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Wednesday, March 6, 2013

The case for prevention: saving more dollars by making more sense

Since an iron lung costs quite a few dollars, the prevention of polio cannot make sense. Right? If that one has you scratching your head, with a "say what?" dangling from your lip, we are on the same page. Let's populate it accordingly. Of course prevention can save dollars. But that will only be the case when what we refer to as "prevention" really makes sense.

Prevention enthusiasts, and I certainly do count myself among them, have long contended that preventive medicine has the potential to add years to life, add life to years, and save a lot of money into the bargain. Members of the other side, let's call them the dubious, because no one is really a prevention "detractor," have argued that the former points may be true, but the last is not.

Prevention, especially in the form of clinical preventive services such as cancer screening, costs money. And since part of the preventive medicine imperative is to find and fix disease early, prevention encourages healthy people to undergo medical testing to identify problems no one knew they had. Suddenly there is expense where there would have been none.

This case, and variations on it, has been made many times, including very recently in Reuters. The Reuters article, which some of my colleagues have already confronted, cites a recent report by the Trust for America's Health on transitioning the U.S. system from "sick care" to genuine "health" care, and a paper published in 2010 in the peer-reviewed journal Health Affairs. The analysis in Health Affairs suggests that widespread use of preventive services could help us all save 0.2% of personal health spending in the U.S.

The folks at Trust for America's Health, clearly prevention proponents, seem a bit more sanguine about the potential savings involved. The reporter at Reuters, however, apparently something of a nihilist, throws the "annual physical" into the prevention mix, noting that collectively these exams cost a lot of money and do little if any good.

However, as a board-certified specialist in preventive medicine, and co-author now of four editions of a textbook on the topic, I must protest! There is no formal recommendation for annual physicals by our college, and we know they are not cost-effective. Everybody knows. They are simply a holdover from the long traditions of medicine, and a more formal embrace of evidence-based preventive medicine would consign them to history. Many of us have already done so.

But even if we define clinical preventive services more reasonably, we are left with uncertainty and debate about whether prevention saves money. This debate is ostensibly all about dollars, but should be more about sense, namely, the sense we make or forsake when throwing the term "prevention" around. That which we call prevention is not all equally sweet, or cost-effective, let alone cost-beneficial.

Of course prevention as commonly defined doesn't save money. Cancer screening is about saving lives, not money. Trauma surgery doesn't save money, either, for whatever that's worth.

Since prevention is about, well, preventing bad things, then all of medicine might be considered variation on the preventive medicine theme. A construct called Leavell's Levels essentially defines preventive medicine in just such terms, ranging from the promotion of health (primary prevention) to the prevention of dysfunction even after serious chronic disease is established (tertiary prevention).

Risk factors are treated to prevent diseases. Diseases are treated to prevent permanent illness or disability or complications. Calamities are treated to prevent death.

All of this costs money. In contrast, we could do nothing for free. We can die, and let others do so, for free. It would save a lot of money to prevent nothing. Just let come what may.

I trust we all agree there's a problem with this. For one thing, we value life more than money (I hope!). For another, there is, in fact, a financial impact when we check out. We are no longer here to do any work, or provide for our families. We leave a hole in the economy.

There is, in particular, a gaping economic hole if we check out slowly rather than fast. If we are sick for a long while before dying, and that, by definition, is what "chronic disease" is all about, and chronic disease is overwhelmingly the primary exit route for those of us in modern society, then we work less, or not at all, long before dying. We become less productive, costing the same or more, contributing ever less. Among my friends and colleagues are world-class health economists, and even they have difficulty getting their heads around all of these so-called "externalities," and the extent to which they alter the pecuniary assessment of prevention.

But, of course, treating chronic illness is a very imperfect solution to this problem. The issues of illness and impaired function invariably persist, if to a lesser degree, with treatment. The costs of disability attached to chronic diseases are then compounded by the costs of chronic treatment. And, in fact, the better we get at preventing death despite chronic disease, cancer, cardiovascular disease, diabetes and its complications, dementia, respiratory diseases, stroke, and so on, the longer that period of poor health and high cost.

