We all know that preventing disease is the best way to reduce healthcare costs, so I thought it would be interesting to estimate the cost savings created by a person who manages to avoid preventible disease for the large part of their life.
Assuming the average age of diagnosis is 45 and disease could be potentially prevented until a few years before mortality (78.7 is current life expectancy in the US) — so let’s say that’s 30 extra years of healthy living, the total healthcare savings is $457,508 over a person’s lifetime. And given that healthcare costs are growing at 4-5% per annum, this is just over half a million dollars as of 2019.
So every American we can help prevent disease reduces healthcare expenditure by $15k per annum and half a million over their lifetime. Over two-thirds of this healthcare expenditure is paid for either by government (federal, state, local) or by individuals (insurance premiums and out of pocket expenditure).
Therefore every individual who stays healthy benefits all of us – via lower taxes and lower insurance premiums. But little of that $15k annual savings from staying healthy returns to the individuals who do – therefore there isn’t a strong incentive to invest in it.
What if we could create a mechanism to provide a payback for prevention — firstly by accurately measure the most important measure of preventive health and secondly rewarding individuals based on their preventive health status? This would be a win for everyone. Love to hear feedback via the comments below.
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For the last few years I’ve not had health insurance – yet I’ve found effective ways to stay healthy. And I wonder if others might benefit from an approach like this.
HEALTH INSURANCE IS A WASTE OF MONEY
The story starts in 2013 when I left Bausch & Lomb to start Revvo. I continued to use Cobra for the full 18 months – mainly because my second kid was born that year. And that’s not cheap – I paid ~$1800 per month to insure a family of four, way higher than what I paid when I worked for the company of course. Luckily I was able to use up my HSA funds to pay for part of that premium.
And then Cobra ended – but the Affordable Care Act was passed and insurance exchanges had launched, so I switched to buying on the marketplace – purchased a silver plan initially that cost roughly half what Cobra had. But had high deductibles and co-pay, which meant we were paying money for the right to pay more money – not something we could afford since I was bootstrapping the startup.
It also seemed pretty illogical — it was cheaper to focus on prevention and pay out of pocket for occasional expenses like wellness visits or vision tests rather than spend money on health insurance payments given the high deductibles & co-pay before we would be reimbursed. Of course if we had a serious illness or accident this equation would be very different – but that wasn’t the case.
And then the Trump administration discussed passing a new rule that would penalize those who utilized state subsidies — at that point they were considering including Obamacare subsidies. Since I was waiting in green card queue (still am), we decided to dump our insurance coverage so it doesn’t affect our green card prospects. The final ruling that was passed earlier this year, leaves out Obamacare subsidies but includes Medicaid — which I am technically eligible for but decided not to utilize.
For my kids however, I decided to utilize Medicaid — that was too big a risk to take especially since both play sports (so I have no idea how that affects green card prospects–their life was too important to risk). But for me, I felt it was a risk worth taking.
HEALTHCARE IS MOSTLY BANAL GENERIC ADVICE
The second and equally important consideration in all this was the lack of quality health care thatcan address root cause behind many of the health issues that I faced during this period. In 2011 I discovered during my routine wellness check-up that my blood pressure was starting to rise above 120/80. My doctor gave me pretty generic advice on diet and exercise — and so I ended up running a bunch of experiments on myself to eventually discover that my cardiovascular fitness (VO2Max) was the culprit — increasing my VO2Max improved my blood pressure near instantly.
If I had followed the doc’s advice and participated in conventional healthcare, I’d probably be on 3 BP meds right now. Which unfortunately is how most doctors seem trained to deal with chronic disease — resolve symptoms with drugs instead of working to identify, experiment and address root cause. And as someone with an extensive family history of heart disease, I’m increasingly skeptical of the medical establishment’s ability to actually prevent these conditions – clearly, there isn’t any incentive to do so today.
Following that I discovered I was borderline anaemic — due I’m sure to my vegetarian diet. My doctor’s advice again was to pop an iron pill — which is perhaps the right temporary solution. But long term I needed to work on my food choices — I learnt a ton about vegetarian sources of iron, how to improve my iron absorption — about the negative effects of coffee etc. And that improved the iron content in my blood – plus it also improved the quality of the food I ate. In the end the low iron was a signal that I needed to work on my food intake — not the problem. And here’s the remarkable thing — all this information is available free. All I needed was the willingness to experiment — to figure out what works best for me.
