to Health Care

With health care costs skyrocketing, Dr. Richard Carmona thinks there is a better way to save lives and money: focus on preventing chronic disease. PJM discussed Carmona's new approach with him.

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April 22, 2008 - 12:50 am

Health care has been front and center in the 2008 presidential campaign, with candidates sparring over the plight of uninsured Americans and the rationale, or lack thereof, for greater government control. The emphasis is well placed. The United States spends $2 trillion a year on health care and there is a nagging concern that the nation might not be getting enough bang for its buck.

Dr. Richard Carmona, the U.S. surgeon general from 2002 to 2006, believes that the key to both curbing costs and saving lives is to refocus health care on the prevention and early detection of chronic disease — long-term and typically incurable conditions such as cancer, heart disease, diabetes, and asthma. Three-quarters of U.S. health care expenditures go toward treating such diseases because “our system is set up to wait for people to get sick and then care for them.” His organization, the Partnership to Fight Chronic Disease, seeks to bring a more preventive approach to health care.

PJ Media editor David J. Rusin sat down for an exclusive interview with Dr. Carmona during his visit to Thomas Jefferson University, an institution that trains medical and health sciences professionals in Philadelphia.

PJM: How did you get involved in the Partnership to Fight Chronic Disease? What is your inspiration?

Carmona: When I left my statutory term as surgeon general of the United States, as you could imagine I had a lot of opportunities and people approached me to do a whole host of things. I was particularly enamored with this organization which was starting up because it really was a continuation of what I was doing as surgeon general — you know, really being challenged with how do you keep the nation healthy, what do we need to do to fix our health system in dealing with a specific and finite part of that, which is chronic disease. They made their case to me and I said, “I believe it; this is what we should be doing.” And I spoke to some of my fellow surgeons general, who agreed to help me as well as I moved along with this, because they felt equally that this is important. And now we have over 110 organizations — academic and private and advocacy groups, nonpartisan — and all of us are focused on how to eliminate chronic disease as a partial solution to this health care crisis we have.

PJM: Yes, the range of organizations involved in this program is impressive. I guess it’s not too surprising. Nobody is against saving people’s lives and nobody is against saving people’s money. What are the primary goals of your organization and what routes do you take to try to achieve them?

Carmona: The primary goal, broadly stated, would be to improve the health literacy of America as it relates to the burden of chronic disease and the cost of chronic disease. We spend over $2 trillion a year — that’s about 16% of our gross national product — on health care. Seventy-five cents of every dollar we spend is on chronic disease, most of which is preventable or mitigatable. So if you were running a business where you were throwing 75 cents away on every dollar that came in, your board would get on you pretty quickly.

PJM: You’re not going to stay in business very long.

Carmona: And that’s what’s happening to us because we can predict in the next few years we’ll be spending 20% of our gross national product and $4 trillion. So we recognize as thought leaders, if you will, in health — all of us, our 110 partners and even more who haven’t joined us — that you can’t attack this health care problem in the nation unless we start dealing with all that’s preventable, and that’s chronic disease: asthma, cancers, diabetes, cardiovascular, and so on.

PJM: I wanted to ask you two questions about some of the specifics of chronic disease, based on information from the literature you have online. In one of your charts, you show that the fraction of people who are suffering from at least one chronic disease is increasing. Maybe ten years ago it was 40%, now we’re up to 45%, and your projections show it going up to 50% by 2030. Is this simply the result, for example, of an aging population? Or is this more a result of poorer lifestyle choices that people are making or degradation in the way that we approach health care in this country? What really drives this trend?

Carmona: All of us are going to develop aches and pains as we age. There’s no question. That’s part of aging. The real challenge to us is how do we age as healthy as possible? And that’s where this whole issue of chronic disease comes in, because 40% of the cancers that we have are fully preventable. Much of the cardiovascular disease and heart attacks that we have are fully preventable — diet, lifestyle, exercise. Type 2 diabetes — fully preventable. Nine million children who are overweight or obese and many of whom have type 2 diabetes now and high blood pressure in grammar school — fully preventable. So when you look at normal aging, sure, when we get older we all slow down, get some aches and pains, and if we lived a very full life and played sports as a child, we’ll have sore knees and so on. That’s not what we’re talking about. What we’re really talking about is eliminating all of these chronic diseases that make your later years, middle age and older, much more problematic, much more costly, and rob you of quality of life.

