OP-ED

Prevention is Not Only Good Health Policy, It’s Good Economic Policy

W3956 The current debate around how to best control burgeoning health costs has  pushed the issue of prevention to the forefront. That’s right where it should be. By shifting our health care to be more pro-active and prevention-oriented, we can make a major impact on common and costly chronic diseases such as diabetes. In turn, this will help to secure the financial stability of our health care system and continued economic growth and prosperity.

Over the past century, the burden of disease among Americans has shifted from acute and infectious illness to chronic disease. With more than 75 cents of every dollar in this nation spent on patients with chronic disease, prevention offers the opportunity not to spend more money — but spend smarter. By embracing prevention, we can help more Americans lead healthier, active lives free from disease, so that they can avoid costly complications and hospitalizations, and remain productive in their communities and workplaces.

Prevention today involves a lot more than flu shots, cancer screening, and annual checkups. It is a pro-active strategy of disease avoidance and mitigation that should be embraced throughout and beyond the health system. In the context of chronic illnesses such as asthma, cancer, depression, heart disease and diabetes, prevention runs the gamut from lifestyle changes to screening for risk factors and symptoms, to early intervention to slow or reverse disease, to active management of already present cases.

The case of diabetes — one of the fastest growing and most-threatening chronic conditions in the U.S. — provides perhaps the most compelling example of our opportunity. For most individuals who progress to type 2 diabetes, the disease can be prevented or delayed significantly by following a well-established routine of diet and exercise. The potential impact of such an approach is enormous, both in terms of lives saved, and dollars saved.

Consider the economic impact alone. On average, diabetes patients have medical expenditures 2.3 times higher than those of other patients of the same age. With the incidence of diabetes expected to double worldwide by 2030, it is not only a medical necessity but an imperative to identify those at highest risk and implement disease prevention strategies.

Fortunately, we now have the tools to do just that. Recent advances in understanding the biological complexity of human disease have transformed our ability to predict and prevent the onset of chronic diseases such as diabetes. Where previously we had one somewhat inadequate tool for measuring diabetes progression — the fasting glucose test — today we have sensitive diagnostic tests capable of measuring a wide range of biological processes implicated in the advance toward diabetes. As a result, physicians can identify those patients at highest “near-term” risk for diabetes — and target intervention efforts to them.

Stratifying those truly at highest near-term risk among the 57 million Americans now considered to be “pre-diabetic” would streamline diabetes prevention, and allow physicians to focus their efforts on those most in need — thus transforming preventive medicine from a means to protect the general population to a truly personalized effort to fight disease in at-risk populations.

This fundamental shift would pay substantial long-term dividends in reduced medical expenditures, improved patient quality of life and improved workplace productivity. Economic research unveiled at the most recent American Diabetes Association meeting shows that such a prevention strategy would be cost-effective in the near-term, and actually save the health care system money over the long-term. Likewise, the Diabetes Prevention Program administered in community based settings — a well-recognized “gold standard” — illustrates that cost-savings can be achieved in two to three years.

Effectively adopting such a strategy requires a new approach throughout the health care system, from physicians whose familiarity or comfort with new technologies can be slow to develop; to professional organizations who can be slow to adopt changes that deviate from the status quo; to private insurance companies and government health plans, whose reimbursement support for physicians and patients who adopt such tests and prevention strategies into clinical practice is critical.

Health reform opens the door to making true progress on prevention. On the other side of the door lies better health for our entire population — and a healthier, more vibrant economy. To get there, we must embrace policies that make it easier for patients to actively prevent and manage disease — as well as those that encourage health care providers to collaborate on care of chronically ill patients and take steps towards paying for outcomes and not just volume of services.

These types of “game changers” are required to set us on the right path for our health and our economy by providing better results for all our health care spending.

Emory university’s Dr. Kenneth Thorpe is the Robert W. Woodruff Professor and Chair of the Department of Health Policy & Management. Dr. Thorpe is currently executive chairperson of the Partnership to Fight Chronic Disease. In the early 1990s he served as a health care advisor to President William Jefferson Clinton.

