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Calling Obesity A Disease Dooms Dieters

Obesity US News

Photo Credit: US News

In June of 2013, the American Medical Association officially recognized obesity as a disease. The organization had its reasons. For starters, obesity leads to heart attacks, strokes, diabetes, early-onset degenerative arthritis…and just about every other illness on the planet. In addition, people with obesity face a very difficult time overcoming their condition: Short of highly invasive stomach procedures, very few treatments succeed in helping people lose weight and maintain that weight loss. Finally, the organization may have been motivated by the desire to reduce stigma surrounding obesity; by labeling obesity as a disease, it hoped to signal that people with obesity cannot be wholly blamed for their affliction.

But will deflecting blame from obese people backfire? Now stricken with a “disease,” will obese people be less motivated to lose weight?

This is the question Crystal Hoyt and colleagues set out to answer in a study published in the prestigious journal, Psychological Science. Their concern? As they put it: “The term disease suggests that bodies, physiology, and genes are malfunctioning. By invoking physiological explanations for obesity, the disease label encourages the perception that weight is unchangeable.”

To see whether this concern was justified, they decided to run some studies. In one, they asked people how concerned they were about their weight. They also asked these people to select a sandwich for a hypothetical lunch. And they varied whether people in the study were exposed to a message that obesity was a disease. (To read the rest of this article, please visit Forbes.)

Posted in Health & Well-being, Health Policy | Tagged ,

Celebrating Colorful Language

whiskeytangofoxtrotI realize that I do not have the most focused blog in the world. Some people blog about nothing other than, say, capital punishment or new developments in whiskey. I write about psychology, behavioral economics, ethics, the doctor-patient relationship, health policy, political partisanship… a relatively wide range of things, but topics often linked by the connections I make between them and the weird way we humans make judgments and decisions. On occasion, however, I go even further afield to celebrate great writing. And I just finished reading a fun, new novel called Whiskey Tango Foxtrot, by David Shafer. And I felt compelled to share some tidbits to give you a flavor for his writing style.

For starters, he can’t help himself from commenting on the name of the country one of his characters is working in at the beginning of the novel:

“Myanmar, which sounded like a name cats would give their country .”

And then, for anyone who’s ever traveled to a country in Southeast Asia, there is his wonderful description of a ceiling fan:

“There was a ceiling fan in her two-room flat; it was on now. But it whorled and kerchonked around at such an unstable and idiotic rate that what it gave in breeze it took back in worry.”

Or this wonderful description of one of the characters in his book:

“He drove an old Saab. He read and read and read. It was like being a professor but with no students, which he understood from professor acquaintances was pretty much the way you wanted it. He had a wicker lampshade over his kitchen table; stalagmites of magazines and journals grew in his living room.”

His hilarious take on chemical ingestion gone bad:

“The one banana he’d eaten at seven a.m. fought bravely against the double whiskey, the two chardonnays, and the Xanax. Or what he’d thought was a Xanax. But when he didn’t fall into a dry-mouthed slumber, he’d realized that, in his stupid drunk, he had fished out the wrong pill—a Nuvigil—from the bottom of his Dopp kit, and he went into a kind of fugue, and his mind kept running, and he kept drinking (the Nuvigil in valiant neurochemical conflict with airplane whiskey) until the flight attendant cut him off, and then he and the ghoul driving his body deplaned together, and the turquoise carpet in the Portland airport nearly made him ill, and the beach-themed restaurant in the concourse had quit serving so his ghoul got them a taxi and got them to the hotel and there was a fridge in the room and more pills in Mark’s Dopp kit and then they went out together, his ghoul and he, Mark as blank as a bodhisattva, but also gross and reeling.”

And I leave you with one final thought, a simple little description which takes a third of the verbiage of my set up:

“He just lay there, half out of his sleeping bag, like a banana begun.”

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Podcast on the Challenge of De-adoption

GW Clinical Practice Innovation PodcastHere is a podcast I participated in, put out by folks at GWU. A quickish interview on the challenge of getting doctors to stop doing things they ought to stop doing.

You can also listen to it on iTunes, or on Stitcher.

Posted in Health Policy, Medical Decision Making

The High Price of Affordable Medicine

animatedcouponIn the old days, blockbuster drugs were moderately expensive pills taken by hundreds of thousands of patients. Think blood pressure, cholesterol and diabetes pills. But today, many blockbusters are designed to target much less common diseases, illnesses like multiple sclerosis and rheumatoid arthritis or even specific subcategories of cancer. These medications have become blockbusters not through the sheer volume of their sales, but as a result of their staggeringly high prices. Tens of thousands of dollars per patient, per year.

The high cost of such blockbuster specialty drugs creates significant financial burden for many patients. When a drug costs $90,000 per year, and a patient pays 10% of that cost, we are talking about a serious chunk of change. Not surprisingly, as these out-of-pocket costs rise, so too do the rates of “non-adherence,” medical lingo for “the patients didn’t take the medicines that I, their doctor, thought they should take.” Non-adherence used to be called noncompliance, which sounded too paternalistic. Now some experts are shifting to an even less judgmental language of “medication abandonment.” Indeed, here is a picture of the likelihood that patients will stop taking specialty drugs as a function of their out-of-pocket costs:

The High Price of Afforable Medicine Figure 1 NEJM

What can we do to help patients afford these medications?