PJM: Okay, a second question is related to a picture you have on your website that shows the geographic dependence of chronic disease rates across the country. I was quite surprised to see that it’s very much grouped by region. The West and Southwest seem to be the healthiest among us. The mountainous and Rust Belt areas of the East are doing much worse. What is the explanation for these geographic trends?

Carmona: It’s really interesting because different people interpret it different ways. When you look to the East and Northeast around the industrialized cities, you start thinking right away, “Does environment have anything to do with this?” Sure it does. The closer you are to places that are dropping toxic substances into your water or contaminating your food, the air you breathe, and so on, sure. The area in the East also coincides with what’s called the “stroke belt,” which is lower Southeast — Tennessee, Georgia, down in that area, South Carolina — it has the highest incidence of stroke in the United States, and it’s in mostly the African American population in the Southeast. So there are a lot of correlates here. But what really is interesting is that it looks like it’s easier to be healthy as you move west from the Midwest, than it is in the East, although there are pockets within the East that could be improved as well. So there’s a lot you can read from this as it relates to Pennsylvania.

PJM: Yes, we are one of the worst places according to that map.

Carmona: And it’s costing Pennsylvanians over $60 billion a year in lost productivity and cost of care for chronic disease.

PJM: That’s a lot of money.

Carmona: It is.

PJM: What are the primary shortcomings of the health care system in the United States as it functions today regarding chronic disease?

Carmona: Well, you got a few hours?

PJM: I don’t think you have a few hours!

Carmona: The shortcomings are really, first of all, when we look at the system — we don’t have a health care system; we have a sick care system. Our system is set up to wait for people to get sick and then care for them. And when you look at how we pay our providers of health care, it’s to take care of sick people. How many people do we pay or how many systems do we have that reward you for keeping me healthy? Before I went into public health I was a trauma surgeon. I got paid very well to take care of people, in emergency situations usually, who either had bad behavior that day — drunken driving, violence — or people that made bad decisions their whole life — ate the wrong food, sedentary activity, come in with a stroke or heart attack, whatever it happened to be. And so when we look at this whole issue of chronic disease, it is clear that we must do something to prevent it because it is the largest driver of the cost of health care and is robbing us of quality years of life.

PJM: There’s always much political discussion, especially in this election season, about 40 million uninsured people. But the scope of the problem with chronic disease that you’re describing is so vast that obviously something is also going wrong with the treatment that the 200-plus million insured people are getting. Is it that even if people go to the doctor every year they’re not getting the proper screening and diagnostics, or are they just not following the lifestyle advice that they’re given? What is the problem with those insured people?

Carmona: Most of it is lifestyle. If you go to your doctor for a physical every year and every year the doctor tells you, “You know, you’re gaining weight every year. Your cholesterol is higher. You really need to stop smoking. You should wear a seatbelt when you ride in your car.” And if you don’t do those things, you’ll come back the next year, and your cholesterol will be higher, your weight will be higher, your exercise tolerance will be lower, the cost of your health care will go up. So, really, the doctor, nurse, primary care provider, health practitioner whom you see can only advise you as to the path to take to achieve optimal health and wellness. Somewhere along the line, it’s partially our responsibility that we need to walk a little bit, get out and stop being so sedentary, eat a little bit less, eat healthier foods, stop smoking. Smoking is the number one preventable cause of death and disability in this country.

PJM: I guess you would argue that we have not only an individual responsibility to keep ourselves healthy, but also some level of civic responsibility because of all the money and lost productivity that’s eaten up by chronic disease.

Carmona: I think it really is a partnership between government and the citizens. Government can provide you guidance and can provide you programs that can help you understand. But if you don’t take the initiative to use those programs and make healthy decisions in your life, there’s no money in the world that’s going to undo what’s coming to you.

PJM: How does our health care system and its approach to chronic disease compare with other nations’ systems in the industrialized world? Do they do an appreciably better or worse job of preventing and detecting and treating early?

Carmona: As a scientist, let me give you the facts. We spend more money per capita than any other nation in the world. And when you look at the World Health Organization statistics of how they categorize countries in relation to health, we’re anywhere from about 27th to about 35th or 40th in the world. Swedish people live several years longer than we do. Cubans live longer than we do. Okay? So there are many other countries that do better in preventing chronic disease and keeping people healthy. Yet we spend many, many more dollars per capita in the United States. So clearly there’s a better way. We need to adopt some of those best practices. And that is changing our culture, embracing optimal health and wellness, putting an infrastructure in place that rewards providers to keep us healthy rather than waiting for us to get sick, making sure our children get vaccinated, making sure that all of our mothers who are pregnant get prenatal care. We have 150,000 birth defects in this country every year; 80% of them are preventable. If you make sure that a pregnant mom has a prenatal plan, eats, takes a multivitamin and folic acid, you eliminate over 100,000 birth defects a year. We haven’t done it.