There are lesser and greater problems, however, with this constrained and unflattering view of prevention.

The lesser problem is the often-overlooked financial benefit of so-called "health care" to the economy at large. We make a big fuss about how much disease care costs our economy. But it also contributes, and mightily. Throughout the great recession, one of the few sectors of the economy that never really slowed down, and that consistently offered jobs to those qualified was, yes, indeed, health care. Biomedical research is big business. It costs money but it also creates jobs and, from time to time, breakthroughs.

Pharmaceutical companies, health care companies, and pharmacies populate the Fortune 100, and the Dow Jones Industrial Average. They are engines of the economy. Hospitals, clinics, medical practices, and device companies all make their contributions as well. Consider what would happen to the economy if all of these jobs went away.

Frankly, it's well above my pay grade to figure out whether our disease care system is more good than bad, or vice versa, for the economy overall. A lot of money goes into it, yes. But that is money in circulation, being spent, and spent again. Like all money changing hands, it means jobs, purchases, and tax revenue. These are the building blocks of economic vitality. If all of this is bad because of the money changing hands, then wouldn't it be better to "save" all the money we spend on housing as well, and live in caves? Wouldn't it be better to save all the money we spend on education?

So, the reality is this: Yes, we spend way too much on disease care. But probably not because of the financial costs, per se. But rather, because those financial costs represent human costs: years lost from life, life lost from years. Jobs not done. Families undone.

Which, of course, reframes the whole concept of prevention and costs. It's not about saving money. It's about saving lives. And once that's clear, then it becomes relevant to ask: What's the best we can do for lives? And what is the most cost-effective way to do it?

That, largely, has been the defense of prevention, and it is a good one. But as noted several paragraphs above, this is all about the lesser problem. The greater problem has to do with what we mean by "prevention" in the first place.

The iron lung, with which this jeremiad began, is a costly half-measure. It's a form of prevention, yes; it prevents death in the early stages of poliomyelitis. But it's not nearly as good as preventing polio outright, which of course is now the global norm, courtesy of immunization. Once polio is eradicated, assuming we can get there, its prevention becomes permanent and free. Were we to look at the iron lung and renounce further prevention efforts as financial folly, no such progress could occur.

Similarly, dialysis is expensive; preventing end-stage kidney disease brought on by hypertension or diabetes, or, better still, preventing hypertension and diabetes in the first place, is dramatically less so. Coronary bypass surgery is expensive; preventing coronary disease in the first place can be dramatically less so. Bariatric surgery and potential alternatives cost money, while avoiding that weight gain in the first place could be free.

And, similarly, screening for cancer in a population that gets it often enough to warrant screening is a fairly expensive half-measure. Better than nothing, certainly; but not nearly as good as going all the way. What would going all the way look like? Preventing so much cancer outright that screening for it is no longer warranted.

Is that possible? Almost certainly, yes. Studies (1, 2, 3, 4, and so on) spanning decades consistently indicate that fully 80 percent or more of all chronic disease, including cancer, can be eliminated outright with knowledge already at our disposal. Not treated more effectively. Not managed. Eliminated.

The method? Good use of feet, forks, and fingers. Being active, eating well, and not smoking. Lifestyle as medicine. That's it.

We can avoid tobacco for free. We can be active for free, although we can also spend money on it if so inclined. And we have to eat one way or another. We can eat better without spending more money than we already do.

If we got down to the bedrock of true prevention, lifestyle as preventive medicine, we could add years to life, add life to years, and save a whole lot of money by putting to use the science and sense long at our disposal. Doing so will, of course, require changes in how we think about health, changes in our culture. But culture is what we make it, and we can change it for free.

Which brings us to the bottom line, figuratively and literally. We have the science we need to eliminate outright most of what ails us. Prevention could save us a whole lot of dollars if, when we used the term, we made a bit more sense.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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