January 10, 2006
Prevention…the forgotten lever.
One of the most difficult things to do is to prove that something that would have happened in fact never happened because of an intervention you did.
Proving the negative with a positive. It requires a leap of faith.
And it's even more difficult when the intervention you do is human behavior change. For the better. For their own benefit.
But what if changing behavior is difficult to do and the benefit is delayed? Really difficult. Think diet modification or smoking cessation here.
In the debate about rising healthcare costs, prevention is usually not discussed much since it is both difficult to do and requires a leap of faith. And it's not “new”.
But consider some December, 2005 statistics from the Centers for Disease Control and Prevention (CDC) on Americans aged 55-64:
• 50% have hypertension
• 40% are obese
• only 30% are physically active during leisure hours.
This is the chronic disease pipeline—heart disease, stroke, diabetes. And that pipeline leads all the way back to the rising prevalence of obesity in childhood.
Kenneth Thorpe, Jr. writing in the November-December, 2005 issue of Health Affairs suggests that rising health care spending will not abate by financial restructuring or rationing of services or restricting access to care or by treating more chronic illness.
He posits that health care spending increases will not abate until prevention is entertained in a serious and pervasive and successful way.
Finance and delivery reforms are not enough. They will not be effective until we have prevention. It makes sense. Less disease leads to less treatment which leads to less cost. Incentives on the demand side, that is “over-using” medical interventions, will by themselves not lead to the desired results. Again, makes sense.
His article entitled, “The Rise in Healthcare Spending and What to do About It” gives the answer in the subtitle: “Disease prevention/health promotion approaches are key to slowing the rise in healthcare spending.”
As one who cut his health prevention teeth on smoking cessation and who predicted in the 1980's that obesity would be the next huge challenge, I have always thought this hypothesis makes intuitive sense. It sure has been hard to prove consistently and in a manner that is compelling to employers, the government and third party purchases, much less to the individuals who have to do the changing.
Thorpe points out that much of the growth in healthcare spending in the past 20 years is linked to modifiable populations risk factors such as obesity and stress. Rising disease prevalence like those listed above—heart disease, obesity, hypertension, diabetes—and new medical treatments for these chronic conditions account for about two-thirds of the rise in spending.
Obesity per se impacts healthcare spending because of increased prevalence of disease and increased healthcare spending per capita for obese individuals. Many of the obesity-associated conditions and risks are treated earlier, that is, at a lower threshold, and the available menu of treatments is expanding. Innovative new treatments are available increasingly rapidly and contribute to rising costs.
Bottom line, less obesity, less costs. Health savings accounts will not accomplish this by themselves.
What solutions are recommended by Thorpe:
- Slow and reverse the growth in prevalence of obesity
- Diet modification and increased physical activity
- Attention to stress management
- Home, school, workplace, community-based programs—i.e., comprehensive, integrated, and pervasive approaches
- Decrease medical treatment “at the margin”—that which is high cost, low benefit
- Financial incentives for program development
- Financial incentives for participation and successful behavior modification
- Continued development and distribution of Health Savings Accounts and other “demand-side” control approaches
Basically this is a big simple idea. Simple but not easy to do until we understand how to more effectively control and diminish the prevalence of obesity. Much of Big Pharma is pursuing this big prize—better living through chemistry. A pill for a paunch, I always say. Well, whatever works, I guess. Eating less and better and exercising more might be a good idea too.
This is a long article that says: if we have fewer risk factors then we would have less disease associated with that risk factor. And if we have less disease then we would have less treatment for that disease. And if we had less treatment then we would have less cost associated with that treatment.
I love logic. But I'm all for this one. It makes sense.
Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.
Read other blogs in this series.
