Preventing Rather Than Treating Illness
In order to talk about reforming how providers are paid whether it is fee-for-service, capitation, or at-risk contracts, it is first necessary to talk about why we need to reform it.
Disease and disability are doing more than harming the health of Americans. The costs of medical care and an unhealthy workforce are crippling the U.S. economy and its ability to compete in the world market. We’ve heard the litany of reasons why save one—preventing rather than treating illness.
Preventing illness—a major feature of a functional health care system—is not valued in the United States, and is usually measured in terms of dollars spent and lives lost. Currently, we’re not spending a lot of dollars on improving our health and we’re losing a lot of lives. The leading causes of preventable death — tobacco use, physical inactivity, diet, and alcohol use — account for about 1 million deaths annually and for nearly 20% of total healthcare expenditures. In a healthcare system that spent about $2.2 trillion in 2007, this represents almost $450 billion. The real cost, of course, is premature loss of human lives. The financial incentives that would spur the efforts to control the underlying causes of preventable death, however, are severely inhibited. Why? In the current system, resources are heavily concentrated on paying providers for the treatment of disease—the more advanced the disease, the more handsome the payment. Oft times for tests and procedures of uncertain effectiveness. Yet, only 2-3% of health care dollars are expended on avoid the diseases that drive this spending.
Part of the reason that we have failed to finance efforts that improve our health comes down to basic economic principles. While the cost of preventable diseases is enormous, there is no immediate return on investments in early clinical intervention or prevention. Any savings would most likely occur in the relatively distant future, beyond normal budget cycles and political campaigns, and returns from any upfront prevention investments by insurance payers would most likely be reaped by another payer many years from now. Our current system of employer-based third-party insurance has strengths and weaknesses on its own merit, but it is clearly not a good fit for efforts to keep us healthy. Barring a radical shift in provider reimbursement, our current approach of squeezing nonmedical costs into the medical reimbursement system is not a sustainable option.
A focus on ensuring good health could strikingly alter this dysfunctional and inefficient characteristic of the U.S. health care system. It would bring about a new payment model that takes into account a core principle—clinical and community preventive services are complementary. What do I mean by this? Some preventive interventions (e.g., colonoscopy screening for colorectal cancer) happen in a clinical setting, where they are delivered by a health care professional; these are known as clinical preventive services. Community preventive services are put into practice where people live, work, and go to school and include policies, programs, and services that aim to improve the health of the entire population or specific populations that have far worse health outcomes that the general population. Any new payment model has to recognize that a doctor’s advice to make a lifestyle change is of little good if the resources for change do not exist in the community. Moreover, it must understand that any patient can be advised to exercise regularly, but may not succeed if there are no safe places to walk outside.
This form of payment system would ensure smooth handoffs among primary care, specialty care, community health, and allied health professionals in helping patients change behaviors or obtain services early. It would move us from the payment for specific preventive services to, for example, blending capitation with fee-for-service and pay-for-performance model to support the integration of population and personalized care.
Not all preventive services are effective and not all effective services offer good value on the dollar. Beyond cost, the logic that it is better to prevent illness than to wait until people are sick and then try to catch up is compelling.
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3 Responses to “Preventing Rather Than Treating Illness”
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As someone with a family history of sometimes-fatal breast and other female cancers, I’d like to see more research on cancer prevention, particularly in regards to carcinogens. I see a lot of news stories about cancer treatment and survival, but not nearly enough regarding research and particularly policy action that might result from such research. Not to sound dire, but I believe we are poisoning ourselves and our environment; we need to take more of a proactive and less of a reactive stance in addressing this problem. Thanks. BK
Everyone knows the list of lifestyle changes that improve health: smoking cessation, improved diet, lose enough weight to have a BMI around 25, excercise, stress reduction, get a good night’s sleep without pills, etc. But of all the strategies, one stands out as highly effective, easy to do, extremely inexpensive, and likely to have good compliance: improve your vitamin D status. Most people have 15 ng/mL as measured by the 25(OH)D blood test, but if you can elevate it through supplementation to 50 ng/mL, the odds of cancer, heart attack, diabetes, and a host of deadly degerative diseases drops about half. For most people this requires a daily supplement around 5000 international units or 125 micrograms. Hundreds of reports in prestigious medical journals leave no doubt a widespread vitamin D deficiency leads to a colossal public health crisis. The trouble is clinically observable symptoms take decades to appear, usually in the form of a life threatening illness. The medical community is suspicious but more and more doctors are embracing the concept as more research is published. More to the point, doctors diagnose and treat illness, but it is up to each individual to get educated, take personal responsibility, and take a proactive approach to prevention. Ideally you want to do all things I mentioned in the first sentence, but if overcoming a lifetime of bad habits seems too intimidating, the least you could do is pop a vitamin pill that costs under 10 cents. There is abundant proof of vitamin D’s multiple protective effects but it takes effort and sophistication to find it, understand it, accept it, and implement it.
Check out VitaminDCouncil.org, run by John Cannell, MD.
Many are still worried about D toxicity. That’s like worrying about drowning on a desert; see Dr. Heaney’s Chart for reassurance:
http://grassrootshealth.org/_download/Heaney_What%27s_Vitamin_D_Deficiency120208.pdf
Q: Why is prevention so difficult to achieve from the top down?
A: Consider that Medicare has announced they won’t pay for D blood tests as part of a routine blood panel, regardless of the patient having a history or signs of heart disease, hypertension, TB, MS, depression, and more — despite research showing these and more are prevented or alleviated by D repletion. See citations at http://goodschoolfood.org/pdf/D-Light-Full_VitaminD.pdf
Q: Who was in the room when this decision was made!
A: Obviously, Big Pharma would not want to turn off the profit spigot by having people no longer paying for their prescriptions. So the change won’t come from the top, but must come from the grassroots up.