Improving my iron level also improved my fitness significantly — since haemoglobin binds with oxygen to carry it to muscles and organs. Now I’m back to eating meat (for many reasons — but the challenge of getting iron via vegetarian sources was one big reason for the change).
A year ago I again discovered my blood pressure was high — this time in the 140/90 range. My doctor’s advice again was hyper generic — lose weight and exercise. She did not even care to measure my fitness level — if she had she would have discovered I was borderline pro athlete. And my weight was in the normal BMI range, my fat % was also well within the healthy limits. I measure all these pretty regularly.
I was taken aback by the news, since I thought I had resolved blood pressure. Perhaps I was getting caught by my genetics? So I laid out other potential causes — lack of quality sleep could be one (I noticed I was snoring occasionally), stress was another (I was bootstrapping a startup and trying to patch up a failing marriage – so no shortage of stress there). But there was another potential cause – for the last 8 months I had lived on a diet of processed, microwaveable food (I blame the startup life here!). And when I went to my grocery store and scanned the sodium content of the food I normally bought, it was off the charts.
So I decided to experiment with cutting all the sodium from my diet — measured my BP daily and within 2 weeks it was showing a clear downward trend. By the end of the month it was below 120/80 and next month at the doctor’s visit it was 116/68. Problem solved again — but more importantly root cause identified and lasting changes made to my food habits.
I didn’t have health insurance through this period — so I paid out of pocket for these wellness visits. While there wasn’t much value to the doctor’s advice, the battery of tests done was tremendously valuable. Interestingly — these are the kind of changes that pretty much everyone facing lifestyle conditions — high blood pressure, type 2 diabetes, heart disease and many lifestyle driven cancers needs to make. And yes — if you’ve reached the point where the condition is serious, you’ll need medication and intensive medical care. But for the rest of us — the medical care provided today doesn’t actually cure people, unfortunately. Therefore why pay for the related health insurance?
AN ALTERNATIVE APPROACH TO MEDICAL CARE
I’ve been thinking about alternative approaches to conventional health insurance and medical care that might be more relevant and more effective for the vast majority of adults. Here are some principles that should form the foundation:
1/ We should reward preventive behaviors — such as being fit.. Perhaps with some sort of a crypto-currency. That could be used to pay for the services people need.
2/ Individuals should have the freedom to pick the services they want — those who want more services should pay more, those who want less, pay less. Combined with the idea of a crypto-currency, that could create a tidy marketplace / self-contained economy for health services.
3/ Privacy is non negotiable. My data belongs to me — no one else has the permission to use it. Each instance of its use should be signed off by me — not via a generic release. And ideally it should not be stored anywhere else other than on my own devices.
And if you’re going to make money off my data, I want to receive the majority of that money cause its my f**kin data.
4/ Emergency healthcare is important for everyone — I don’t have any currently and it does concern me, especially since I bike regularly on roads that car owners think belongs to them alone. Accidents happen, unknown medical emergencies occur — the human body is unpredictable to say the least.
5/ Regular testing is critical — I’d love to get a comprehensive lipid panel done regularly, BP and blood sugar / HBa1c, fitness and body comp are essential. Plus other add-ons like iron, vitamin D, cancer screening, DNA tests, vision, STD tests etc. It’s the regular testing that helped me identify health issues and take corrective action before they progressed too far.
6/ Convenience — as far as possible I should be able to run all the tests and the services I need right at home or via my mobile phone. Convenience is #1 for building a successful preventive health program. Today we’re trying to force fit these needs into a healthcare system that was built to handle infectious diseases and accidents — therefore the excessive cost and failure to actually prevent these very preventable issues.
6/ Young people and older adults need comprehensive health insurance — I don’t think this is avoidable. Both my grandmothers died past 80 with no health issues until just before their death — but that world is gone for the most part.
7/ Fitness, wellness and nutrition services are more important than conventional medical care, for the vast majority of adults.