(To read the rest of this article, please visit Forbes.)







Posted in Health Policy, Medical Decision Making | Tagged , , , , , ,

Here’s Why I’m Guilty Of Experimenting On People

facebookexperimentLast summer, Facebook received terrible press for running experiments on its users, adjusting the proportion of happy and unhappy posts at the top of people’s news feeds to see how that effected their moods. Shortly after that controversy surfaced, OK-Cupid founder Christian Rudder proudly announced “we experiment on human beings.” He unabashedly admitted that he runs experiments without users’ consent, but pointed out that this is a practice common to the majority of internet companies. What headline will grab the most clicks on HuffPo? You can guess that this company has run scads of experiments to answer this question. But Rudder didn’t simply run harmless little trials on whether putting the word “bikini” in a headline leads more people to click on it. Instead, his company actively lied to its consumers.

OK-Cupid is a dating site, you see, which purportedly learns enough about people who use its services to match them up with compatible partners. “We took bad pairs of matches,” Rudder proudly announced, “and told them they were exceptionally good for each other.” They found almost no reduction in how likely such people were to pursue relationships with each other.

Putting aside the evidence Rudder collected of the uselessness of his company’s matching technology, his experimental method raises questions about whether it can ever be ethical to experiment on people without their consent.

Well, I, like Rudder, have conducted social experiments on unconsenting, unwitting people. But the experiments I run differ in very important ways from the unacceptable methods with which OK-Cupid ran its experiment. Given the potential for companies like Facebook and OK-Cupid to cause real harm with their research, we consumers should at a minimum demand that such companies get feedback from independent ethics boards.

(To read the rest of this article, please visit Forbes.)

Posted in Behavioral Economics and Public Policy | Tagged ,

Why It’s Not Time For Health Care Rationing

In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. Back then, we had a Democratic president working to reform the health care system. Experts from across this system were promoting the importance of controlling health care costs; the growth of health care expenditures even slowed considerably around that time. Now we have a Democratic president who not only tried to reform the health care system but also managed to pass a complex health care law. As in the nineties, experts have been promoting the importance of controlling health care costs, and health care expenditures have even slowed over the past four years.

But for those working at the intersection of health care policy and ethics, there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted. The decline of rationing debates may reflect shifting emphases in health care policy. In the nineties, managed care companies (which the Clintons hoped to promote in their reform efforts) were capitating medical care, paying health care providers lump sums to care for panels of patients, thereby giving them a financial incentive to withhold medical care in order to hold on to some of that money. Such a strong incentive to withhold care inevitably sparked rationing fears.1 By contrast, the Affordable Care Act promotes accountable care organizations,2 which for the most part function on an old-fashioned fee-for-service basis, with modest incentives to contain costs while demonstrating high-quality care.

Rationing debates may also have declined because of changes in how policy experts analyze health care delivery. Back in the nineties, medical ethicists and health care experts debated the pros and cons of cost-effectiveness analysis,3 an economic tool that its proponents contended would demonstrate the most rational way to ration care.4 For a while, Oregon even tried to ration services to its Medicaid population using cost effectiveness in order to maximize the number of people it could enroll in Medicaid without surpassing its budget.5 In policy discussions now, however, cost-effectiveness analysis is practically nonexistent, replaced by comparative effectiveness research, a set of noneconomic analyses meant to guide health care decision-making without relying on rationing. Indeed, the ACA promotes the idea of CER while specifically requiring federal funding of such research not to be directed toward studies of cost.

In the nineties, bioethicists pumped out articles and books endorsing the idea of health care rationing while trying to determine the best way to ration care in a just manner.6 Now? The ethics of health care rationing seems to have faded from the literature.

Is health care rationing passé? I contend that debates about health care rationing have waned not because the need to ration has dwindled nor because ethical debates about how or whether to ration have been resolved. They have declined because the word “rationing,” and unrelated concepts such as cost-effectiveness analysis, have been replaced by terms— “parsimony,” “value,” and “CER”—that are not burdened by emotional and historical baggage. Terms like “rationing” and “cost effective” create strong emotions that interfere with rational argument. The newer terms, by contrast, may allow us to reengage in healthy debates about the best way to control health care costs without getting distracted by our preexisting thoughts and feelings.

Sometimes the best way to promote healthy moral debate is to turn to new words that don’t carry the burden of past debates.

(To read the rest of this article, please visit The Hastings Center Report.)

Posted in Uncategorized

How Screwed is North Carolina if Supreme Court Rejects Obamacare?

Affordable-Care-Act-500x218In a few months, we will find out whether the Supreme Court has decided that a critical part of the Affordable Care Act is unconstitutional. If that happens, lots of people will be in lots of trouble, financially speaking. Here is a wonderful article in a North Carolina newspaper laying out some of the issues for citizens of this wonderful state:

A case before the U.S. Supreme Court could threaten the ability for more than a half-million North Carolinians to afford their health insurance.

