Government Affairs Official
How should the national health care reform plan address preventive healthcare? In an informative, passionate interview conducted Oct. 13, 2009, a high-ranking state government official, who currently does not hold elected office and asked to remain anonymous, shared his views:
Q. How do you define preventive healthcare? How significant is an individuals quality of life from the healthcare delivery perspective in relation to prevention?
A. Preventive medicine, or preventive care, refers to measures taken to prevent diseases (or injuries), rather than curing them. It can be contrasted not only with curative medicine, but also with public health methods (which work at the level of population health rather than individual health). This can take place at primary, secondary, and tertiary prevention levels. Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and the emergence of symptoms.
Simple examples of preventive medicine include handwashing and immunizations. Preventive care may include examinations and screening tests tailored to an individuals age, health, and family history. For example, a person with a family history of certain cancers or other diseases would begin screening at an earlier age and/or more frequently than those with no family history. By focusing on prevention, we can have a major impact on peoples health. Think about the great strides we have made over the last decade in reducing the death rates from cardiovascular disease mainly because so many people have made positive behavior and lifestyle changes. More exercise [and] reduced smoking are due largely to the publics increased awareness of how these risk factors can affect the quality of [peoples] health. This is why its important for the medical profession, public health practitioners, community leaders, and policymakers to advocate prevention strategies.
Q. Who should be responsible for preventive healthcare and what specific role should the government play?
A. Basic preventive healthcare services should be an integral part of an equitable, comprehensive healthcare plan. Given that many conditions are preventable, every healthcare interaction should include prevention support. When patients are provided with information and skills to reduce their health risks, they are more likely to reduce substance abuse, stop using tobacco, practice safe sex, eat healthy foods, and engage in physical activity. By reducing these behaviors, we can dramatically reduce the long-term burden and are demands of chronic conditions. To promote prevention in healthcare, raising awareness is crucial to promoting a change in thinking and stimulating the commitment and action of patients and families, healthcare teams, communities, and policymakers. A collaborative management approach at the primary healthcare level with patients, their families, and other healthcare actors is a must to effectively prevent many major contributors to the burden of disease.
Q. How will preventive healthcare improve the quality of health and decrease the cost of care?
A. Again, preventive healthcare can improve the quality of health, but I am not sure it will decrease the cost of care. President Obama stated in one of his town hall meetings in New Hampshire that prevention has an amazing dual purpose. It saves lives. It also saves money. Democratic leaders like Nancy Pelosi also believe the Presidents claim. Reform proponents repeat this like a mantra. Because it seems so intuitive, it has become conventional wisdom but it is wrong.
I believe overall preventive care will increase medical costs. Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness. I know what you are thinking: How can this be? If you prevent someone from having a heart attack, arent you necessarily saving money? The fallacy here is confusing the individual with society. For the individual, catching something early generally reduces later spending for that condition. But we do not know in advance which patients are going to develop costly illnesses. To avert one case, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. This costs society money that would not have been spent otherwise. Think of it this way: Assume that a screening test for disease X costs $500 and finding it early averts $10,000 of costly treatments at a later stage. Are you saving money? If one in 10 of those who are screened tests positive, society saves $5,000. But if only one in 100 would get that disease, society is shelling out $40,000 more than it would without preventive care. I am not saying we shouldnt prevent illness; of course we should. But in medicine, as in life, there is no free lunch. The idea that prevention is somehow intrinsically economically different from treatment and that treatment increases costs and prevention lowers them is simply nonsense. Prevention is a great thing, but in the aggregate it costs society money. There is nothing wrong with that. Thats the whole premise of medicine. Treating people with heart conditions or setting broken legs also costs society money. But we do it because it alleviates human suffering. Prevention is not the magic bullet for healthcare costs.
Q. Who are the major players in the U.S., and what are the positive and negative affects they may have on preventive healthcare?
A. Major players in healthcare, from the drug companies to the insurance providers to hospitals and doctors, have joined President Obama to commit to serious reform. Some of the organizations that have fought hardest against changing the system in the past are, for now at least, saying they’ll work for it this time around. To demonstrate how serious they are, they joined the President to say theyll work voluntarily to cut the growth rate of healthcare costs by 1.5 percent each year for the next decade. Unchecked, costs would increase by more than 6 percent a year, so the administration says the countrys private employers and the government combined would save $2 trillion from the effort. An average family of four could save $2,500 a year within five years. But the problem is the administration admitted theres no way to force the groups to do what they say theyll do. The proposal from the healthcare players is light on specifics, but it is fairly heavy on symbolism; getting everyone from the Service Employees International Union to Pharmaceutical Research and Manufacturers of America on the same page before the serious debates on healthcare legislation began means the White House has the political momentum, and opponents of reform dont.