8/ Outcomes are crucial — knowing what works is super important to filter out the oceans of snake oil that pervades the wellness & nutrition space. That’s another reason why regular testing is crucial.
9/ Personalization – everyone is different. So it’s not enough to know what works at a population level — its crucial to figure this out for the individual.
So in sum, we need to build a solution that has a suite of services — convenient and accessible to everyone, that can be paid for either by earning crypto-currency (for being fit) or straight out-of-pocket.
And since this is direct to consumer, we can avoid all the millions of intermediaries that pervade the healthcare system today — which would dramatically reduce costs for everyone I think.
Love to hear thoughts and suggestions — via the comments below. And if you’re interested in staying touch on this, please sign-up via the form below – you can also share your comments privately if you so prefer.
Its been a busy year for us at Revvo — based on user feedback from our gym pilots we simplified the fitness testing experience, significantly improved the training programs, saw strong participation in challenges and leaderboards and most importantly – had over 86% of repeat users record a positive increase in fitness!
Really excited to announce that we’re now experimenting with a radical subscription price of$99/month(+taxes, cancel anytime) – to make it easier for individuals to use Revvo at home.About the cost of a monthly gym membership but with an engaging user experience, effective real-time guidance and time efficient workouts that make it possible for fitness to become a daily habit.
The subscription includes the bike, software, installation and support – for up to two users/unit (addtl. users charged $9/month). You’ll need to provide the iPAD.
We have a limited number of pilot units (10), some of them already committed — so if you’re interested drop me a note and schedule your free fitness test via the website: http://revvo.co. The goal of the pilot is to validate the feasibility – operational and financial before we look to scale. SF bay area only.
[In Part 1 of this analysis of over 750 fitness tests conducted on Revvo, we looked at how metrics of overall fitness (VO2Max, Recovery) correlated with activity, weight and other demographic indicators.]
In this second part, we’re taking a deep dive into some of the performance metrics we collect on Revvo, to better understand how they correlate with each other.
MAX POWER (ANAEROBIC CAPACITY)
Max power is the maximum cycling output, measured in watts that an individual can produce on average over 30 seconds (called a Wingate protocol) and is considered one of the best ways to measure anaerobic capacity / output. I think of this as “sprint power”.
Revvo measures max power by guiding the individual step by step through a ~15 minute fitness test where the target increases progressively until the person reaches exhaustion. (Click here to see how the test works).
Max power was pretty well distributed across the 750+ tests and centered around 300-400w – with men producing on average ~100 watts more than women. Gender differences in max power persisted even after correcting for weight (men produced 5.1 watts / kg on average versus women who produced 4.4 watts/kg) and might reflect underlying differences in fitness levels and body composition.
VO2Max and Max Power
VO2Max had a strong positive correlation with max power – both in absolute terms and particularly when adjusted for weight (max power in watts / body weight in kg). Higher aerobic capacity could therefore create a strong foundation to help maximize anaerobic output.
Its also well established that high intensity (anaerobic) interval training is very effective at improving VO2Max. Tabata et al studied the effects of moderate intensity endurance and higher intensity interval training on both VO2Max and anaerobic capacity. The study found that high intensity interval training increased both metrics significantly, whereas moderate intensity endurance training only increased VO2Max (to a lesser degree).
So while VO2Max could improve without increase in anaerobic capacity, it seems likely to improve more when anaerobic capacity is also simultaneously targeted/increased.
Weight and Max Power
Does body weight make a difference to your max power output? Other things being equal, the heavier you are the more power you should be able to produce on a cycle due to sheer gravitational effect. And that’s what the data shows – max power in absolute terms increases with body weight.
However, max power per unit of body weight declines with increase in weight — i.e. heavier you are, less the power produced per unit of your body weight. And max power / kg is a better indicator of performance on the road, particularly when going uphill.
Recovery and Max Power
Could your state of recovery affect your max power output? Turns out it does – doubling your recovery (e.g. from ~5%, which is low to about 10%, which is good), increases max power by around 0.25w/kg – which can make all the difference in a competitive sprint.
Revvo detects the lactate threshold by analyzing the heart rate response to different levels of stress as the individual progresses through an intermittent ramped cycling test.