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26 replies »

  1. 1. There’s a movement to radically change California government, by getting rid of career politicians and chopping their salaries in half. A group known as Citizens for California Reform wants to make the California legislature a part time time job, just like it was until 1966.
    leatest trend

  2. I agree with those who have commented that prevention does not just mean better screening for chronic conditions and cancers. I believe it does begin with lifestyle changes- eating healthy, exercising, reducing stress, wearing seat belts, etc. However, this is, indeed easier said than done. Yes, it must be difficult for doctors to try to convince patients to make healthier choices, but what happens when patients do not even have choices because of circumstances and environment? We must consider the additional factors that could contribute to the difficulty of making healthy choices, especially when socioeconomic status is concerned. What if people want to eat healthy, but the closest and most convenient place to buy food is the local fast food restaurant? A single mother juggling 2-3 jobs probably does not have much time to cook the healthiest dinner for her kids (not to mention, may not be able to afford the freshest ingredients—the reality is, healthy food is expensive). What if they want to be physically active, but the neighborhood they live in is unsafe for jogging and a gym membership is just unaffordable? If we want to advocate prevention in health care, it seems necessary to address not only healthier attitudes, but environmental and social issues as well—to see the patient not only as a single, isolated entity, but to take them in their context and community. In doing so, we must discover what prevention means in their context and how it can be applied where they live.
    Also, on the physician’s end, if there is to be any call for prevention as a means of lowering health care costs, it seems that there must also be a call for more primary care physicians (PCPs). An increasing number of specialists are having a difficult time finding work because there are too many specialists and not enough patients who require their services. Meanwhile, PCPs are swamped with patients, allotting maybe 15 minutes per visit and probably find it difficult to address preventive strategies in such a short amount of time. If patients don’t get preventive counseling from their PCPs, by the time they get to a specialist, it’s just too late. More PCPs may mean more time per patient, and therefore more opportunity to address preventive strategies, which would hopefully lead to a healthier nation. With many medical students swayed by the promise of prestige and financial return of going into a specialty, perhaps some serious measures must be taken to encourage those pursuing medicine to consider primary care.

  3. Ironically, one of the problems with wellness and health in the USA is the vast array choices. A lot of the products and services that are offered are nothing more than fancy packaging and labels. From yoga and pilates to acupuncture and chirpropractors, it is nice to see that a variety of health and wellness options are available. However, like anything else, education and careful discretion is advised. Don’t believe the hype – do your research and you can find good, inexpensive wellness options almost anywhere.
    I’ve started using somibo.com – a good site where you can find lots of health and wellness businesses and read and post reviews on them.

  4. MD as HELL may indeed be correct in the comment about trying to save people from themselves. Our Team (Ex Physiologist, Physical Therapists and MD’s) have put together a FREE site that provides a daily prescription of what we deem the lowest level of movement needed to obtain basic benefits of “prevention.” It gets some use, but nowhere near what it should/could. We thought we were going to radically change the lives of so many but have found the behavioral side very challenging!
    http://www.movementforlife.com
    We can tell people what to do, provide them with tools to do it and it is still amazing how many just can’t do much to help themselves…….

  5. MD as HELL, this has absolutely nothing to do with evolution. Lower-class obese people have plenty of kids in their teens, 20s, and 30s before they have a chance to die in their 50s and 60s.
    If bad-health people live to be 58 on average, and good-health people live to be 116, that doesn’t change the fact that bad-health couples can have 3 kids each and good-health couples might only have 1 or 2.
    Human evolution is dead, and has been for some time.

  6. The fastest way to a healthier population is to get out of the way of evolution and let the gene pool improve. Quit trying to save people from themselves. You can’t!

  7. Agreed that this is a somewhat disingenuous article. The only kind of “preventive medicine” that generally universally says money is immunizations. For almost all of kind of preventative medicine, it depends on several factors that go into a cost-benefit/cost-effectiveness analysis.

