|President's Column 9/3/09|
CAN PREVENTIVE MEDICINE SAVE THE AMERICAN HEALTH SYSTEM?
By Mark B. Johnson, MD, MPH, FACPM - ACPM President
"There is no such thing as bad publicity except for your own obituary." Brendan Behan
Preventive medicine has probably received more media attention and press over the past year than at any other time in history. According to Brendan Behan, this should be a good thing, and for the most part, it has been. Much of the press has been about the great future that preventive medicine will have in helping save the American health care system.
A lot of this attention began during the presidential campaign in 2008. The New England Journal of Medicine summarized it this way, "The first element in Hillary Clinton's plan is to 'focus on prevention: wellness not sickness.' John Edwards has stated that 'study after study shows that primary and preventive care greatly reduces future health care costs, as well as increasing patients' health.' Mike Huckabee has said that a focus on prevention 'would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.' Barack Obama has argued that 'too little is spent on prevention and public health.'"1
Lately, however, much of the press has been skeptical or downright negative. On behalf of ACPM, the staff and I have responded to articles in the national press with titles such as, "Preventive medicine doesn't work," "An ounce of prevention is no cost-saving cure," and "Preventive medicine does not reduce costs." We haven't had time to address many of the others, such as, "Can we please stop pretending that preventive medicine saves money?" and "Prevention will reduce medical costs: A persistent myth." Unfortunately, it seems that in the minds of the nation's politicians and pundits preventive medicine's value rests solely on whether or not it can bring the runaway spending of American health care under control. It is also unfortunate that the debate surrounding preventive medicine seems to have become more and more ideological and partisan.
The general public, however, continues to strongly support preventive medicine, regardless of party affiliation. Earlier this year, a national survey funded by the Robert Wood Johnson Foundation and the Trust for America's Health revealed that 76% of American voters believe the level of funding for prevention should be increased, and this support was not partisan - 86% of Democrats, 71% of Republicans, and 70% of independents supported more investment in prevention. This wasn't just because they thought it would save money. An overwhelming 72% agreed that "investing in prevention is worth it even if it doesn't save money, because it will prevent disease and save lives."2
Many businesses, organizations and worker's unions also have strong support for prevention and believe it has more than just economic advantages. Examples include AmeriGas Propane, Inc., who last year gave all of their employees an ultimatum: get prevention-oriented physical exams, including blood-pressure checks, cholesterol and blood sugar tests, and where appropriate, Pap smears and mammograms, or lose your health insurance.3 The Senior Vice President for Human Resources of IBM Corporation testified before Congress that IBM had enhanced their focus on wellness, prevention and primary care, and that their health plan enrollees receive deductible-free coverage for preventive services. He encouraged Congress to adopt a comprehensive national health reform agenda that included significantly improved wellness, prevention and primary care coverage.4 A coalition of more than fifty organizations and unions addressed Congress with a letter that began, "On behalf of the undersigned organizations, we want to express our support for health care reform proposals designed to improve access to preventive services and encourage healthy lifestyles. We support positive incentives to encourage individuals to be actively engaged in their health care, pursue recommended screenings and preventive services, and maintain or improve their health through physical activity, healthful diets, good nutrition, smoking cessation, and other healthy behaviors."5
Some of the claims used against preventive medicine are obviously straw man arguments, such as the assertions that widespread screening programs, with their subsequent follow-ups for false positives and complications, are much more expensive than it would be to treat the few real positive cases if we just let them go ahead and get sick. The admitted high costs of screening are directly related to the indiscriminate use of these tests. This is why prevention guidelines universally recommend targeted screening programs for at risk individuals. Another common claim is one that uses an example such as a smoker who quits and then requires hundreds of thousands of dollars more in lifetime health care costs than the unrepentant smoker who died years sooner because of his habit. Taking this argument to its illogical conclusion, the best way to get cost savings in health care reform would be to abort every pregnancy. This would remove an entire lifetime of health care costs. If memory serves me, two former Eastern Bloc countries actually used this type of logic in their social policies - one by encouraging abortions, and one by encouraging smoking.
The American College of Preventive Medicine is actively involved in the health care reform debate that is occurring in Washington, DC. We are strongly encouraging Congress and the Administration to include incentives for healthy lifestyle behaviors and adequate coverage for evidence-based wellness programs and clinical and community preventive services in any legislation that moves forward with health care reform. In our advocacy, I believe we need to shift the attention from cost alone, and concentrate on four fundamental principles that are at the foundation of preventive medicine:
1. Preventive medicine is the humane choice. It is unquestionably better for individuals to be healthy than it is for them to be sick. While large components of individual health may be outside of anyone's control, healthy lifestyle choices and preventive medicine services consistently elicit forces that push individuals toward the healthy end of the health continuum, and away from illness, disability and death.
2. Preventive medicine encourages healthy lifestyles. Much of the work of preventive medicine is educational and extra-clinical. The major causes of death and increased health care costs in this country are related to individual behaviors. Promoting good health and avoiding disease involves being physically active, eating a wholesome diet, managing one's weight, not smoking, drinking alcohol in moderation, driving safely, managing stress, getting adequate sleep, and being appropriately immunized. This is the true meaning of primary prevention, and the acquisition of these behaviors requires education and reinforcement, but very little time spent in a clinical setting.
3. Preventive medicine maintains health. As Dr. Ernst Wynder allegedly said, "It should be the function of medicine to help people die young as late in life as possible."6 Clinical and community preventive medical services play fundamental roles in the phenomenon Dr. James Fries defined as "the compression of morbidity." His hypothesis, which has subsequently been shown to accurately describe current trends in the U.S., was that age at the time of initial disability will increase more than the gain in longevity, resulting in fewer years of disability and a lower level of cumulative lifetime disability. This leads toward the social ideal of "a long, vigorous life culminating.with a sudden terminal collapse; vitality until the end, and death coming without fear or fury at the natural end of the individual life span."7
4. And, yes, preventive medicine is indeed cost-effective. We must be honest, and admit that not all preventive services save money, and that preventive medicine cannot single-handedly save the American health care system. But, instead of trying to justify preventive medical services by their ability to lower overall health care costs, we must insist that they be evaluated by whether or not they provide high value for their cost (i.e., are they cost-effective when analyzed by their cost per quality-adjusted life year (QALY)?). It is true that some clinical preventive services, including childhood immunizations, smoking cessation and aspirin use by patients at risk for cardiovascular disease, do indeed offer net savings, but no other medical treatments are unilaterally judged to have "worked" only if they save money. The value of all medical services, preventive and otherwise, should be determined by how much they improve the health of the public for a given cost. When held to this standard, most preventive services, including both clinical and community preventive interventions rank very well.
1 Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. NEJM 2008;358:661-3
3Mathews AW. When all else fails: Forcing workers into health habits. The Wall Street Journal, July 12, 2009. (Accessed August 31, 2009 at http://online.wsj.com/article/SB10001424052970203577304574274102603258642.html)
4MacDonald JR. Health reform in the 21st century: An agenda for mutual responsibility. Testimony before the Committee on Ways and Means, April 29th 2009. (Accessed August 30, 2009 at http://www.allhealth.org/briefingmaterials/RandyMacDonaldIBMTestimonyFinal-1503.pdf)
5 (Accessed August 30, 2009 at http://www.allhealth.org/briefingmaterials/healthybehaviors_3_-1504.pdf)
6This quotation is ubiquitous and attributed to Dr. Ernst Wynder. However, I cannot find the original source and would appreciate it if anyone can forward it to me!
7Fries JF. The compression of morbidity. The Milbank Quarterly 2005;83:801-23