Lactic acid is produced as a by-product when muscles use glucose as fuel, creating the familiar sensation of “burn”. The lactate threshold is the highest intensity at which you can tolerate the amount of lactic acid being produced and can therefore sustain. As a result, the threshold has a ~90% correlation with endurance performance.
At intensities above the threshold, there is excess lactic acid produced,slowing you down when you cannot tolerate the “burn” anymore.
Based on the threshold watts per kilo of body weight, cyclists are typically classified into the following 9 categories. Where Pro are typically national champions and elite are world class.
The distribution of the Revvo sample is below — with a good spread from Cat 3 (experienced cyclists) to novices.
Threshold and VO2Max
How does VO2Max impact the lactate threshold — in theory the two are semi-independent. High VO2Max is a necessary but not sufficient condition for endurance performance.
And the results confirm that — there is a positive but weak correlation between VO2Max and threshold in absolute terms. The correlation does strengthen when we consider threshold watts / kg but this is still not as high as that between VO2Max and Max Power.
The implication from a training perspective is to focus on the factor that is relatively weak — improving that will deliver the biggest bang for your effort. And to polarize training (mid of high intensity interval training and moderate intensity endurance training) so that is able to target these two systems more directly and effectively.
Threshold and Weight
The relationship between threshold and weight is very similar to that between max power and body weight. In absolute terms threshold output increases with body weight but threshold watts/kg declines fairly significantly as weight increases. A 25lb. increase in body weight is the equivalent of dropping one category in terms of threshold output.
Threshold and Recovery
Low recovery clearly dampens threshold output, very similar in magnitude to the effect on max power.
MAX POWER AND THRESHOLD
Cycling is a sport that requires both endurance and power (to take on hills) – elite cyclists need to develop both capabilities. So not a surprise that there is a pretty high correlation between the two.
Traditionally, studies on performance metrics have been conducted largely amongst population of well trained athletes and as such its hard to see much divergence in these metrics across populations that have been training for long periods of time.
The Revvo sample on the other hand reflects a much broader range of individuals and therefore we are able to see how these metrics perform in less trained individuals / closer to their natural state.
From the perspective of an amateur endurance athlete in particular, it seems very likely that different individuals (even with similar performance levels) may have very different physiological make-ups. And understanding the underlying physiological make-up would allow you to customize the training program — so you’re targeting the area of greatest personal opportunity for improvement.
Weight is a very poor proxy for fitness (even though culturally we think fitness = “being in shape”). Increasing activity improves fitness but does not lead to lower weight. Fitness declines with age, but this is not a given. Improving recovery is an ‘easy’ win for everyone.
THE FULL ANALYSIS
Revvo is the first exercise bike to measure an individual’s fitness profile : Aerobic Fitness/VO2Max, Recovery and Endurance/Threshold. And right from the earliest test, we’ve captured information on the individual’s demographics and current weight, activity levels (mainly because it was required pre-screening information).
While we’re definitely not the first to aim to understand how these different variables correlate, the fact that we are measuring a wider range of variables on the same individuals with a pretty high degree of accuracy and consistency should hopefully provide some additional insight. Details on the test methodology can be found here: Revvo: Science.
1. We tested people across a wide range of fitness levels
While our sample is not a fully representative one (we do not have many at the lowest and highest ends of the fitness spectrum), it does represent a broad spectrum of fitness levels – both in terms of VO2Max and Recovery.
Interestingly, Recovery is skewed lower than the VO2Max results and this is something that we’ve anecdotally observed in quite a few “fit” individuals. Recovery is partly an indicator of lifestyle – stress, lack of sleep will show up here. So if you’re looking to enhance performance or general wellness, check your heart rate recovery status — sleeping better and reducing stress might give you immediate results.
2. If you’re already fit, focus on recovery
In fact this opportunity to improve Recovery becomes more obvious when you cross-analyze VO2Max and Recovery data. In general, there is a positive correlation between the two i.e. higher the VO2Max, higher the expected Recovery. However this is a weak correlation as you’ll see from the plot.
I’ve often seen people with relatively poor VO2Max scores who’re doing fine from a health perspective since their heart rate recovery is good and also fit people with poor recovery that indicates underlying health issues (perhaps genetics the culprit here rather than lifestyle). Fit people also often have poor recovery due to excessive training loads i.e. if you ran an ultra-marathon over the weekend, it will take a few days for recovery to return to normal levels.