In North Carolina, more than 560,000 people have enrolled in health coverage through the federal Health Insurance Marketplace, nearly all of whom have done so with the promise of help paying their monthly premiums in the form of subsidies from the federal government.

Based on final enrollment figures released Tuesday by the U.S. Department of Health & Human Services, 92 percent of customers received monthly subsidies at an average of $315. That’s about 515,500 North Carolinians eligible for $162.4 million to help pay their premiums each month, and almost $1.95 billion in 2015.

But the legal mechanism through which this money flows is the subject of a lawsuit under consideration by the nation’s high court. A ruling to uphold the claim in King v. Burwell could revoke the Internal Revenue Service’s ability to give advance premium tax credits – essentially subsidies paid directly to insurance companies – to customers in states that do not run their own exchanges.

The question before the court is whether an insurance exchange set up by the secretary of Health & Human Services in the event a state does not can receive those subsidies the law says can be provided for plans purchased through an “exchange established by the state under section 1311″ of the Affordable Care Act.

In North Carolina, where lawmakers chose not to create a state insurance exchange, a ruling in favor of the plaintiffs would mean residents who have purchased insurance with the help of subsidies would no longer be eligible for that financial assistance unless the General Assembly opted to create an exchange or Congress stepped in to tweak the law’s wording.

Health policy experts in the state are quick to say there is a great deal of uncertainty about how the court might rule and what conditions could be applied to a ruling, particularly one in favor of the petitioners.

But for the North Carolina residents who would lose their subsidies, Jonathan Oberlander can sum it up in one word: devastating.

(To read the rest of this article, please visit The Fayetteville Observer.)

Posted in Health & Well-being, Health Policy | Tagged

More Encouragement to Walk the Stairs

A while back, I posted an interesting effort to get people to walk upstairs, rather than take the escalator. It involved a staircase designed to look like a piano, with musical sounds generated when people stepped on each stair. I love that approach not only because it is clever, but because I am a serious pianist. It appealed to my inner musician.

For those more visually inclined, here is another interesting set of stairs, in a picture brought to my attention by Bob Peck (@MakeABetterOne).

Colorful Stairs

What do you think? Will it convince anyone to climb the stairs who otherwise would have taken the escalator?

Posted in Behavioral Economics and Public Policy | Tagged ,

Are Patients Harmed When Physicians Explain Things Too Simply?

Poultry and Hog Farms Face Possible Dioxin ContaminationA quick quiz before we start today’s lesson.

What do we call a tree that grows from acorns?

What do we call a funny story?

What sound does a frog make?

What is another word for a cape?

What do we call the white part of an egg?

On that last question, were you tempted to answer “yolk?” If so, you are in good company, because most people give that answer even though the correct answer is “albumen.” People answer yolk – after oak, joke, croak, and cloak – because that’s the fast choice. Primed by rhymes, people provide the wrong answer.

Sometimes fast-thinking is not so good. Which raises an interesting question for physicians trying to help patients navigate important medical decisions Will they harm patients by explaining things so simply that patients make fast, erroneous choices? (To read the rest of this article, please visit Forbes.)

Posted in Behavioral Economics and Public Policy, Medical Decision Making | Tagged ,

The Key to Winning a Pulitzer? Don’t Take Time To Think!

Bret Stephens won a Pulitzer Prize for his foreign affairs column  in the Wall Street Journal op-ed page. Only in his early 40s, Stephens can already boast of an enviable number of accomplishments. He has already been Editor-in-Chief of the Jerusalem Post. And he is now Deputy Editor at the Wall Street Journal, one of the nation’s best newspapers. Pretty decent for someone who graduated college 20 years ago.

So what’s his secret? Apparently, it’s his ability to avoid thinking before publishing. I wish I was making this up, but here is how Stephens described his Pulitzer Prize-winning writing technique, in an interview published by the University of Chicago Magazine:

“Columns are a bit like pancakes,” he said. “They need to be cooked and eaten right away.” To his credit, Stephens demonstrates an excellent understanding of pancakes. Nothing is as good as fresh off the griddle. But what do pancakes have to do with newspaper editorials? Stephens elaborates: “I’ve never written a column on a Thursday and just put it aside and then run it on Monday night. I think that’s deadly.”

What?!? Deadly to wait a few days, revisit your ideas after you’ve had time to reflect on them, before publishing them in one of the world’s most influential newspapers?!?

Copyright The University of Chicago Magazine

Copyright The University of Chicago Magazine

I’ve had more than several days to consider Stephens remarks, and I continue to find them deeply disturbing. I am not disturbed simply because one prominent writer brags about his unreflective methods, but because I expect he is describing how many prominent opinionaters work. They crank out columns. They react to the issues of the day with little desire to slow down and ponder what is truly important. (To read the rest of this article, please visit Forbes.)

Posted in Uncategorized