Public Health

A Lot of Americans Eat Fast Food. Do You Know What That Means?

By M2|2018-10-09T14:06:16+00:00October 5th, 2018|Public Health, Uncategorized|

A Lot of Americans Eat Fast Food. Do You Know What That Means?

I eat fast food and I don’t mind saying so. My favorite is a Big Mac meal at McDonald’s and I have the blanket to prove it. I also eat my fair share of hot fudge sundaes at Dairy Queen.

Although it isn’t clear which fast food outlets are people’s favorites, a recent study shows a lot of people eat fast food, but maybe not the people you might have thought.

As part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of about 5,000 people were asked what they ate in the 24 hours before the survey. As reported this week in the data brief, Fast Food Consumption Among Adults in the United States, 2013–2016, about 37% of people over the age of 20 ate fast food in the previous day. Younger people were more likely than older people to have enjoyed fast food, men typically eat their fast food at lunch time, and women evidently are more likely than men to have fast food as a snack (probably hot fudge sundaes at McDonald’s or Dairy Queen!). As the chart below shows, at dinner time, fast food is equally popular with men and women.

These survey results were a popular news item, so you probably saw the information somewhere already. But a few points stood out to me about the importance of updating information we may have learned in the past, either because new data has become available, or simply because we haven’t yet had an occasion to refresh our knowledge. If you haven’t read it, Factfulness: Ten Reasons We’re Wrong About the World–and Why Things Are Better Than You Think by Hans Rosling is a great book about various facts we might have learned that need to be updated.

First, as a person trained in public health, I have been taught that people consume more fast food if they have lower incomes, in part because fast food is most affordable and available to them. This data brief indicates the relationship between income and fast food consumption goes the other way. That is, people with higher incomes ate fast food more frequently than people with lower incomes as shown in the chart below.

Yes, you could calculate “fast food consumption” in different ways, and perhaps the quantity of calories consumed as fast food is higher for people with lower incomes, but an idea I had in my head about who eats fast food needs to be updated. Maybe an idea in your head needs to be updated too.

Second, I also know as a person trained in public health, that most people, even those who eat fast food, also eat other things, and that the relationship between food, weight, exercise, and metabolic and cardiovascular health is very complicated. Still, a first of its kind study published in 2014 found that, at least for kids, poor dietary habits outside the fast food environment “may be more strongly associated with overweight/obesity than fast food consumption itself.”

Let’s add that information to our brain’s database as well.

The fast food consumption brief created lots of headlines this week. Hopefully we all took the opportunity to read the articles that went with the headlines and update our point-of-view on what the information actually means.

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More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

By M2|2018-06-15T19:32:48+00:00June 15th, 2018|Health Care Trends, Health Disparities, Health Information Technology, Health Reform, Innovation, Public Health, Social Determinants of Health, Uncategorized|

More on social determinants of health: What are they, why are we talking about them so much, what’s happening now?

Here at M2, we spend a lot of time thinking about the social determinants of health (SDH), or the nonmedical factors that can affect a person’s overall health and health outcomes. We have blogged recently about this issue, and . The issue is gaining momentum and we are seeing more articles and studies addressing how to better incorporate SDH into programs and technologies; for example, former CMS administrator Andy Slavitt recently announced his new venture capital firm will focus on companies in this area. Another recent article highlights the opportunities for technology entrepreneurs as adoption rates for SDH technologies are projected to increase over the next ten years. Today we are taking a close look at a recent position paper from the American College of Physicians (ACP).

SDH are defined as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life”. In other words, “where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy,” the ACP notes in its recent paper.

SDH are “responsible for most health inequalities,” the ACP says; the paper examines the complex issues involved and provides recommendations on “better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.”

The paper was drafted by the ACP’s Health and Public Policy Committee, and the ACP notes that it is charged with addressing “issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties.”

“Understanding and addressing social factors that affect health outcomes is a pressing issue for physicians and medical professionals,” the ACP says. The group is issuing a set of recommendations “to empower stakeholders to advocate for policies aimed at eliminating disparities and establishing health equity among all persons.”

The paper features nine policy recommendations. Most notably, these include: integrating SDH into medical education at all levels; adequately funding federal, state, tribal, and local agencies in their efforts to address social determinants of health; developing best practices for utilizing electronic health record (EHR) systems as a tool to improve health without adding to the administrative burden on physicians; and adjusting quality payment models and performance measurement assessments to reflect the “increased risk associated with caring for disadvantaged patient populations.”

Expanding on one of the recommendations above – the importance of EHRs and collecting data – the paper notes that in 2014, a National Academies of Science committee identified 12 social determinants to be included in EHRs as part of meaningful use stage 3, and issued recommendations on standardizing collection of measures of these social determinants. Several behavioral and social domains are currently collected: tobacco use; alcohol use; race/ethnicity; and residential address, which is geocoded.

The report says that in terms of racism and health equity, the ACP’s policy on racial and ethnic health disparities “acknowledges that addressing social determinants of health is a key component to increasing health equity among racial and ethnic populations.”