3. You could be fat & fit or thin & unfit
We often conflate weight and fitness – but these are two semi-independent variables. We’re seeing lots of people who are relatively heavy but score pretty well on VO2Max (despite the fact that weight is the denominator in VO2Max calculations). And on the other hand many who have perfect BMI but with suffer from aerobic fitness.
Above 250lbs however, its rare to find someone who’s really fit. But below 200lbs there’s a huge variation in fitness levels – if we only analyzed that population there would be very little correlation between fitness and body weight. So just because some looks thin doesn’t mean they are fit and vice versa.
Recovery versus body weight shows the exact same pattern.
4. Being active improves fitness, but doesn’t impact body weight
We’ve now seen a ton of data confirming that activity, on its own, doesn’t seem to make much difference to body weight. And our analysis supports that conclusion.
There’s practically zero correlation between how active people say they are and how much they weigh and a slight negative correlation when you contrast BMI vs. Activity. Yet we keep telling people that they should exercise more to lose weight, setting them up for failure!
Why does increasing activity levels not help with weight loss? Vox did a fantastic summary of the available evidence in this video and article.
The real benefit of activity is an improvement in fitness – and this is what our analysis reveals as well. Higher activity levels correlate pretty well with higher levels of fitness.
And aerobic fitness (VO2Max), as I’ve explained before, is not just an indicator of athletic potential but also the single best overall indicator of health. The primary purpose of exercise is to improve the functioning of your heart and muscle. Weight loss, if it happens, is a spin-off benefit.
Therefore if you want to assess if exercise is yielding results, track your fitness level, not your body weight.
This is not of course not a perfect correlation as different types of activities have different effects: walking for an hour will not improve VO2Max as much as 10 minutes of high intensity interval training. And genetics also effects how well activity translates into an improvement. Which is why, even for people at the same level of activity, there is such a wide variation in fitness levels.
The correlation between Recovery and Activity is not as strong – and this makes sense. Lifestyle factors (sleep, stress etc.) often have a bigger effect on improving Recovery than increasing activity per se. And of course being too active can negatively impact Recovery. Recovery is intrinsically a more complex variable.
5. Fitness can – but need not – decline with age
At a general population level, VO2Max is reckoned to decline ~1% per year as we age and our analyses confirms the broad trend. However within that trend, there is huge variation: we’ve seen so many young people who are less fit than their grandparents and so many older individuals who’s fitness level has been an inspiration to me personally.
So your fitness is in your hands (or legs!).
Recovery seems to be even less correlated with declining age.
Ever since I started working on Revvo a few years ago one of the key questions for me has always been how accurate is the data compared to gold standard measurement of VO2Max using oxygen masks in a lab. And now we have an answer — and it looks like we are getting really close !
In our previous methods we were close for most — but for some we did see an over-estimation. The new method is overall slightly more accurate but also consistentlyaccurate across everyone tested.
19 people tested on Revvo (following our standard process) and also tested in a lab using gold standard Parvomedics metabolic measurement cart that measures their respiratory gases (oxygen, carbon dioxide etc.) to firstly estimate their VO2Max and also estimate their ventilatory thresholds (which corresponds to their lactate threshold).
The sample consisted of men and women, 30-50 years old, with VO2Max levels ranging from <20 to >70 (which is a pretty wide range). This validation sample also included some of the highest (70) and the lowest (18) VO2Max scores from amongst the 600+ tests we’ve done so far which gives us confidence that our methods have the potential to span a very wide range of humans. Our goal is to continue to enlarge the sample and look for diverse populations to test.
This video is a very scientifically grounded yet easily understood review of how short bouts of interval training can achieve dramatic improvements in your fitness level (VO2Max). Great effort by the Australian Broadcasting Corp!
In brief, high intensity interval training increases the mitochondrial density of your muscle cells. These are the energy producing elements of your muscle — more you have, the more oxygen your muscles can uptake to burn glucose as fuel.
Low mitochondrial density not only makes you less fit but also exposes you to a range of health risks.