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.
Last week I attended the first ever Quantified Self Expo in San Francisco – which had a ton of interesting products and sessions on various topics covering areas of self-measurement. I was there demoing Revvo and also gave a talk titled “How to Measure Your Fitness Level”, which I thought would be useful for a wider group to review. Below are my slides :
I was inspired to write this post by a slew of recent studies showing that midlife fitness (midlife roughly defined as 40-65) makes a big difference to health outcomes and cognitive function for the rest of your life. I’ve certainly experienced this personally – increasing my fitness at 40 helped normalize my blood pressure levels. And I’m probably fitter today than I was in my 20s (talk about wasted youth!).
Here’s a short list of recent studies showing the connection between fitness, age and health issues / benefits. (Fitness, as I’ve explained earlier, is the ability of your body to supply fuel to muscle when you are active):
The interesting thing about these studies is that you don’t have to be a super-athlete at 50 to stay healthy – the level of fitness expected – 12-13 METs is well within the reach of the average 50-year old male as you’ll see from the charts below.
(Many of these studies have been conducted amongst male cohorts so difficult to be as precise for women — I’m hoping to see more studies on female fitness & health impact in the future).
The other interesting question that it raises – if you can stay as fit as the average 30-year old (which is an achievable goal for most 50-year olds) can you entirely avoid aging related health issues ?
Disclaimer: The content on this blog (and linked websites) is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this blog or linked websites. Reliance on any information provided on this blog is solely at your own risk.
Yes its the time of the year when a remarkably large number of people resolve to do something they will predictably give up within a few weeks of starting i.e. trying to get fit. And until recently I was part of this pattern — resolving countless times to get fit yet giving up within a few weeks of starting an exercise program. Something however changed the year before & for the last ~2 years I’ve actually managed to stay at it for long enough to now genuinely claim that I am indeed fit.
The biggest challenge with getting fit – as we all know – is to actually stick with it through thick & thin – rain, snow and heat – long days & sleepless nights (thanks to my 2-year old!). And to achieve this I had to completely ignore conventional wisdom on the subject (as reflected in countless articles – for example, see here & here).
1/ Find Something You Like Doing
Conventional wisdom suggests you should find an activity you like doing and do just that if you want to get fit. I LOVE cycling along the Erie Canal (which is a few minutes walk from where I live) — I can cycle for hours. Yet I managed to do this just twice in the whole of last year!
It’s not difficult to explain why — I need to dedicate a significant chunk of time for the activity, the weather needs to be decent and my kids cannot ask to join me (which they inevitably do & I find difficult to refuse and in which case all we end up doing is a short & gentle trip where my heart rate goes up only because my 8-yr old keeps trying his best to jump into the canal).
Also the reason why I like the long canal biking trips so much is their rarity .. if I was doing this daily (say this was my commute), I’m pretty sure I’m not going to like it quite that much.
So forget trying to do the thing you like … instead focus on finding something that you can actually do on a daily basis.
2/ Find a Friend
When I was 27 (that feels like a looong time ago!), I had a friend living in the apartment below who would wake me up at 5.30 so both of us could go for a run. And on days that he was being lazy I would pay him back! Even after nights of partying until 2 am I still managed to get out for a run early the next morning, thanks to him.
Things change when you have kids — your friends don’t control your schedule, your kids do. And that’s true for your friends too. Its still possible occasionally to co-ordinate our schedules so we can all get together for activity. However its incredibly rare to be able to do this on a daily basis.
So ignore conventional wisdom & find an activity you are happy to do on your own. Think of this as your time, free of work, kids, family & social commitments.
3/ Set a Weight Loss Goal
This is the conventional wisdom that in my opinion is the most dangerous & counter-productive. Yet how could you argue against setting a weight loss goal ? The reason – weight loss does not really happen via exercise alone. Many studies have shown that the average person loses very little weight solely through exercise. And some of course even gain weight (because we want to reward ourselves for that long ‘hard’ run we just finished!).
And so if you do set a weight loss goal, you’ll probably end up giving up on exercise because you won’t see results.
Ideally you should measure and track your fitness (which until now has required a visit to an exercise science lab). Or track a proxy – such as your average heart rate for the same activity level, or your average pace / finish time for a fixed distance you run or bike. And particularly if you’ve been sedentary for a while, you’ll see improvement within a few days / weeks of starting an exercise program.
So what are my personal suggestions to help you meet your fitness goals?
1/ Set a Fitness Goal
2/ Find a Short Workout Effective at Improving Fitness
3/ Integrate that into your Daily Life
My workout is indoor cycling (at home), at high intensity, for 10 minutes daily — I can do this rain or shine, sleepy or otherwise. It may not be quite as much fun as cycling on the canal but it does not require that I change my lifestyle, plus I can watch music on youtube as I bike. I track changes in my fitness each time I workout so I know how much meaningful progress I’m making. I am change the intensity as I make progress so I don’t plateau. (Full Disclosure : I’m building a smart exercise bike called Revvo that does all this).
I do this pretty much the same time everyday — its now literally like brushing my teeth or taking a shower so it doesn’t require an enormous amount of willpower to get me going. It’s just a habit and that’s how it should be.
Disclaimer: The content on this blog (and linked websites) is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this blog or linked websites. Reliance on any information provided on this blog is solely at your own risk