Dr. John Troup speaks with Dr. Paul Keckley on the future integration of dietary supplements into the healthcare world, including what it will take for dietary supplements to be eligible for FSA/HSA benefits. They explore the influences of the changing self-care industry on disease prevention and optimal well-being.
The views expressed in this podcast are solely those of the speaker and do not necessarily represent the opinions of the Consumer Healthcare Products Association.
- Episode Transcript
Anita Brikman: What is it going to take for the dietary supplements category to become part of the broader healthcare conversation? How do we make that happen? Today, a healthcare policy expert joins us to talk more about it.
Speaker 2: Welcome to CHPA Chat, conversations in the consumer healthcare industry with Anita Brikman.
Anita Brikman: Hey, everybody, thanks for checking out CHPA Chat, the podcast of the Consumer Healthcare Products Association. I'm super excited to bring you a series within season one of CHPA Chat featuring, Dr. John Troup, as your host. As consumer interest in health and wellness grows, it's leading to greater demand for dietary supplements. John will explore current issues and topics of interest in the supplement space, bringing in thought leaders on the show to offer a broad perspective about the category and its role in self-care. Take it away, John.
John Troup: Thanks, Anita. We've got a really great podcast coming up right now with Dr. Paul Keckley, who's a leading thought leader in the world of health policy and healthcare. He has been a major influencer in the world of healthcare and had been an advisor to four administrations over the last, I guess whatever that is, 20 years, or 25 years. It's really my great pleasure to introduce everybody to Dr. Keckley. Paul, thanks for joining us today.
Paul Keckley: My pleasure, John. Thank you.
John Troup: I've been looking forward to this discussion for some time, mostly because of the dynamic of healthcare today is at a place that I think has been more open now to considering innovations and healthcare and health practices, including the recognition of nutrition and dietary supplements as being and should be an integrated part of healthcare practices. But tell us before we really get into the detail of say, nutrition and dietary supplements. What's the current dynamic of healthcare? What does the future look like? And what are some of the hot topics that are being discussed both legislatively and also just in the healthcare and the insurance world?
Paul Keckley: Sure. Well, healthcare is a big deal, as you know. It's the largest employer in the private economy. 18 million work in healthcare in the US. It's an industry that's highly regulated at a federal, state, and local level. It's capital intense, so it's dependent on private capital, not just government funding. And it is very expensive and complicated, and that's what has been the conundrum because this industry has evolved in its modern form over about 40 years, since the mid-'80s, to a set of sectors that operate very independently. They make their own rules and they seek their own regulations. And some of these sectors, for instance, are regulated at a federal level, so drug manufacturing is regulated federally. But retail pharmacy is regulated at a state level. So this is a hodgepodge. It's a very expensive industry. It's 18 percent of the GDP. It's almost $12,000 per capita in the US. It's growing faster than any other line item in the federal budget.
It's 28 percent of the total spend of the federal government just for healthcare. Put that in context, that's next only to social security. So it's a big deal, and coming into the administration and kind of post-election, what was clear is that the industry has protected its own interests, but its costs are becoming unsustainable. And employers and health insurers and consumers are bearing a bigger part of that burden. So there was already underway a lot of change to the industry, the shift that you hear about from volume to value. In other words, change all the incentives of the system to produce better results, not just do more stuff. And that's pre-pandemic. What the pandemic did, interestingly, is really expose the weaknesses of the system and force some changes that were not welcome, candidly.
So for instance, we knew that tele-visits and virtual medicine could effectively replace about 40 percent of the in office visits to physicians. But the reason we didn't use it is because the payment system paid doctors and hospitals and clinics for an in person visit. They didn't pay for a tele-visit, even those most of the visits, especially for intermediate patients, don't require physical exam. It's an exchange of information, and we have technology to measure some of your vitals and biometrics and things. So two things have now collided. We had coming to 2020, we had this growing concern about health costs that were getting too high, and the value for the dollars being spent, not necessarily prudent, not understandable.
And second, the pandemic said we can't operate the way we have in the past. So the sum of the two is kind of a major change. It's a reset of healthcare coming out of the pandemic, and most of the healthcare organizations are having to make some big bets about how they're going to think about the future. And to the context of nutrition and food insecurity and dietary supplements, what the industry has recognized is that a lot of this unnecessary cost relates to things that don't involve an accident or necessarily a condition that's diagnosed. It has a lot to do with lifestyle. And not surprisingly, 70 percent of cost of healthcare are a direct correlate to lifestyle choices people make, or the inadequacy or the unavailability of nutritious food, clean air, and safe housing. So that's where I think dietary supplements can play a huge role in the future.