  8. The current debate around how to best control burgeoning health costs, has pushed the issue of prevention to the forefront. That’s right where it should be. By shifting our health care to be more pro-active and.

  9. The battle for the prevention of diabetes will not be won by the medical profession, it will be won when we change our food policy that allows advertising junk food to children and which subsidizes HFCS and beef production through subsidizing corn. High calorie/high sugar/high carbohydrates/high fat has become engrained in our food culture because it’s easy and cheap for corporate America to sell food that way, while they pass the costs onto the healthcare system.

  10. “More exercise, less smoking, drugs and alcohol, healthier food, safer sex, safer traffic: that provides a healthier population!”
    Most of us know all this without needing a doctor to tell us. For many, though, they’re easier said than done. Millions of smokers would probably love to quit and have tried unsuccessfully numerous times but, for whatever reason, can’t. Exercise takes time, effort and discipline. For the non-athletic among us, it’s not fun which makes it a slog. A lot of healthier foods don’t taste very good. On the positive side, seatbelt use is up to 84% and traffic fatalities in the U.S. are at the lowest level on record based on deaths per 100 million miles driven. Doctors can advise, exhort and cajole their patients until the cows come home, but better lifestyle choices, for the most part, need to come from within ourselves.
    Screening tests to find problems at an early stage when they are easier and less costly to treat are a different matter. We need doctors for that, and the lower income segments of the population need some help in paying for them. On the negative side, its hard to know how many issues are identified that never would have caused any harm yet result in additional, often expensive, testing and treatment.
    If we want to nudge personal behavior in the right direction, we would impose high taxes on cigarettes, alcohol and unhealthy foods while offering financial incentives in the form of insurance discounts or rebates for people who don’t smoke or quit smoking, maintain a healthy weight and keep their blood pressure and cholesterol within recommended limits.

  11. Prevention of chronicle disaeses starts with health promotion for all people: lifestyle – intervention: More exercise, less smoking, drugs and alcohol, healthier food, safer sex, safer traffic: that provides a healthier population!
    The problem is: our environment (physical and psychosocial) seduces us to live unhealthy. It’s not easy for all people to live your life healthy. Especially if your economic status is low.
    In Europe (I live in the Netherlands) we try to go further than community based prevention: Together with the local government and the food industry we try to make changes in the environment: to reduce the seduction of too less exercise, and too much fat food.
    It’s a slow process, it will take decades, but it is for the long term!

  12. Let’s try to remember the definition of words when we talk about prevention. Mammography and other types of early detection screenings have nothing to do with prevention. They are detection devices to detect a disease already in progress.
    True prevention lies in one’s own control in diet, exercise and avoidance of environmental influences. Changing our habits to a healthy lifestyle would have a dramatic reduction on the financial burden of care, but I’m not sure policy changes will bring about these types of changes.

  13. This fundamental shift would pay substantial long-term dividends in reduced medical expenditures, improved patient quality of life and improved workplace productivity.

  14. I used to work with a fellow who’d had a major heart attack. He had a gut that hung over his belt in a major way. He couldn’t walk too far or his “ticker” would get out of wack causing him to have an elevated heart rate, get all sweaty (and smelly) and sometimes he’s pass out. To his credit, our instructions were not to call the rescue squad when this happened. He’d always come-to eventually.
    But he could walk to the sub shop, which he did everyday. He’d bring back a huge steak and cheese or a meatball sub. He enjoyed one of those every day telling us that it didn’t matter what he ate because of the drugs he was taking for his heart to keep his lipids in check.
    I guess it didn’t matter to his heart about that gut it was trying to pump blood through.
    That’s not my idea of prevention.

  15. Margalit,
    Less talent because the best and brightest will no longer seek careers in medicine, leaving open the profession for the B squad.

