The Politics of Prevention

If there’s one thing everyone in Washington can agree on it’s that prevention is good. And that’s about as far as the agreement goes.

As for the rest of it – who is responsible for prevention, how to define prevention, what is the government’s role in prevention, how much to spend on prevention and when to spend it – is not so clear, and wrapped up in the bitter politics (and difficult economics) of the day.

Then, there’s the question of the Prevention and Public Health Fund created by the Affordable Care Act to enable states and communities to try to prevent illness and promote longer, healthier lives. To backers of the law, the fund is an engine for public health, community transformation, and a pivotal part of the effort to create a “health care” system instead of a “sick care” system.

To foes, it’s a “slush fund”, a $13.8 billion monument to everything they don’t like about the 2010 legislation.  It’s $13.8 billion that could easily end up on one of the deficit-cutting chopping blocks.

Even some Democrats are considering cutting some $8 billion from it, as part of a still-elusive larger supercommittee deal.

Dr. Howard Koh, the assistant secretary of HHS, lives and breathes prevention. Board certified in four medical fields (internal medicine, hematology, medical oncology, and dermatology – plus an M.P.H.) he has a keen eye as both a clinician and policymaker for unnecessary and avoidable illness, death and suffering.

The preventable suffering “is a source of tremendous anguish, not just for the patient and family but also for the provider,” he told a recent briefing in Washington sponsored by POLITICO Pro. “There’s got to be a better way.”

For Dr. Koh, the better way can be found, at least in part, through the health reform legislation and the prevention funds. It can be found by expanding access to care. And it can be found through science. All, in his view, are linked.

“We have the potential to expand coverage, which is tremendous, but also really advance the promise of a new system for prevention and public health and that is what excites me the most,” he said.  He called the prevention fund “transformative,” but stressed that grants were being made in accordance with the evidence, the science, and sensitivity to making sure that money is well-spent. (Although in a bow to deficit-cutting reality, he also acknowledged there could be some “possible” but unspecified budget tradeoffs.)

“You are looking at outcomes every step of the way,” he said. “It has to be rigorous.”

“This is a great opportunity. These funds will potentially transform the country,” he said, urging that investments in public health not be put off any longer, that they will pay off both monetarily and in better health.

But where Koh and others in the administration see transformation, some Republicans see boondoggle.

Sen. Tom Coburn, for instance, an Oklahoma Republican and physician who spoke earlier at the same briefing, says the country just can’t afford to be using public funds to build things like basketball courts in the name of public health.  People, he said, should be encouraged to take brisk 15-minute mile walks – for free. “Building basketball courts and all this other stuff… that’s all great,” Coburn said. “[But] our country doesn’t have that luxury right now. There are a whole lot of ways to get exercise rather than spending 10 billion out of the federal government.”

Coburn did endorse some new care delivery models, such as medical homes, that can enhance preventive care and coordination. And he said Medicare, even in the current fee-for-service context, could do a better job of incentivizing prevention – by paying for it.

“The way you incentivize that is to pay a doctor for a prevention visit,” Coburn said. “Medicare pays for some preventive care and screening, and that was expanded under health reform. But it’s virtually impossible for a physician to be paid under Medicare for a good, long talk with a patient on ways to exercise and stay healthy,” Coburn said.

“You can’t get paid for that today,” he said. “There’s got to be a disease you are treating rather than a disease you are preventing to be paid by Medicare. That’s stupid.”

Koh maintained that prevention, writ large, is a major theme for the administration.  The long public health campaign against tobacco, he noted, while not complete, had certainly changed behaviors and saved lives –and money.  “I believe we ignore prevention at our peril. Ignoring prevention is penny-wise and pound foolish,” he said. The country spends $2.5 trillion a year on health. Much of that – heart disease, obesity-related illnesses, tobacco – could be avoided. We can save lives, we can prevent suffering and in a number of cases we can save money too,” he said.

Koh acknowledged that spending on “public health” can be a tough sell in times of austerity, because the returns aren’t always immediate. Indeed, they can be decades away. But sometimes the investments pay off far more quickly than people would imagine. Medicaid in his home state of Massachusetts, for instance, for the past few years has covered smoking cessation counseling, and it started paying off in a couple of years.