John Troup: So it's an interesting issue. And actually, I think you're right. COVID-19 had probably really brought to a greater awareness of what the underlying issues are. And I've never really quite understood that if you look at over the last 25 years, the increasing incidence and prevalence of chronic disease, and most of those are related to diet and lifestyle. Yet, the healthcare system today is basically still focused on this, a pill for an ill, rather than trying to either pursue preventive medicine, or fix underlying systems of health, that better diet and better lifestyles could address. Yet, the insurance industry still won't recognize it as maybe even a reimbursable position to encourage more people to make that switch. What will it take for that recognition, that shift, of managing disease to managing health in the healthcare system?
Paul Keckley: Well, I think two things, and both are kind of out of the gate and progressing. One is that employers and private health insurers, so the insurance industry is made up of about 800 organizations, but literally 36 Blue Cross plans, five big public companies control about 70 percent of the US insurance market. So when those 41 organizations say, "We've got to change the way this thing operates because the costs bear no resemblance to the outcomes, and we know that food insecurity and lifestyle decisions people make are not something that primary care physicians pay attention to.
And that's kind of part A of this. The payers are quickly transitioning from kind of looking at lifestyle-related issues as a risk factor, to being a root cause. And they're investing money and benefits designs, and ways of structuring their coverage to pay more attention to these lifestyle issues, and even to incentivize doctors to pay attention to this stuff. That's the nature of the accountable care organizations and things like that, so that's part A. The payer kind of drives that agenda. But B, and as significant, we recognize that there's a wide diversity in the extent of these problems. So not coincidentally, chronic conditions and lifestyle-related avoidable costs are substantially more prevalent in underserved populations, in populations of color, in populations of low income, in urban populations, in lower educated populations and certain rural settings.
So as you've thought about what you've heard since the election and in the administration's thinking, you're hearing a lot about equity and diversity. So here we go, we've got payers saying, "The system is not rewarding lifestyle enhancement, population health improvement. That's not smart. And second, society is saying, "And that has disproportionately, negatively impacted disenfranchised people among us." And the number is staggering. It's more than half of the population that have one or more chronic conditions, but it's more than two out of three adults over 45. And those numbers climb even higher if you're getting into various ethnic populations, Hispanic populations, African American populations and other.
So John, it's a two for. And now people are saying, "Maybe we need to take a fresh look at nutrition." Maybe we need to think about this whole notion of food oasis, where even if a person was inclined to eat healthy, there's not a bus stop near them, or transportation available to them, to get to a place to buy fresh food. So this is a problem that's now recognized. And back to regulation, as you well know, what makes this even more complicated is the food supply chain has been regulated primarily through the US Department of Agriculture, but healthcare is regulated through the US Department of Health and Human Services. So you're seeing a lot of synergies developing between those two departments, two of the 15 major departments of the federal government. And I expect in the short-term here, you're going to hear more about this than most of us have heard in our adult lives because it's that important.
John Troup: Well, you talk about it being a problem. It's a big problem when you consider some of the statistics. 60 percent of Americans have at least one chronic disease. 40 percent have two or more. And on top of that, at least an estimated 50 percent of Americans have nutrient deficiencies reaching about 40 percent levels of deficiency in some of the major nutrients that affect metabolic processes, and then lead to the progression of chronic disease states. So with that kind of information out there related to the issues of poor nutrition, that gap in part ought to be fixed to some certain extent with the appropriate use of dietary supplements. Yet, dietary supplements have typically been kind of poo pooed by the health insurance and by the healthcare industry. But so why is that? What can we do as an industry to change perceptions and to change views and increase awareness?
Paul Keckley: So the world is opening up to the fact that science is not perfect, and science is expanding. And therein lies the opportunity for dietary supplements because there's as much science supporting many of the evidence-based dietary supplements as there is for things that are done by doctors every day. But then the second issue, so I think we've got payers beginning other ways of thinking about healthiness. You've seen this in the Medicare Advantage plans, which are hugely successful. They represent about 28 million Medicare enrollees in this country.
But the second thing is in the world of medicine and in the world of diagnosis and treatment, there's increased attention to this notion of lifestyle. It's being phrased as social determinants of health. And that phrase is now integrated into all of the medical training, the 140 schools of medicine around the country, the schools of nursing, and so on. So they're beginning to hear about this notion of social determinants, of which nutrition is one, food insecurity a major factor. And younger physicians entering the workforce are inclined to recommend where they know that the individual has the resources to purchase or access to those resources. So it's changing, changing favorably.
But it'd be less than candid to say that the majority of physicians are talking about dietary supplements to their patients. They're not. And they'll tell you this is the reason. I only have in a seven minute visit with a patient, where I'm talking for about three minutes, and my staff has done another two to three minutes, and I've got one minute to answer any questions, I don't use that time. I choose not to use that time to inject myself into what they're eating, or whether they're anxious, or whether they have clean air at home. That's the problem. So how are we going to fix that? Systems of health are fixing that.
