March 10, 2005

The Honorable Bill Frist, MD
Senate Majority Leader
509 Hart Senate Office Building
Washington, DC 20510 

Dear Senator Frist,

This letter is in response to your lecture entitled “Health Care in the 21^st Century” that appeared in the January 20, 2005, issue of the New England Journal of Medicine. The American College of Preventive Medicine (ACPM), the professional society for physicians who specialize in disease prevention and health promotion, agrees that the rapidly rising health care costs, reduced access to care, large quality gaps, health disparities among different segments of the population, inefficiencies, and medical errors currently hobbling our health care system are unacceptable.  We commend you for your forward-thinking solutions to these problems, particularly your proposed transition to a fully electronic, universal health information system and more rapid translation of biomedical research into clinical practice.  However, we find that your proposal neglects the critical need to prevent chronic disease before it occurs.

The hypothetical Rodney Rogers, with his multiple chronic illnesses and behavioral risk factors, is indeed representative of the patients for whom the 21^st-century American health care system must be equipped to care.  As rates of obesity, overweight, and type II diabetes climb, our health care system is struggling and, as you point out, largely failing to meet the needs of a growing chronically ill population. 

ACPM agrees that today’s health care system “cannot meet the needs of 21^st-century America without a true transformation.” It is true that wide-scale electronic health information systems and other biotechnologies have great potential to improve quality, efficiency, and safety, but this will not be enough to cope with the tremendous amount of morbidity resulting from chronic disease.

Obesity is a case in point.  Health care costs directly attributable to obesity amounted to $75 billion in 2003,¹ while direct and indirect costs combined have been estimated at $117 billion.² The obesity epidemic in this country shows no signs of slowing, and the staggering health care costs associated with it are bound to outstrip our system’s ability to pay, even if we are able to make the changes you describe.  Why not shift our focus to prevention research and intervention to reduce this growing burden on the health care system?

Our health care system has been aptly characterized as a “sick care” system.³ Ninety-five percent of health care dollars are spent on disease care, while less than 5% go to prevention.⁴ The deficiency in preventive care allows many thousands of cases of preventable illness to occur or progress each year, further increasing the demand for “sick care,” which in turn drains more of our health care resources and increases costs.

New and improved medical and information technologies can help, but they also drive up the cost of care.⁵ In order to pay for universal implementation of new technologies in the health care system, we must reduce demand for care by preventing or delaying the onset of chronic disease.

ACPM agrees with your call for increased personal responsibility for preventing disease by changing unhealthy behaviors.  But changing the behavior of millions of people also depends on increased community, corporate, and government responsibility.³ We will need to educate the public about the benefits of healthful behaviors, teach and model those behaviors in our communities, help people to change detrimental behaviors, and promote a healthy lifestyle through social marketing, public policy, and socially responsible commercial products and practices.  Such a comprehensive approach will require some specific policy actions:

• Strengthen the preventive medicine/public health workforce by training more preventive medicine specialists and other public health professionals.

• Fully reimburse (through Medicare and other federal programs) all evidence-based preventive services recommended by the U.S. Preventive Services Task Force.

• Increase funding for effective population-based health programs, such as those recommended by the Task Force on Community Preventive Services.

Our health care system clearly needs renovation, but in order to reach the level of sophistication, quality, accessibility, and affordability you envision, we must shift our focus from crisis care to prevention.  ACPM would be delighted to meet with you to discuss strategies for preparing our health care system to provide the highest quality chronic disease care to people like Rodney Rogers, while ensuring that vastly fewer Americans will ever need that care.

Sincerely,

Neal D. Kohatsu, MD, MPH, FACPM
President

Sources

1.      Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obesity Research. 2004;12(1):18-24.

2.      U.S. Department of Health and Human Services. The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.

3.      U.S. Senator Tom Harkin. Speech at the Annual Meeting of the American College of Preventive Medicine, Washington, D.C., 2/17/2005.

4.      Julie Gerberding, Director of the Center for Disease Control and Prevention. “The State of CDC.” Speech at National Press Club, Washington, D.C., 2/14/2005.

5.      Ginsburg PB. Controlling Health Care Costs. NEJM. 2004;351(16):1591-3.