Most of our health statistics still focus on mortality. This is a left over of the time when infectious disease was what concerned us the most. Infection kills quickly. It was the correct focus to have when this was the battleground.
But today infection has largely been pushed into the corner and we face instead long term chronic illness that takes years to kill but that can and does disable us – making it impossible to work or even look after ourselves. On PEI the average man becomes disabled by 65 and lives for 9.6 years in this state. This is where the real costs are to be found. Costs to each of us as we are unable to earn or cope with daily life. And costs to us as a society – for medicine can only keep us ticking over.
This group do die at the latest in their 70’s. Leaving another group the Very Old who have been fit and active all their lives. Why is another question for later. But this group too reach a stage when they too become disabled and this is where the costs and the burden mount. For their families and for the state. Until now there have been so few of these that we could afford to shelter them in institutions. But with so many that will live well into their 90’s in the pipeline – we will not be able to afford this.
Ironically, the worst thing we can do for people like this is to institutionalize them. Their health collapses when they have all control and role taken away. But as I am finding with my own mother, medicine can keep us ticking over for decades.
CIBC and VAC have worked for over 15 years on reducing the load on their medical systems.
Together they offer a useful model for how any population might look at its own load issues. Load being defined here as the impact of those people that become disabled by illness and live a long time. For the most important cost drivers in any health system are not mortality or morbidity but disability. It is disability and not acute illness that drives the costs. Once we understand this term, many options open up for us to reduce costs and increase care.
- Disability Load = incidence X duration of reduced capacity.
- Disability rate – has to be addressed though policy, better support for wellness activity, working conditions etc.
- Reduced capacity – person perceives that they cannot fulfill their full function. More likely to seek medical care and as a result drive other benefit costs.
The total population contains two Disability risk segments. The “Young” aged up 65 and the “Very Old” aged 75 – 110.
The Young increasingly develop chronic illness such as Type 2 Diabetes. This segment becomes progressively more ill until they are disabled and require both ongoing treatment and social support sometimes for decades. We call these diseases, the Diseases of Modern Civilization
Diabetes drives many other conditions including cardiovascular disease. On PEI adults in 2006 with diabetes had to be hospitalized much more often than those without it. 16 times more often for lower limb amputations. 6 times more often with kidney disease. They had 5 times more heart attacks. 4 times more heart failure. 3 times more strokes. They stayed 3 times longer in hospital. Had 2 times more visits to physicians and 2 times more to specialists
Most diabetics don’t just take one medication, but several. A typical regimen for an adult diabetic after a couple of years of treatment and following the dietary advice of the American Diabetes Association includes Metformin, Januvia, and Actos, a triple-drug treatment that costs around $420 per month. Two forms of insulin (slow- and fast-acting), along with two or three oral medications, is not at all uncommon
The real societal problem is not that we die of these diseases but that we that suffer from them. All or concerns in the past have been mortality. But with this large and growing group of people, the issue becomes not mortality but care.
Diet is at the core of this epidemic. Most of the information related to diet today is at least misleading or even wrong. A new understanding of our evolutionary past shows that grains, the core of the recommended diet, are in fact the pathway to insulin resistance and so to this family of diseases.
Social Status and Managerial Culture then act as an amplifier on vulnerable people. Those in organizations with the least amount of control will have a mortality rate 4 times greater than executives with more control and status.
The breakthrough then in costs and care are that diet and issues of managerial culture can be positively affected by social intervention.
The issue of control and social status is the vector for Load in the very old as well. Social Intervention works best here as well.
The “Very Old” aged from 75 – 110. This group has usually avoided the chronic illness and has remained well and independent until they become too frail to live on their own. But if they are institutionalized, they tend to lose their health and then can also live for many years.
Currently we just treat these groups medically. CIBC and VAC treat them socially to great effect. They can prevent, reverse and mediate the illness. I will offer up 2 case studies to show you how.