Would you have guessed that, one fine day, health insurers
will regret the demise of big tobacco and its contribution to health care
costs? Would you have guessed that, when that day arrives, health insurers
would also learn to love other frowned-upon-vices of their policy holders, such
as getting fat and lazy? Your answer is probably "no, I wouldn't have
guessed that in my dreams.".
And also very probably this answer is based on what you
typically read in the media, such as this piece of news titled "Obesity
Adds More to Health Care Costs Than Smoking, Study Suggests." released on
April 3, 2012, on sciencenews.com. The article text wraps the title message
into a substantially larger amount of unsubstantial words, before it concludes what you
would probably subscribe to blindfolded: the "...study [1] provides new insights into the long-term
costs of obesity and smoking, showing that both risk factors lead to
persistently higher health costs throughout a seven-year follow-up period.".
Dah, what else is news?
Well, for one, that the Joe Camels and the lardbuckets, with
all their vices, cost their health insurers actually LESS money than Mr. and
Mrs Healthy. For one simple reason: the "vice guys" die earlier.
But let's hold that thought for a moment and let's look at
the figures. In a Dutch study performed by Pieter van Baal and colleagues, the
authors compared the annual and lifetime health care costs of three cohorts,
namely the obese, the smokers, and the healthy living people [2]. As the basis of their
calculations they used the Dutch National Institute's of Public Health and the
Environment (RIVM) chronic disease model, which, the authors assure us, has
been widely used and validated in disease and cost projection analyses.
To make their results more comparable internationally, they
ran their analyses with altogether 7 different scenarios, to account for
different health care systems and for different mortality risk estimates. The
latter had been drawn from observations in the U.S. published by Flegal and
colleagues [3] who had found declining
mortality risks in the obese cohorts. I mention this because I don't want you
to suspect that the Dutch authors had based their calculations on an unrealistically
high keeling-over rate for the obese. Now, fast forward to the astonishing
results.
In all 7 models, as well as in the unadjusted base case
scenario, the financially most attractive "villains" to health
insurers are the smokers. The most expensive are always the goody-two-shoes
healthy-living people. Somewhere in-between are the fat ones. In the model
which assumed a yearly 1% increase in health care costs, the lifetime costs for
an obese person amounted to € 399,000, compared to which the smoker comes at a
14% discount of € 341,000, but the healthy living person with a 17% premium at
€ 468,000.
How can that be? The answer is not where you and I would
have looked first: The diseases which directly associate with smoking and
obesity (heart disease, cancer, diabetes, pulmonary diseases, musculoskeletal
disorders). They account only for 20% of total disease costs. The remaining 80%
are for ailments and conditions, which come with age. But when that age doesn't
come, because you die earlier, then those costs don't come either. And Joe
Camel and Ronald McDonald are rather effective in cutting years out of your
life, and thereby costs out of your health insurers balance sheet. For 7 and 5
years respectively, to be precise.
So, where are the premium discounts for the obese and the
smoking policy holders? Why are the healthy living people permanently miffed
about not getting premium discounts, when they actually cost more? I have to
admit, I belong to the latter, too. But recently, after having listened to one
of my talks at a conference, a friend of mine, the CEO of a German health
insurer, took me aside and told me, that my indignation about the healthy
people having to share the cost burden of their willfully negligent peers, was
unfounded.
As much as I wanted to disbelieve, I also knew that these
insurance guys do one thing very well: calculating risk and premiums. So I had
to give him the benefit of the doubt. Which is why I began to check. And by
checking, I came to know about quite a number of studies confirming my friend's
argument. One of those studies was van Baal's, which I chose to quote from because
he is actually working for the Dutch National Institute of Public Health and
the Environment. Not that I'm biased in favor of the Dutch. I'm biased in favor
of anyone who articulates a viewpoint which is in stark contrast to what I
would expect merely on the basis of his association. I mean, here you have
someone telling you to NOT confuse health with health care cost savings, when his
employer is actually trying to make everyone with a cigarette or a burger in
his mouth feel guilty about sending health care costs sky high.
So what now? Shall we promote the vices and lower our health
care costs in a decade-long smoking and feeding frenzy? Well, it's your choice,
but I'm not convinced that we have got the reasoning or the arguments right
just yet. We need to do a little more detective work to solve this case.
Now, you know how the French, at least in their novels, dish
out that piece of advice to the detective: Cherchez la femme (look for the
woman)? Maybe it works in the French universe. In mine, I have always found
this one to work better: "Cherchez l'argent" (look for the money).
Which will lead us to another few surprising discoveries in
the next post. And, of course, a couple more reasons to believe that there are
quite some powerful players around who yearn for the good old times when
Marlboro Man and Ronald McDonald delivered us from the risk of a costly long
life.
PS: To meaningfully pass the time until the next post, watch this video on the calorie cartel
1. Moriarty,
J.P., et al., The effects of incremental
costs of smoking and obesity on health care costs among adults: a 7-year
longitudinal study. Journal of Occupational and Environmental Medicine,
2012. 54(3): p. 286-91.
2. van
Baal, P.H.M., et al., Lifetime Medical
Costs of Obesity: Prevention No Cure for Increasing Health Expenditure.
PLoS Med, 2008. 5(2): p. e29.
3. Flegal,
K.M., et al., Excess deaths associated
with underweight, overweight, and obesity. Jama, 2005. 293(15): p. 1861-7.
Moriarty, J., Branda, M., Olsen, K., Shah, N., Borah, B., Wagie, A., Egginton, J., & Naessens, J. (2012). The Effects of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults Journal of Occupational and Environmental Medicine, 54 (3), 286-291 DOI: 10.1097/JOM.0b013e318246f1f4
van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, Engelfriet PM, & Brouwer WB (2008). Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS medicine, 5 (2) PMID: 18254654
Flegal, K. (2005). Excess Deaths Associated With Underweight, Overweight, and Obesity JAMA: The Journal of the American Medical Association, 293 (15), 1861-1867 DOI: 10.1001/jama.293.15.1861