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“[Next Medicine] is the replacement paradigm. Higher taxes will not fix American’s health, nor will politically driven health care reform. Increased debt won’t do it either. Prevention will.” Walter M. Bortz, MD, Next Medicine (Oxford University Press, 2011)
“Heart disease is a choice, not a fate, and addressing the risk factors is an obvious first-principle strategy.” Walter M. Bortz, MD
NEXT MEDICINE: A New Model for Health Care
Health before Repair
Dr. Bortz has a far-sighted and bold plan to fix our healthcare system. Although I’m against turning healthcare over to politicians and bureaucrats (as he seems prepared to accept), I concur with the emphasis on health and prevention proposed in his groundbreaking book: Next Medicine (Oxford University Press, 2011).
(More about my objections to government-run healthcare at the end of this article)
Walter M. Bortz, MD, is Clinical Associate Professor of Medicine at the Stanford School of Medicine, author of We Live Too Short and Die Too Long—and an old friend. I have delighted in exchanging correspondence with him over the years. Now in his 80s, he has run a marathon a year for 40 consecutive years, including Boston in 2010. He is a respected authority on aging. I hold him in the highest regard.
Bortz’s vision of healthcare is grounded in self-efficacy and personal responsibility. Let’s begin by examining those concepts.
Bortz believes that health begins with a well-developed sense of self-efficacy. He calls it a “central axis for health and for Next Medicine.” Put another way, we must become knowledgeable about our own body and health. And we must believe in and rely on ourselves.
Citing noted psychologist Albert Bandura, who has made studying self-efficacy his life’s work, Bortz lists the four core building blocks: 1) small steps of mastery, 2) peer examples, 3) social persuasion, and 4) diminishment of cues of failure.
Bortz translates that into examples we can all understand and relate to: “First, do not try to run a mile right away; walk to the mailbox and then work up from there. Second, look around you and take cues from others who have built their competence. Third, social persuasion means developing a markedly greater health literacy and personal responsibility to act on the behaviors that determine health, and not delegating health to [others]. Fourth, do not accept a pain in the foot as a reason to stop walking. Get a pair of shoes that fit, walk more slowly—but walk.”
“Taken together,” Bortz explains, “these four principles specify how the most disenfranchised individuals can reach their potential.”
In short, don’t offload self-care to others. Take charge. Be your own front line of defense against ill health.
“The fact that 60% of those who visit a doctor have dominant lifestyle issues (poor diet, physical inactivity, smoking) is a testament to the epidemic nature of low efficacy,” Bortz writes.
If the doctor tells you to clean up your diet and start exercising, learn how and why, and do it. Don’t opt for pills or other quick fixes—step up. Rely on yourself first.
Self-efficacy, of course, goes hand in hand with personal responsibility.
More than a half century in medicine has shaped Walter Bortz’s world view: Rights ultimately derive from responsibilities, and when you are not responsible, you forfeit the right. Years of doctoring and observing have brought him to believe that axiom is “directly relevant to our present medical mess.”
The bottom line is that we can do more for ourselves, by a factor of five or more, than any doctor can do for us. Far too often we put off healthy living until it’s too late, and sometimes not even then. We are largely responsible for our own health.
Bortz cites several experts on this point, but the quote that says it best is from Robert Blank, professor of politics at the University of Canterbury in New Zealand. In 1997 Blank wrote, “Although people have a right to design their own lifestyle, if they choose to engage in practices and behaviors that put them at higher risk, they should be prepared to relinquish their claim on societal health care resources. By failing to balance their rights with responsibilities, they will surrender positive extension of their rights. The concept of responsibilities places rights in a social context.”
That statement has never rung more true than today. Some things are accidents or unforeseeable, matters of fate, but more verifiable risk factors are coming to the fore almost daily. Modern science has made it possible to prove good and bad practices that were formerly matters of opinion or speculation. (Many gray areas, of course, still exist.)
Dr. Bortz gives some stark examples of the type of cases that are stretching our resources to the breaking point. Here’s the most egregious.
This is a case that Dr. Bortz encountered about 30 years ago. It involved a 20-year-old man who was suffering from a virulent infection of the lining and valves of the heart. Emergency room staff promptly diagnosed his case and sprang into action. “Critical to his history was that he was an acknowledged intravenous heroin addict,” Bortz relates. “His unsanitary self-injections gave bacteria easy access to his circulatory system.”
The infecting bug could not be controlled; surgery was the only answer. The cardiac surgery team “vigorously scraped the infection from the interior of his heart and replaced the torn heart valve.” He recovered and was released. Unfortunately, that was only the beginning.