PJM: That’s an incredible statistic. It seems that your organization wants a refocusing of the health care system. You don’t talk much about a lot of the restructuring debates that are going on — health savings accounts, nationalized versus private health care. Do you think that we can make the advances that we need to make in the prevention and treatment of chronic disease within the general framework of the health care system we have now, or do we really need a restructuring at some level rather than just a refocusing?

Carmona: All of the above. I think we must start making the changes now. But I also recognize that we need a radical transformation of the existing system. The existing system is predicated on a much simpler world, where there were few advances in medical science. There were a couple of antibiotics; there were no psychotropic drugs; there were no CTs, MRIs, or minimally invasive surgery; genomics was science fiction. So that’s the world that we were in a half century ago that Medicare and Medicaid is predicated on. Now we keep putting Band-aids on this system in hopes of trying to fix it, but the system is accelerating too fast. It doesn’t have the capacity to accept the new science, the new technology, the new knowledge base we have. So we can’t wait to restructure the system because politically that’s going to take a long time. But we can start making strides forward to eliminate chronic disease based on the information we are putting out through the Partnership to Fight Chronic Disease, which are very simple steps, and work with organizations to deal with infrastructure issues. We are not prescriptive to say “this is what you must do.” But we certainly have the opinion leaders and thought leaders in this area that can help any branch of government make some prudent decisions as to what is needed to change the infrastructure of our system to be more efficient and effective in delivery of true health care, not sick care.

PJM: Okay, Barack Obama, Hillary Clinton, John McCain.

Carmona: My friends.

PJM: One of these people is going to be the next president. How much traction has your message gotten in this campaign season?

Carmona: I think there’s good news and bad news. I think from when we started the Partnership a year ago, we have seen all of the candidates at least engage, somewhat superficially most of the time, on the issue of prevention of chronic disease — and even Barack Obama one time thanking the Partnership to Fight Chronic Disease for their work. I’m not happy that the discussion hasn’t gone more in depth to substantive discussion of what each candidate would do when and if they come into office to address the issues. I’m hoping that in the future debates, and ultimately when we have two candidates, we will hear more substantive discussion as to how he or she sees the path forward to provide optimal health strategies to transform our system and keep the cost of health care down while improving the quality and quantity of life.

PJM: So are you optimistic about the near-term future with respect to getting your message out and achieving some of these changes that you seek, say, within the next decade — turning that plot around to where fewer people are going to be diagnosed with these diseases.

Carmona: I’m optimistic for two reasons. First of all, I’m inherently optimistic; I’m an eternal optimist. But I’m also optimistic in that I recognize that nothing really comes quickly in Washington, where the leadership has to move forward on this, and that we will see incremental changes. We’re going to see, probably in the next Congressional sessions, most likely some form of expanded care for the uninsured — you know, if you want to call it universal care — but something that brings in more people. My guess is we’re not going to see much change as it relates to payer, or universal payer, because that’s going to be a quite contentious issue, because you’re going to upset the economics of the dollar flow. But I think we’ll see incremental changes as we move along. I think there’s going to be a greater appreciation of the value of prevention and the challenge to chronic disease as outlined by the Partnership to Fight Chronic Disease, because we can’t afford the trajectory we’re on now. It’s too costly. The bank is breaking now, and we’re telling you it’s going to be twice as expensive in the next few years. We’re going to be forced to do the right thing because of the economic realities of chronic disease.

PJM: Obviously if you are trying to turn around something that is 15% of the gross domestic product, that’s going to take quite a while. But I think that your message is very self-empowering in the sense that individuals and their doctors have a lot that they can accomplish right now within the confines of the current system to really improve matters.

Carmona: Yes.

PJM: We wish you the best of luck.

Carmona: Well, thanks very much. I’ll need it. And thank you for helping us get the word out to the American public.

PJM: It’s our pleasure. It was a great opportunity.

Carmona: Well, the Partnership to Fight Chronic Disease is a good organization. And as you saw, there are some very credible organizations there. And we come from both the left and right side of the aisle. We tell everybody: Leave your politics at the door. This is about improving the health of America, period.

PJM: Excellent. Thank you very much.

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