Health Care Reform Starts with a Healthy Lifestyle: A Conversation with Paul Mango
Paul Mango is a Director in the Pittsburgh office of McKinsey & Company, where he leads the Global Health Care Practice. Working with some of the country’s largest health insurers and providers organizations with an emphasis on health reform, we sat down with Paul to discuss how real health care reform really starts at home.
ZocDoc: Before we address the weakness
es in the US health care system, let’s talk about its strengths. Where do we succeed?
Mango: We have four really impressive, distinctive aspects of our health care system here in the United States. Scientific achievement and advancement in medicine, for example. 70% of Nobel Prize winners in medicine are US based. Also, the most sought after place for advanced clinical technology is the US. We are the number one destination for access to superior technology. The US also has shorter wait times relative to other developed countries.
ZocDoc: So are we a good example to other nations?
Mango: Well, there are a number of aspects where we’re lagging. The US health care system has twice the average per capita costs than the OECD countries, in general. We’re very expensive, and we do not necessarily deliver better outcomes. Infant mortality rate is higher and life expectancy is shorter than it should be. And we still have this big black mark as a health care system with 15-16% uninsured people.
ZocDoc: Where do we need to reform health care the most?
Mango: The nature of medical risk has made a dramatic shift away from random infrequent and catastrophic events outside the control of the individual to common, frequent events within the control of the individual. So any type of health reform has to address two things:
The epidemic-level of growth in lifestyle-induced chronic diseases. We can narrow this down to a few bad habits: lack of exercise, poor nutrition, smoking, alcohol abuse, and unprotected sex. We have seen a rise from 14% to 34% clinically obese citizens in 25 years – genetics has very little to do with that.
Economic distortions on both the supply and demand sides of this industry also need to be addressed. Providers are being paid in ways that are not at all linked to value, and on the demand side people are consuming in ways that are linked in no way to value.
ZocDoc: If our own behavior is contributing to our declining health, should we be looking to the government to save us, or can we save ourselves?
Mango: If you expect an outside agency to be more responsible for your health than you are, we’re never going to win the battle. This requires a huge mindset shift.
ZocDoc: Who is going to shift our minds, and how?
Mango: An absolute multi-institutional approach. Here’s an example: We’ve had a fairly successful run at per capita tobacco consumption reduction in the last 25 years; it’s dropped about 50%. That was a result of a multi-institutional, multi-lever approach – direct, indirect, and contextual. Contextually, 1st graders were taught that smoking is bad. Indirectly, a tax of $4 on a pack of cigarettes was set. Directly, smoking was banned in all restaurants. We’ve had a hybrid of change levers that have been cobbled together over time that have had a dramatic impact on people’s mindsets and behaviors as it relates to smoking.
ZocDoc: Sounds like an effective approach – this idea of “small nudges” to influence people’s behavior. But how do you counter people who say it interferes with the free market? How much influence is too much influence?
Mango: The best paper I’ve read on this was in JAMA by Kevin Volpp, George Loewenstein, and Troy Brennan, and they coined a very important term called “asymmetric paternalism.” And they recognize exactly this issue because, for instance, if you and I were going to take care of ourselves anyway, it’s a pretty heavy handed approach for the government to tell us that we have to go get our annual physical. We don’t need that invasiveness. So asymmetric paternalism means rearrange the environment and the incentive such that those who would not normally do something actually change their behavior, but don’t feel invaded by the intervention.
The classic example of this was a study done at Subway sandwiches. They tried three different methodologies to alter people’s behavior to select lower calorie sandwiches. One was to list the calories next to each meal. It had zero effect. The second was to put a discount on the low calorie sandwiches relative to the others. Zero effect. The third one was put low calorie options on the first page of the menu before people had to open it and look at the rest. It had a substantial impact.
So what does this mean? If you and I were looking for the low calorie sandwich, we would not feel offended by this intervention. We would just happen to find what we were looking for on the first page. But the study statistically proved that if someone who wouldn’t normally order a low calorie sandwich didn’t even have to open the menu to find something else, he would.
ZocDoc: What are your hopes for the health care reform under the new Administration?
Mango: I think what we’re seeing is a public-private partnership which says the government is going to be the chief architect of the health care delivery system in terms of its structure, its rewards, and its scope. Our government up to now has played too little a role in this, and they should be more active in promoting healthy behaviors.
They should take 20% of the health care budget out of cure and treatment and put it into prevention. I think we’re spending less than 2% right now. I’d have bike trails, exercise programs, and mandatory nutritional programs. Medical risk is determined almost entirely today by individual behavior, so reform has to get at changing behavior.