  16. Employers could potentially save approximately $5,000 over 5 years for each employee by introducing proven health promotion programs into employee wellness programs.” Mitigating the impact of the financial crises is only one beneficial side effect of creating healthy, happy, creative and productive employees.
    The conservative projected saving of $5,000 is based More then 700 scientific studies conducted at 250 independent universities and medical schools in 33 countries during the past 40 years has verified the holistic benefits of the Maharishi Vedic Approach to Health. This prevention-oriented system employs forty approaches including the Transcendental Meditation (TM) program (http://www.tm.org/research-on-meditation), diet, daily and seasonal routines, herbs, and toxin removal – life in harmony with Natural Law
    Multiple studies analyzing insurance records of health care utilization have documented cost savings by preventing disease from arising in the first place with nonmedical interventions. (http://www.doctorsontm.com/reduced-health-care-costs). One study: The Transcendental Meditation group and NonTM group payments to private physicians had similar growth before the intervention. After learning the Transcendental Meditation technique, the TM group made an abrupt change and decreased while the NonTM group continued to grow. The TM group averaged an additional 14% less payments each year for 5 years with 55% less payments compared to the NonTM group in the 6th year. (Herron, R.E. Cavanaugh, K. Can the Transcendental Meditation Program Reduce the Medical Expenditures of Older People? A Longitudinal Cost Reduction Study in Canada. Journal of Social Behavior and Personality 2005; 17: 415–442.)

  17. True Prevention is stopping disease before it arises. One randomized controlled study, presented November 16, 2009 at the American Heart Assn.’s annual meeting, found that heart disease patients who practice TM have 47% lower rates of heart attacks, stroke and deaths compared to similar patients who don’t practice meditation. The 9 year study was funded with a $3.8-million grant from the federal government (NIH) and was conducted at the Medical College of Wisconsin in collaboration with the Institute for Natural Medicine and Prevention, at Maharishi University of Management in Fairfield, Iowa. Dr. Robert H Schneider, MD, Institute Director and lead author, has received over $25 Million in funding from NIH for his Transcendental Meditation research. (http://news.bbc.co.uk/2/hi/health/8363302.stm)
    A major study is under way with the Ho-Chunk tribe in Nebraska to verify their observation that TM is the only observed effective intervention for Native Americans with diabetes. Eighty percent of Native Americans have diabetes. Individuals typically report normalized sugar levels within a few weeks or months with reduced or eliminated insulin need accompanied by multiple beneficial side effects. (http://www.davidlynchfoundation.org/videos.html)
    http://www.tm.org/research-on-meditation

  18. Prevention is best seen in the context of risk assessment, which converts the population-based approach to a patient-centered view.
    Instead of stratifying prevention by cohorts, we need to have tools that allows each individual’s particular risk profile to be assessed, and identify the most important health concerns that can be prevented or mitigated.
    Prevention applied to a person = risk assessment + appropriate intervention + measurable goals for process and outcome

  19. Dr. Thorpe correctly observes that we are undergoing a national “debate about how to best control burgeoning health costs.” He places great reliance on “[r]ecent advances in understanding the biological complexity of human disease [which] have transformed our ability to predict and prevent the onset of chronic diseases such as diabetes.” He seems to be saying that we should focus on getting the medical providers and payers to adapt more quickly to new screening tests so that intervention can occur sooner.
    Forget the new tests, think of the savings if patients were to receive correct screening and follow-up care based on existing technology. It has been estimated that patients receive recommended care barely 50 percent of the time.

    Overall, participants received 54.9 percent of recommended care (95 percent confidence interval, 54.3 to 55.5) (Table 3). This level of performance was similar in the areas of preventive care, acute care, and care for chronic conditions. The level of performance according to the particular medical function ranged from 52.2 percent (95 percent confidence interval, 51.3 to 53.2) for screening to 58.5 percent (95 percent confidence interval, 56.6 to 60.4) for follow-up care.
    Our results indicate that, on average, Americans receive about half of recommended medical care processes. Although this point estimate of the size of the quality problem may continue to be debated, the gap between what we know works and what is actually done is substantial enough to warrant attention. These deficits, which pose serious threats to the health and well-being of the U.S. public, persist despite initiatives by both the federal government and private health care delivery systems to improve care.
    What can we do to break through this impasse? Given the complexity and diversity of the health care system, there will be no simple solution. A key component of any solution, however, is the routine availability of information on performance at all levels. Making such information available will require a major overhaul of our current health information systems, with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.49 Establishing a national base line for performance makes it possible to assess the effect of policy changes and to evaluate large-scale national, regional, state, or local efforts to improve quality. (McGlynn, et al., The Quality of Health Care Delivered to Adults in the United States, NEJM, June 26, 2003.)