Washington politics isn’t the only barrier to change, he said. People’s understanding of public health – and how and why recommendations evolve with the science and evidence – is also problematic, as the recent outcry and confusion over mammograms and PSA tests have made all too clear.

People can understand, say, a new drug or treatment. They don’t necessarily understand that the science of prevention evolves too. Koh called for a more attention to – and research about — health literacy and communication.

He was also optimistic about physicians’ growing understanding of how broken the system is, and the opportunities that health reform offers to begin to fix it, to take better care of their patients, to help them live healthier lives.

And he strongly argued that prevention and public health, while a matter of personal responsibility, is also a matter of collective responsibility. “It has been said that the government is the only part of society that has to care for all people all the time. I would like to think that regardless of your political view on life, we all treasure the gift of health. It is a gift. It is so precious, it is so fragile, you have it today but you cannot assume you are going to have it tomorrow. It has to be protected.”

Joanne Kenen writes monthly news features about health policy innovation and what works in our health care system, as well as the politics of health policy and reform for the Altarum Health Policy Forum where this post first appeared.

11 replies »

  1. Even as a small business, we are finding that we are able to have significant impact in assisting Americans with the healthcare problems they are facing today. We do this through our business, of course, but also through volunteering our time to help those in need and through our employment policies.

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  2. Thank you for the literature, Rose, I appreciate it. It motivated me to look around a little bit myself, and I have to say, Rose, that your selection is a little biased, and the quality of the available evidence is not great to begin with (systemic review: Interventions for promoting physical activity.AUHillsdon M, Foster C, Thorogood MSOCochrane Database Syst Rev. 2005; another review found small benefits:
    Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force.AULin JS, O’Connor E, Whitlock EP, Beil TLSOAnn Intern Med. 2010;153(11):736.

    Even if there was a proven effect of counseling (the magnitude of which appears to be rather modest based on available studies), it would not change my opinion stated above, however: if one intervention helps (counseling), it does not prove that another intervention (e.g. financial incentives) could not be helpful (or even more beneficial) as well, alone or in adiition.
    Make unhealthy lifestyles more expensive, and these lifestyles will become less prevalent (that’s PART of what we did with smoking, and as a side note in an unrelated field, miles driven in the US negatively correlate with gas prices).

    I think we should have a good sized randomized trial (e.g. based on Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation 2010; 122:406). Note that as per the literature, effective counseling is done by nurses, NPs, nutritionists with special training, NOT by PCPs. IMHO, PCPs should be asked to support the intervention and refer to a trained professional, but not just paid for what they deem is counseling.

  3. Agree, mostly. Except that counseling the healthy is difficult to do and unlikely to happen if the expectation is that the physician will do the counseling. Are you really going to come in for your “lifestyle assessment and counseling visit”? Yes we can and do provide some of this with the annual physical, but I don’t think there is going to be much interest in expanding this visit in a way that would meaningfully provide the type of counseling that would have a positive effect on the population. If we had some sort of program for universal patient education in the office setting it would most likely be done by a nurse or other educational support staff. The key would be not in funding the physician, but in reforming the payment constraints so that in-office education was reimbursed.
    The physician will continue to provide lifestyle advice for those who are experiencing detrimental effects on their health from their poor lifestyle choices. Funding this separately is not necessary as we already have a mechanism for being paid for counseling in this situation (time based coding of visits – 99213 = 15min, 99214 = 25min, etc.)

  4. ^^ What he said. My kids spent 7 hours at school each day and learned squat. All their learning seemed to come in the 3 hours of homework that we helped them with each night. At least having the kids exercise at school would be something useful. Of course then I’ll get appointments every day with kids and their parents asking me to write excuses from PE.

    If you have ever traveled outside our country you know that most places eat better than we do. We use the wrong standard when approving all the various chemicals as ‘food’ and therefore safe. The standard should include consideration of its overall impact on health.