Within several days he was back. “Our patient was re-injecting drugs, even though this was what had led to his earlier problem,” Bortz continued. “In another major operation, surgeons implanted a new heart valve. In a week or so he stabilized enough to go home. Predictably, within a month he was back in the emergency room…A similar surgical rescue was performed. A third heart valve was implanted.”
“He, of course, paid nothing for all his bills, which probably came to about $50,000 per valve. They were assumed by Medicaid—or, in effect, the American taxpayers.
He didn’t come back, but it was later learned that he had taken his dangerous—and costly—behavior to another hospital.
Medical experts have long known that individual choice and social costs are on a collision course. Bortz contends that now is the time to act. “We must look at reality and set boundaries on an individual’s right to self abuse in order to bring the spiraling social costs of harmful behavior under control,” Bortz writes. “We might reduce the message to: If you want to kill yourself, go ahead, but don’t send me or anybody else your bill."
A decade or so back a famous liberal politician spoke of life’s lottery. He was referring to the economic system, but I’m sure he would happily extend the concept to nature’s lottery, and the seemingly capricious nature of illness. “Defaulting to such fatalism,” Bortz writes, “masks the reality of our new ability to choose health, a choice made possible by the fact that we know the details of health—its origins, its language, and its metrics. It is a choice that is central to Next Medicine.”
A few chapters later, Dr. Bortz discusses some of the clearest lifestyle choices. His review of what we know about preventing heart disease, cancer, diabetes, arthritis, and brain disease is both telling and liberating. He explains why health, not repair, should be front and center in dealing with these deadly and debilitating diseases. Prevention, of course, is far superior to pills and surgery in terms of cost and quality of life.
Preventing Heart Disease
“Until recently, we lacked knowledge of the biological mechanisms inherent in prevention,” Bortz writes. Heart disease, cancer, diabetes, arthritis, and brain disease, which have enjoyed extensive investment in research and repair, are now prime targets for preventive strategies.
He begins with a hard hitting look at heart disease. (We’ll focus on heart disease and let you read about preventing the other diseases in Next Medicine.)
“Heart disease is a choice, not a fate, and addressing the risk factors is an obvious first-principle strategy,” Bortz writes unflinchingly. He presents the case for prevention concisely and convincingly. (Volumes could, of course, be written on the subject.)
“Thirty years ago, the heart-related death statistics had been ominously worsening for decades,” Bortz relates. “Then something happened; heart disease-related deaths began to drop—now they are 40% to 50% less than they were at their highest level. Experts debated the relative contribution of prevention versus treatment in this turnaround, but most acknowledged both early aggressive treatment and improved behavior patterns (lowered smoking levels are a major factor) played a role.”
He cites a 2009 paper which constructs a model for “perfect care” where all preventive goals were achieved by addressing risk factors, in addition to maximum drug and acute events therapy. (The paper is entitled “Comparative Effectiveness of Heart Disease Prevention and Treatment Strategies.”)
“The authors concluded that the largest increase in deaths prevented or postponed from ‘perfect care’ would result from increasing the physical activity of the asymptomatic group, followed by meeting dietary requirements and stopping smoking. Increasing physical activity was also the most powerful preventive strategy for those with known heart disease. One third of all deaths are prevented when perfect care is delivered to those with no known heart disease, while perfect care for all those known to have heart disease could prevent or postpone 23% of deaths.”
The authors concluded: “Conceptualizing heart disease as a chronic disease, rooted in behavior acquired early in life, rather than acute disease that strikes individuals in late life, is most likely to lead to breakthrough innovations.”
“Prevention trumps treatment,” Bortz recaps.
He’s not done, however.
He moves on to artery size, an “almost invisible” subject in the literature of heart disease. “These tributaries are largely regarded as passive tubes to which bad things happen, clogging and inflammation among them.” Much has been reported on the plasticity or remodeling of the vascular system, “but most has been on the structural responses to various pathological states.”
He laments that little attention is paid to big arteries—because “they are healthy.” A study of coronary artery size in ultradistance runners, he observes, “proved that the diameter of an artery responds to the flow within the artery, and the more flow, the larger the artery becomes in response.”
“[Big arteries] get no recognition but are obviously of dominant significance in the story of heart disease.” he continues. “One can even ask, Who cares what your cholesterol level is, if your artery is an inch across? The prevention of heart disease should begin with a crusade for big arteries. The throb that accompanies a brisk walk or jog is the artery stretching and reconfiguring to reflect greater flow.” (Cooper Clinic cardiologist John Ho, MD, told me on my last visit that the CT angiogram of my heart “looks really good…Your arteries are quite big and there is really nothing to worry about.” So some doctors are paying attention to artery size.)