I think what you're going to see is that, and this is something all of you will recognize, the system, the health system is consolidating rapidly. We have for instance, ten health systems, ten multi-hospital slash physician organizations in this country that represent 24 percent of the patient care in this country. We've got about 80 of those that represent about 85 percent of the patient care in this country. So the standardization of how we diagnose and treat in clinics is becoming more alert to this notion of nutrition and lifestyle-related factors. And their incentives are changing to encourage that. In tandem with, the insurance industry, the medical directors of the insurance industry are discovering that it's good business to keep people out of hospitals and not do tests that are not necessary. And coincidentally, pay more attention to where they live, what they eat, whether they walk. And all of that's coming together. That's the reason, John, I think the time is ripe for dietary supplements to be relevant because candidly, dietary supplements is not part of the national health discussion.
John Troup: I know that there are initiatives in Congress and discussions across the different agencies trying to create a food czar to look at food policy and combine health and human services and the department of agricultural committees on some of this. But it is amazing to me. What is going to be the stimulus to all of a sudden create that call to action as an increase awareness?
Paul Keckley: We did discover as a result of the pandemic that the public's health, the public health apparatus in this country, which is largely funded by state and local government, so imagine this, John. You hear about this big number. We'll spend $4.2 trillion on the healthcare system this year. Three percent of that is spent on public health. Everything else is spent in other places. Three percent is spent on public health. And public health covers a multitude of population issues, including food insecurity and other stuff, but it's three percent. And yet, you turn around and look at the data, and it says 70 percent of our health cost, the cost is a derivative of poor food, poor housing, poor air. And it's lifestyle.
So can Congress take the mantle and run with it? I think that will happen. And it's basically because it's good business. The federal government cannot afford the healthcare system as it operates today. They've got to find a way to cut what they're spending. A very good place to start would be nutrition. Investing in nutrition reduces costs across the system quickly. It's not something you have to wait 30 years for. So I think you'll get that attention paid. I do think, and I'm not a partisan, I studied policies and respond as administrations ask me to respond. And what I see in the Biden administration is a sensitivity to this that I haven't seen in prior administrations. I do find that this notion of equity and diversity across the healthcare system easily converts to more attention to food insecurity and to nutrition deficiency. And so I think I'm very optimistic. I don't think the funding has been there for anybody to do much. It's paltry compared to what we spend on everything else.
John Troup: Well, you mentioned Congress finally may be getting ready to finally act. But there's been legislation that have introduced, as one example of eligibility for dietary supplements under HSA and FSA. And from everything that we hear or listen to being discussed on the Hill and the different committees is it's going to be a difficult bill to get passed. But why is that? Everything you just said, and the readiness and the need for the healthcare system to change, cost-effectiveness of dietary supplements have been demonstrated in a number of studies. What should industry do to help influence legislation like that? And do they have a chance of getting bills like this passed?
Paul Keckley: Yeah. But they've got to do a little clean up work in their own backyard. There's also lots of sensitivity to rogue actors who put supplements out with promises that are in many cases outrageous. And of course, that's when the FDA gets involved around claims like that. But the way Congress works is they try to take the lowest friction route to get an incremental change made. They don't do bold anything because they're always counting votes in the next election cycle. Everybody's teed up right now for the '22 election cycle.
So would there be a case to be made that state Medicaid programs should integrate dietary supplements as part of those programs and that CMS, which oversees Medicaid, would develop a number of pilot programs to demonstrate efficacy and effectiveness? That's the way you build. That's the way you move the DC ship of state. I mean, the way Congress works is you have to bring an incremental change that can get multiple sponsors, hopefully on both sides of an aisle, that move things along incrementally. And when you start talking about insurance design, HSAs and so on, that's more than incremental.
Remember, 160 million people in this country get their insurance from private insurers. These are the people under 65 years of age. And those benefit designs developed by the insurance company, basically the federal government wants to let the states manage that. Again, as I said earlier, some sectors are regulated more federally, other states. Insurance is primarily regulated at a state level, so they'd rather a state Medicaid director encourage dietary supplements or integrate it into whatever, than they would create some kind of a federal program. That's the way to tackle it. It's got to be tackled probably more a state at a time than it is at a federal level.
John Troup: Right. So it sounds to me, Paul, that what you're making a case for and suggesting is that industry's best way forward, and when I say industry now, I'm talking about the dietary supplement industry, best way forward is to take the responsibility itself to advance the insight that you're talking about is missing. So for example, we collectively need to invest in these demonstration studies and spend a little bit more money say in clinical research and R and D to make the case, so it's easier for people in Congress to recognize, and the insurance industry easier and more willing to support this area. So with not enough credibility in the category, then we need to build the credibility with the results that will further emphasize the benefits that this could provide if we find a vehicle to change the healthcare system.