Among the groups involved is Americas Health Insurance Plans, a lobbying group for insurers and a successor to the organization that ran the Harry and Louise ads that helped kill former President Bill Clintons healthcare reform push in the 1990s. Doctors, represented by the American Medical Association, are on board, even though proposals to tie insurance payments for services to the effectiveness and efficiency of the care involved has many physicians anxious. Medical device makers, hospitals, and unions are all major players in the United States.
Some of the savings could come from implementing common billing practices and insurance claim forms, from reducing unnecessary but expensive tests and procedures, from improving electronic medical records to better coordination of care, and other back-end steps. But another part of the push will involve more preventive care, hoping to keep people healthy rather than treating them when they get sick, evaluating current practices, and phasing out treatments that dont work. Those could prove more difficult to put in place.
Q. What are the main social, economic, and cultural factors in American society that pose barriers to preventive healthcare?
A. Health disparities are not just limited to minority populations; they also exist between many other types of populations, such as rural versus urban populations or uninsured versus insured populations. This is an interesting topic for me given my past job [as a government official]. I learned a lot about mens masculinity beliefs as a barrier to preventive healthcare. My staff educated me on studies that showed that middle-aged men who strongly idealize masculinity are less likely than other men to seek preventive healthcare services. I am well educated on the socio-economic and cultural impediments to well-being along the Mexican border. The cultural infrastructure of the region and the political force of this association contribute to the development of the economies and to the outcomes of public health programs and initiatives on each side of the border. Lack of language skills, inadequate education, and a poor understanding of values are not the principle impediments to well-being. Instead, political agendas and a non-global commitment to healthcare are the causes for such discrepancies. The main barrier to preventive care that I am aware of is the perception that health services are not needed; the other barrier is the inability to pay.
Success in the public health arena has translated into aging populations. Increasingly, people live for decades with one or more chronic conditions, placing new, long-term demands on healthcare systems. Not only are chronic conditions projected to be the leading cause of disability throughout the world by the year 2020, if they are successfully prevented and managed, they will become the most expensive problems faced by our healthcare systems.
In their 2001 book, Delivering Healthcare in America: A Systems Approach, published by Jones & Bartlett (www.jbpub.com/), researchers Leiyu Shi and Douglas A. Singh, describe a shift in U.S. healthcare systems from inpatient care to outpatient care and from illness to preventive. Many costly and disabling conditions, such as cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, are linked by common preventative risk factors. Tobacco use; prolonged, unhealthy nutrition; physical inactivity; and excessive alcohol use represent major causes and risk factors for these conditions. Many diseases can be prevented, yet healthcare systems do not make the best use of their available resources to support this process. All too often, healthcare workers fail to seize patient interactions as opportunities to inform patients about health promotion and disease prevention strategies.
Many diseases can be prevented, yet healthcare systems do not make the best use of their available resources to support this process. Most current healthcare systems are based on responding to acute problems, urgent needs of patients, and pressing concerns. Testing, diagnosing, relieving symptoms, and expecting a cure are hallmarks of contemporary healthcare. While these functions are appropriate for acute and episodic health problems, a notable disparity occurs when applying this model of care to the prevention and management of chronic conditions. Preventive healthcare is inherently different from healthcare for acute problems; and in this regard, current healthcare systems worldwide fall remarkably short. Given that many conditions are preventable, every healthcare interaction should include prevention support. When patients are systematically provided with information and skills to reduce their health risks, they are more likely to reduce high-risk behaviors.
Real healthcare reform involves everyone. It is about providing access, coverage, quality care, and payment for services that support people in healthy lifestyles, as well as addressing acute and chronic health conditions. It is about establishing a system that treats people with dignity and worth. It is about moving this society toward generosity, inclusion, justice, and mutual care.
Healthcare reform would provide comprehensive care based on the needs and choices of the individual and offer coverage and payment to meet wide-ranging service and support needs. The mutual engagement of individuals, the business sector, government at many levels, those providing and funding healthcare, the faith community, and a whole host of other organizations will be required to achieve success. Consequently, approaches should be affordable and sustainable for all partners over the long term.
Reform requires adequate, integrated, and well-trained provider capacity that is appropriately funded and positioned to provide quality care. Providers and participants require adequate and appropriate infrastructure to effectively and efficiently achieve a partnership in delivering and receiving quality care. Healthcare reform yields quality for all people as the cornerstone of the system. As healthcare reform moves forward in the U.S., preventive care will become a topic of great interest and importance.
Shi, L. & Singh, D. A. (2008). Delivering health care in America: A systems approach (4th ed.). Sudbury, MA: Jones and Bartlett.
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