  5. In response to rbaer’s first comment, there have been many studies done to show the efficacy of primary care providers counseling patients regarding lifestyle changes. For example:
    Most of these studies show a significant increase in physical activity in response to PCP counseling regarding the benefits of exercise. I believe there is a simple, non-threatening approach to discussing lifestyle changes that will not intimidate most patients. The ACP published a paper that discusses the barriers health care providers have to implementing measures such as counseling, including the fear of offending patients (Improving Prevention is Difficult).
    However, in Evaluating Primary Care Behavioral Counseling Interventions, the USPSTF points out that patients actually expect to receive counseling regarding lifestyle changes.
    I agree with Jenna in that medicine and politics do make a messy combination. I believe the solution lies in changing the attitudes of health care providers as well as the cultural beliefs. However, I also believe many of the US population are ready to hear the message of prevention. Shows such as Dr. Oz as well as numerous popular magazines carrying special health sections illustrate the fact that many Americans do care and do want to be informed.

  6. Providers don’t make money from prevention, duh. Free gym memberships won’t get people away from the TV or their computer screens and Big Macs. Best would be to bring back gym class to schools, at least that would give kids a start on exercise, but taxpayers would have to want to fund that – doubtful. Also stop subsidizing crap food through corn subsidies and taxing high cal/sugar foods – politically impossible. With congress bought and paid for by Corporate America don’t expect sea change of direction. Crisis to crisis mismanagement is the only way this country may move forward.

  7. Medicine and politics make a messy combination. There’s a new film set to come out called Puncture, and it brought to my attention the trouble politics propose in the medical system as well. I love that it’s at least loosely based on a true story. It seems like it is going to be really fast paced. For the medicine world, this seems like a story that needs to be told, http://www.facebook.com/PunctureFilm.

  8. Most speeding drivers are not caught. The US will be better able to compete when it wakes up and stops buying healthcare for people, all people.

  9. I mostly disagree. That’s exactly the type of issue where society as a whole (and government in particular) needs to rise to the challenge. If you want to put in in competitive terms: the US will not be able to compete if the already exorbitant health costs rise further due to the obesity epidemic (not to mention the associated human suffering).
    I agree that many progressives disregard/marginalize the issue of individual responsibility (by talking about food deserts, difficulty exercising, cost of healthy food etc., all valid points). One simply should adress these issues – by policy – and also incentivize via the estimated costs of a few major poor lifestyle choices: (negatively incentivize or spinning it, positively incentivize the opposite of) obesity, sedentary lifestyle, smoking, significant noncompliance with important treatable conditions such as diabetes, hypertension. It’s would be the equivalent of drivers with speeding tickets paying more for car insurance.

  10. “Prevention” is by definition an action that precedes medical action. It is not the same as “early detection”. It is not the same as “risk modification”. It is not screening. It is not presently funded by anyone except the consumer.

    If you want to cut down on obesity, then quit giving food away. Make it expensive.

    Health literacy and communication are not going to change behavior. We have had a generation of say “no” to drugs and we have more drugs than ever.

    You are dealing with people who make choices. If they choose, they should pay for the consequences. If the government is paying for the consequences, it is because government have overreached its proper place. Government does not get to make consumer choices.

    Why don’t we prevent government from defining the debate?

  11. “But it’s virtually impossible for a physician to be paid under Medicare for a good, long talk with a patient on ways to exercise and stay healthy”

    A good randomized study is needed about the benefit of these talks. Most people are aware of the main issues: exercising, being close to normal weight, avoiding excessive sugar loads, no smoking, control of hypertension. A lot of people become defensive even before the topic comes up in the doctor’s office, and feel judged even when the provider tries to be nonjudgmental.

    What the US needs is a cultural shift. We currently have a culture focussed on both unhinged consumption and mindless eating and also on not always realistic ideals of underweight beauty. Unfortunately, other than gyms and makers of exercise equipment, not much money can be made from a healthy lifestyle (except supplements, vitamins, but they don’t help).

    The epidemic of type2 diabetes (and subsequently of degen. arthritis, CAD, nephropathy) is a slow growing, but major threat to US society. Too bad that there is not a critical mass of leaders being aware of the problem.