you can pay me now…

Sunday, November 6, 2016

For football fans, there is nothing worse than a penalty that wipes out a touchdown or erases an interception. Coaches and players work on execution and avoiding errors, especially those that are self-inflicted by penalty. The team that makes the fewest mistakes tends to win the game. So it should come as no surprise that in the real world medical care, the doctor and patient who minimize their error tends to win as well. But while football has officials on the field and in the replay booth, making the right call for medical care is tougher.

Medicine is all about delayed reward. Controlling diseases like high blood pressure, high cholesterol and diabetes can increase quality and quantity of life. But the health care community can only give advice; they can’t go hope with the patient and demand the patient do the right thing. And there are no referees to throw a flag and call out actions that can erase life’s touchdowns.

Some behaviors are not well known and tough to fix. Medications for chronic diseases are supposed to be taken on a regular basis to prevent complications. High blood pressure, high cholesterol and diabetes medications (including insulin) are used to control these diseases to prevent complications. Heart attacks, strokes, blindness and amputations are potentially preventable, but the reward for taking a pill and watching what you eat is 10, 20 or 30 years down the road. Not taking medicine has no upfront risk and there is nobody in a replay booth reminding you to take your emaciation every day.

What is the cost? Individually, it can be an early death or significant disability. For the society, research suggests that failure to comply with medication prescriptions increases medical costs by up to $290 billion a year. 20-30 percent of all prescriptions go unfilled and up to 50% of the time, medication is not taken as directed. This leads to up to 10 percent of all hospital stays and more importantly, 125,000 deaths a year.

Specifically, for diabetes, the numbers are even worse. For those who need medication, not keeping blood sugars under control can increase deaths directly related to diabetes by 50%, and the noncompliance rate does not count deaths from heart disease or kidney failure.

Some behaviors are easy to see and still tough to make better. Drunk driving is unacceptable behavior and it is a societal norm not to drink and drive. Yet while police and the courts are there to throw yellow flags, more than 28 million people admit to that behavior every year and it leads to almost 10,000 deaths a year. Smoking is a behavior that has no positive benefit to the body, and is highly addictive. There are 1 billion smokers worldwide, it directly kills 5 million people a year (167,000 cancer victims in the US) and indirectly kills another 500,000 from second hand smoke. There is no striped shirt blowing the play dead when a person buys a pack of cigarettes.

Why do we care what other people do? The bottom line is that we are our brother’s keepers and resources that are spent on avoidable cancer care, dialysis for kidney failure or nursing homes for stroke victims might be better spent on primary care, preventive medicine, providing good nutrition for the poor and better mental health for those in need. But it’s tough to tell people who have self-inflicted their disease or injury, that society will not look after them…so we pick up the pieces and try to put them back together again. Sometimes, again and again and again.

Financial resources are not unlimited. Taking money out of one bucket, to care for behavior errors leaves less in other buckets. Once upon a time there was a wise commercial for Fram oil filters to increase your cars longevity:

“you can pay me now…or you can pay me later”


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