Social determinants “can exacerbate health care disparities among racial or ethnic groups,” the paper says. “Socioeconomic status, race, and ethnicity are connected in a complex, multidimensional way and may affect a person’s health independently or in combination.” As an example, the ACP notes that Latina women experience a greater incidence of cervical cancer and higher mortality rates than non–Latina women. Access to care for Latina women is also affected, as they are more likely to lack health insurance than white non-Latina women.

SDH has been a bit of a buzzword for a while in public health circles, but it may finally be time for SDH to influence policy, as seen by ACP’s efforts. “Why now?” many are wondering. As proof points pile up, and more people gain an understanding of what SDH are, the concept is gaining momentum and being included in more discussions.

For example, it’s interesting that one of the largest physician groups has developed policy positions on SDH. This may be an indication that physicians in general are realizing the significant role that SDH play in individuals’ health. Incorporating an understanding of SDH into not only the practice of medicine, but also into the tools and incentives that drive patient care, would be welcome steps in helping to reduce the negative health outcomes related to SDH.

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Want to Fix the Opioid Crisis? First, Think Structurally

By M2|2018-05-17T16:49:16+00:00May 17th, 2018|Chronic pain, Evidence-Based Medicine, Insurance, Public Health, Social Determinants of Health, Uncategorized, What do we pay for and why|

Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.

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ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

By M2|2017-12-07T01:22:04+00:00December 6th, 2017|Health Care Trends, Health Disparities, Insurance, Public Health, Retail Health, Social Determinants of Health, Uncategorized|

ICYMI: The CVS-Aetna Proposed Merger Could be Public Health Rocket Fuel

Sunday, December 3, CVS Health announced it will acquire health insurer Aetna for $69 billion. Lowering the cost of care by enabling a broader range of treatment in retail clinic settings, of which CVS Health has more than 1,100 in 33 states, is one of the obvious rationales of the combination. But what struck me in the comments of the merging companies’ CEOs was how much they sound like public health professors. Social determinants of health? Health as a path to fulfillment? What have they done with the business people? In case you missed it…

Mark Bertolini Really Cares About the Whole Person

Aetna Chairman and CEO Mark T. Bertolini has been talking publicly for quite some time about the importance of thinking about people not as patients, but more holistically. In September, in an interview with Dennis Berman, the Wall Street Journal financial editor, he said, “We believe the only way to truly disrupt the cost of health care … is to go into the homes and meet the social determinants that are now driving as much as 60 percent of life expectancy of Americans.”

What Bertolini has had to say now that the merger is official is straight-up public health speak. On CNBC Monday morning, when explaining the vision of the merger, Bertolini sounded like a philosopher: “Most people,” he explained, “find their health is a barrier to the life they want to live.” Indeed.

Larry Merlo is Fixated on Unmet Need

Larry J. Merlo, President and CEO of CVS Health, reminded anyone who was paying attention something that we in public health have known for a long time, but surprised the CNBC reporters, “You look at chronic disease in this country today, about half of all Americans have at least one of those chronic diseases. It’s accounting for 80% of the health care costs.”

Merlo further explains, “there’s billions of dollars every year on unnecessary and avoidable spending because people are not following…care plans.” Merlo’s solution, to be executed in part with the announced merger, is to address the unmet need the traditional health care system is creating, but CVS Health knows first-hand because patients come through its doors with health care needs that aren’t being met.

We “lack the element of convenience and coordination…that is the unmet need we are talking about,” says Merlo.

We Are All Public Health

As a public health student, educator and professional, I am public health. This merger discussion shows we are all public health. Georges C. Benjamin, M.D. Executive Director, American Public Health Association wrote in 2015, “Today, the biggest threats to the health and longevity of Americans are preventable diseases. These are the diseases that are burying us in preventable suffering, as well as crippling our communities with mountains of avoidable medical bills. The root causes of many of these health threats are inextricably linked to the social determinants of health and the conditions that shape a person’s opportunity to attain good health and adopt healthy behaviors. These social determinants include access to safe housing, good jobs with living wages, quality education, affordable health care, nutritious foods, and safe places to be physically active. They also include racism, discrimination, and bias.”

To see such similar language from Mark Bertolini and Larry Merlo in the CVS-Aetna merger discussion to date shows that the leaders of what could become the largest health care company in the U.S. are thinking differently about the broken U.S. health care system. Near the end of the investor call about the merger, an analyst asked whether the combined entity planned to be a person’s primary care physician. Bertolini answered: “The real important part here is that you have to understand that almost 60% of Americans don’t have a regular doctor.”

When you connect these dots, you can really see the big picture come together. The CVS-AET vision is bigger than managing the pharmacy benefit.

Will it work? Hard to say at this early stage. Should consumers want it to work? Absolutely. A health care company with a public health lens that focuses on health well before a person shows up at the doctor and prioritizes convenience, coordination, and social determinants of health would be a welcome change for individuals, families, and employers. Score one for public health.

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