One more telling account from Dr. Bortz’s deep reservoir of firsthand experience: It occurred a few years ago when a guest professor spoke at Stanford on the topic of angiogenesis, the formation of new blood vessels—a hot frontier topic. “The audience was breathless in anticipation,” Bortz writes. The speaker told how genes are inserted into a virus that finds its way into targeted tissue, causing the new sprouting of small blood vessels. “Considerable acclaim greeted this revelation,” Bortz reports.
In the Q&A session which followed, Bortz asked, “But don’t you get the same results from exercise?” The professor replied, “Of course. But there’s no money in exercise.”
Bortz makes similar cases for lifestyle in the prevention of cancer, diabetes (see below), arthritis, and brain disease. Again, we’ll let you read his book for the details.
In closing, let’s touch on to the hottest topic of all, the heightened role Bortz sees for personal responsibility in our health care system. How would lifestyle choice impact care under Next Medicine?
Next Medicine in Action
As we’ve already seen, Bortz and others acknowledge our right to chose how we live, but question whether we should expect our neighbors to pay the bill for irresponsible behavior. On the brighter side, should we be rewarded for taking care of ourselves? How would it work? Who decides?
Dr. Bortz summarizes his vision of Next Medicine at the end of the book. His basic theme is that “heightened personal responsibility for health behavior will be abetted by information and incentives aligned in pursuit of health.” Health delivery would be run by a “multi-representative board as a Commonhealth enterprise, like the Federal Reserve.” Many details are of course involved, but here is the plan in a nutshell (as I understand it).
Health care professionals will be salaried and rewarded for results based on agreed upon standards. Prevention and maintenance will be funded on par with repair. Health education in schools will be supported by “generous monies.” The “community” (government) will oversee the budget.
“Insurance coverage of all the uninsured and underinsured persons will be paid for by the hundreds of billions of dollars left over after we recapture the self-efficacy that had previously been deeded to the medical-industrial complex,” Bortz states. “Accidents and other unforeseeable, ‘nature’s lottery,’ external-agency experiences will be covered by the basic insurance package, but expenses that occur due to lack of personal responsibility will be addressed by risk-adjusted costs.” (Emphasis mine)
In other words, those that don’t take care of themselves will pay higher premiums or be given palliative care. Paraphrasing our President, “We’ll give them a pill to keep them comfortable,” but not open heart surgery or a liver transplant.
Bortz would allow people to choose their own health care provider, but personal responsibility will be a center post of care. “Capitalism will support health instead of disease,” Bortz writes. People will be required to commit to self-care and self-efficacy—or suffer the consequences.
This model will save billions of dollars when fully implemented, Bortz predicts. Type 2 diabetes is a perfect example. Research has shown that 58% of new diabetes cases can be prevented by exercise and diet, compared to 30% that are prevented by drugs. “That 58%, in my mind, is minimal and could be virtually 100%,” Bortz opines.
“The benefits of physical exercise are established and many,” he adds. “Take a walk, not a pill.”
Doctors find “little room in their black bags for exercise, preferring pills and technology, because that’s where the money is.” Bortz writes. He proposes to change that. The money should be in health, not disease.
* * *
As noted at the outset, I agree that emphasizing health and personal responsibility would go a long way toward making our health care system more efficient and sustainable. However, I would prefer to do it in the private market. If you don’t like your insurance company, you can change companies. If government runs the show, you’re up a creek without a paddle. Universal health care in Massachusetts is an example. A new survey released a few days ago by the Massachusetts Medical Society reveals that fewer than half of the state’s primary care doctors are accepting new patients, down from 70% in 2007, before former governor Romney’s health-care plan took over. The average wait time for a checkup by an internist is 48 days. It’s 41 days to see an OB/GYN, up from 34 last year.
The Wall Street Journal editorial page wrote on May 10, 2011: “When government subsidizes something, you get more of it, which means higher demand for insurance and health-care services. Combined with insurance regulations that suppress innovation and competition, this reality helps explain why Massachusetts premiums are among the highest in the U.S. The current physician shortage was inevitable without new doctors”
Insurance companies should be lauded—certainly not demonized—for adjusting health care premiums based on lifestyle choices. The private insurance industry should be unchained from state and federal regulations that dictate the type of insurance they can offer. I believe the public will respond to insurance coverage that encourages lifestyle change—and saves money. The government should get out of the way and let the market work. Carol and I didn’t want to pay for first dollar medical insurance coverage; we took care of ourselves and our son, and didn’t need it. We had major-medical coverage until we were 65, and never made a single claim. Our premiums were low and we were protected against ruinous losses. The insurance company loved us.
Obviously, we aren’t going to resolve these issues here. One thing is sure, however. Personal responsibility should play a greater role in health care going forward. Thank you Dr. Bortz for bringing the subject front and center.
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