Author + information
- Paul A. Heidenreich, MD∗ ()
- Veterans Administration Palo Alto Healthcare System, Palo Alto, California, and the Stanford University School of Medicine, Stanford, California
- ↵∗Reprint requests and correspondence:
Dr. Paul Heidenreich, Veterans Affairs Palo Alto Health Care System, 111C Cardiology, 3801 Miranda Avenue, Palo Alto, California 94306.
The significant and growing cost of health care in the United States has centered attention on avoidable medical expenditures. Hospitals have been a major focus for reducing preventable care, with Medicare imposing financial penalties if a hospital’s 30-day all-cause readmission rate for heart failure and other select conditions is below the U.S. average (1). However, all sectors of the healthcare system are now targets for reducing waste, with providers asked to “choose wisely” (2) and patients financially rewarded by health plans for living a “healthy life” (3). Although shared accountability for health between the individual and the rest of the healthcare system is worthwhile, we must know to what extent any patient’s “lifestyle” is modifiable before we hold him or her financially responsible.
A primary purpose for focusing on lifestyle is the avoidance of chronic disease. According to recent estimates, 58 million individuals in the United States are working with significant chronic illnesses, and the cost of treating chronic disease accounts for up to 75% of national healthcare expenditures (3,4). Indirect costs attributable to time lost from work are also substantial, 4 times higher for those with chronic disease than for healthy employees (4).
Heart failure in particular deserves attention given that the cost of heart failure care is expected to more than double during the next 20 years because of the aging of the U.S. population (5). By 2030, it is expected that 1 in 33 people in the United States will have heart failure (5). Unless preventive measures are taken, these 8 million patients will create a substantial health and financial burden for the United States.
However, if we can identify the important components of a healthy lifestyle, we can create incentives for patients to live a healthy life, reduce the incidence of disease, and lower healthcare costs. In this issue of the Journal, Agha et al. (6) identify important “lifestyle” predictors of the development of heart failure for women. They used data from a cohort of more than 84,000 post-menopausal women from the Women’s Health Initiative who were free of heart failure and provided information on their lifestyle and subsequent outcomes. A healthy lifestyle score was created using 1 point each for not smoking, having a healthy diet, remaining physically active, and maintaining a healthy body mass index (BMI). The investigators found a strong relationship between the healthy lifestyle score (0 to 4) and the incidence of heart failure, which developed in 1,826 women over a mean follow-up of 11 years. The results are all the more impressive in that they confirm previous findings from populations in Finland (7) and in U.S. males (8). The authors note that randomized trials promoting lifestyle interventions have been successful at decreasing cardiovascular disease risk (9). Thus, we should be able to target these lifestyles to improve health and reduce cost of heart failure.
Holding patients and employees accountable for the health impact of their behaviors is growing in popularity. One of the largest U.S. employers, the grocery store chain Safeway, has stated that it believes 70% of healthcare costs are attributable to unhealthy behaviors (10). They estimated that an obese employee in 2011 would cost an additional $1,400 in healthcare dollars annually compared with a nonobese employee. In addition, Safeway estimated that the unhealthy “behaviors” of uncontrolled hypertension, high cholesterol, and lack of exercise each cost an extra $500 to $650 per employee per year (10). Michelin recently switched from providing credits for all employees participating in a plan for improving health to a stricter strategy that only provides rewards (up to $1,000 off healthcare costs) if the employee meets healthy standards for blood pressure, glucose, cholesterol, triglycerides, and waist size (11). It set the waist circumference threshold at less than 35 inches for women and 40 inches for men. If someone does not meet the standard, they can receive a smaller credit if they sign up for a health-coaching program (11).
These financial incentives would be reasonable if everyone had a similar opportunity and ability to reach the goal. But how much of obesity is a lifestyle choice, and is holding everyone to the same standard appropriate? The large increase in obesity in Western countries in the past several decades has been interpreted by some to indicate obesity is largely due to a change in patient choices regarding diet and physical activity. However, substantial hereditability for weight (80%) and BMI (70%) has been found in twin studies (12). Even among children born since the recent obesity “epidemic,” the hereditability of childhood BMI is 60% (13). Genetic differences also have been observed for taste of food (14), ability to exercise (15), and preference for smoking (16).
The findings of substantial genetic effects on BMI are in stark contrast to employers’ views on obesity (17). Among 505 public and private employers surveyed in 2007, 93% believed obesity was the “result of poor lifestyle choices,” 87% viewed obesity as a preventable condition, and only 11% strongly agreed that obesity had a genetic component. Approximately half of the employers agreed or strongly agreed that smokers should pay a higher premium; however, 25% also agreed or strongly agreed that obese employees should pay a higher fraction of their healthcare costs than nonobese employees.
One of the goals of the Affordable Care Act was to prevent health plans from linking insurance premiums to health status (18); however, in its goal to improve wellness, the Affordable Care Act allows employers a substantial amount of flexibility in their programs that can financially penalize those with poor biometric measures. It remains to be seen whether these programs will be successful in improving wellness without penalizing patients who have limited ability to improve because of genetic or other nonmodifiable factors.
We in the medical community need to do more to combat the all too common view that poor health outcomes (high BMI, hypertension, hyperglycemia, and hyperlipidemia) are simply due to poor health choices. Someday, we may know enough to personalize incentives that account for genetic, socioeconomic, and other barriers an individual faces in attaining the recommended healthy lifestyle. For now, we should limit employee and patient rewards to healthy choices (diet, exercise, lack of smoking) and not equate these with healthy outcomes.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Heidenreich has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Mattke S.,
- Schnyer C.,
- Van Busum K.R.
- Heidenreich P.A.,
- Albert N.M.,
- Allen L.A.,
- et al.,
- on behalf of the American Heart Association Advocacy Coordinating Committee, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Radiology and Intervention, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Stroke Council
- Agha G.,
- Loucks E.B.,
- Tinker L.F.,
- et al.
- Wang Y.,
- Tuomilehto J.,
- Jousilahti P.,
- et al.
- ↵Renda L. Focusing on What Matters Most: Healthy Behavior and Accountability. The Institute for HealthCare Consumerism website. Available at: http://www.theihcc.com/en/communities/employee_communication_education/focusing-on-what-matters-most-%E2%80%93-healthy-behavior-a_gqk6ur59.html. Accessed September 15, 2014.
- ↵Kwoh L. Shape up or pay up: firms put in new health penalties. Wall Street Journal, eastern edition. April 6, 2013:A.1.
- Wardle J.,
- Carnell S.,
- Haworth C.M.,
- Plomin R.
- Mennella J.A.,
- Pepino M.Y.,
- Reed D.R.
- Gabel J.R.,
- Whitmore H.,
- Pickreign J.,
- et al.