Paul Keckley: Yeah. Let me add a wrinkle to that, not just the insurers, but large employers in this country have a vested interest in seeing healthcare transition from a sick care system to a preventive health system. So direct to employer efforts in tandem with direct to government, direct to insurers, and direct to providers, is kind of the four legs of this stool of: How do you position dietary supplements to be a relevant part of the remedy to nutrition deficiency in this country? And all four of those singing from the same hymnal will produce some pretty dramatic results, but it will not be one big sweeping bill. It's going to be a number of incremental changes.
John Troup: Yeah. Wow. Okay. There's a lot of work to do there. I'm curious to get your perspective. I actually thought at one point when the Affordable Care Act was introduced, and so when it started taking hold around, I guess it must've been 2014, so two years after I think it passed, was there were two wellness visits that were integrated into that bill, which I at the time thought, "This is awesome." Every person in America can go see their primary care doctor and get a wellness checkup, and that's the conduit to go from the seven minutes of not talking about nutrition and lifestyle, to at least three minutes of talking about it. But it never took hold, it never happened. Why's that? Is there a reason for that?
Paul Keckley: I mean, actually when it passed in 2010, there was a fairly fierce debate, and I was in the White House at this point, about: How do you encourage people to live healthier lives? And at that point, the decision was made, let's penalize bad behaviors. And the only bad behavior that's penalized in the ACA is tobacco, use of tobacco products, where you have to pay a higher insurance premium.
Instead what they did, and this is what's missed, they enacted a number of things that allowed primary care providers, federally qualified health centers, even advanced practice nurses, to really experiment with whole person care. And included in that is nutrition therapy or discussions around food as medicine. So the presumption was if we encourage primary care providers to be more aggressive about lifestyle-related issues, we'll get the trickle down effect. Well, it didn't happen. The reasons are many, but most of those early pilots did not work.
We're back to square one on how you make the delivery system, doctors, hospitals, federally qualified health centers, community health centers, and so on, how you incent them, and now we've got a white board. We're starting over. Most of those things didn't work very effectively. So you're right. There were some things in the law about a wellness visit for Medicare enrollees. Other parts of the law said that a health insurance plan could not charge a co-pay for a set of preventive health measures, graded A or B by the US Preventive Services Task Force and so on. All of that's in the law. Didn't affect behavior, didn't impact the net result of better health, so back to square one.
John Troup: This issue of behavior is such a big deal in chronic health management or chronic disease management. I've talked to a number of my friends who are physicians, and I'll talk to them. Somebody comes in with a cardiovascular disease, lifestyle and diet is the answer. And in fact, in diabetic care, the first approach to care should be lifestyle. But 90 percent of doctors will get their prescription pad out and write a prescription for metformin rather than give them the diet. And so when I ask my friends who are physicians again about: Why do you do that?
Paul Keckley: It's really interesting. This could be a whole podcast of itself around how the medical management function is changing, how physician, diagnostics and therapeutics are changing now, as the way they're paid is changing, as they're being required to use electronic health records, as they're paid less for a visit, but dealing with sicker patients. So in some ways, physicians, their response would be, "Look, if I had time, I could have the discussion with Mary or Joe. I just don't have time I'll tell you how that's going to change, John.
This is kind of fascinating. The introduction of science-based clinical decision support tools into how we manage health, these are biometric sensing devices. These are ways of collecting data about people before they show up in a doctor's office, monitoring their health, even things like biodegradable chips that allow you to kind of monitor a person's metabolics 7/24. And many embrace that. Many are saying, "That's the way it should be. We should be the partner to a patient. We shouldn't be the parent of the patient."
John Troup: Wow. Well, Paul, it's so awesome talking to you and getting your insights. It's pretty clear why you're such an important thought leader in the world of healthcare and health policy.
Paul Keckley: Well, I just want to say, John, I sincerely believe nutrition deficiency and food insecurity are issues whose time has come. I've not seen in my career more attention being paid, but solutions to that are all over the place, so that's the timeliness of this effort. And I think you're going to have a busy next few years.
John Troup: Dr. Keckley, thanks very much for your time. It's really awesome having this discussion. I've learned quite a bit myself. And I'm sure that our listeners have too.
Speaker 2: Thank you for joining us here at CHPA Chat. For more information and to hear our entire catalog of shows, please visit chpa.org.
The views expressed in this podcast are solely those of the speaker and do not necessarily represent the opinions of the Consumer Healthcare Products Association.