    In order to effect change we need performance measurement and transparency, something the medical-industrial complex has resisted. We need a serious change of attitude, not a technological breakthrough.

  20. I agree with previous posters that one has to define what I meant by “preventive medicine”.
    If you talk about medico-tecnical prevention (mammograms, screening colonospcopies, PSA, whole body scans etc.), it is definitely overrated in the US (although some do make sense).
    If you mean addressing western civilization problems auch as sedentary life style and high caloric processed diet, it likely will pay off, since treating 2 decades of DM II is likely more expensive than medicare expenses for a healthy nonagenerian, and I believe there is a statistical model study supporting that.
    I truly believe that Pres. Obama would have a chance to be a trendsetter by living and preaching a healty lifestyle, but so far it looks like he misses the chance (like many others). Or smoking is the issue here. Looks like we need a President Huckabee.

  21. Some time back, Health Affairs published an article about a study done in the Netherlands which claims that preventive care probably increases costs because it extends lives. Smokers, for example, die seven years sooner than healthy people and, according to the study, incur lower lifetime medical costs than healthy people. People who live to old age often get expensive diseases like Alzheimer’s, Parkinson’s, etc. I’m all for good primary and preventive care because I think it will help people to live a longer, healthier life which is, of course, a good thing. I don’t expect it to save health care dollars for the system, however. Indeed, it is more likely to cost money.
    In my own case, I’m on medical therapy for heart disease and have been for the past ten years since my CABG. The cost of the drugs, based on Drugstore.com prices, is a bit over $3,300 per year. If I were born 30 years earlier, I probably would have died of a heart attack in my early 50’s. While that’s obviously not so good for me, my healthcare costs would have ceased upon my death. Heart disease, many cancers, and some other conditions which were once death sentences are now chronic diseases that can be managed, often at considerable cost. Medical management, along with stents and other devices all cost money, sometimes a lot of money. Moreover, many of us develop heart disease due to genetic factors despite sound lifestyle choices. With respect to cancer, aside from not smoking, there is no evidence that any of the other good lifestyle choices including maintaining a normal weight, getting enough exercise, eating plenty of fruits and vegetables, consuming enough fiber, etc. have any discernible effect on whether a given individual will develop the disease or not.
    I think it is disingenuous, at best, to try to sell preventive care as a healthcare system cost saver which many of our politicians are trying to do

  22. Prevention might be overrated in terms of testing, but exercise and a healthy diet seem to make a huge difference, right? The post doesn’t dig into that too much — it is only a blog post after all.

  23. The advantages of preventive medicine, which I support and practice, are overrated. The public believes that these tests, such as mammography, are lifesaving, when their true benefit is much more modest. I do not accept that preventive medicine reduces health care costs, as you suggests. Although it sounds logical, it may not be true. We don’t really have persuasive data to support this. There are some experts who have argued that preventive medicine might increase costs by extending people’s lives. This past week we all witnessed the volcanic reaction from the public and others when the USPSTF issued revised mammography guidelines. Will mammography save women in their 40s who are at average risk of breast cancer? Perhaps, but much fewer than the public believes. See http://bit.ly/656CwP

  24. This will be great for health, but also evolution. A smart person will see the catastrophic destruction of health care in America and realize he/she is on his/her own. The smart person will therefore be highly motivated to stay healthy and out of the clutches of health care.
    The not-so-smart person will not have the same reaction, leaving them vulnerable to the short comings of the system, now increased geometrically by the combination of less talent in the ranks and more people demanding salvation as promised.
    Remember, prevention is free. Early detection is very expensive. Lots of mistakes, too.
    Good luck.

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