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Commentary: What to do about health care? Spend more on prevention

This article first appeared in the St. Louis Beacon, Oct. 24, 2009 - When I was a young physician in the Navy, a Marine colonel told me, "Where you sit, determines what you see." As the latest round of health reform heats up, and as media ads appear cautioning change or extolling the virtues of aspects of the proposed health reform laws, I again recall his words.

The segments of our enormous health-care system would like us to see the system from where they sit -- and they are investing in getting their message out. We should resist looking at the system from someone else's view. Each of us should look at it from our personal perspectives, weighing what is good for us and what is good for society. Each of us has a responsibility to communicate our views to our legislators.

The important national debate on reform (ongoing for about 90 years and now in its 6th cycle) has brought out the differences in views held by the segments of our increasingly complex $2 trillion health-care system. There are so many moving parts in this modern, marvelous machine: hospitals, managed care plans, physicians, nurses, pharmaceutical manufacturers and other ancillary service providers. Each sector wants to maintain its autonomy and protect its cash flow. But at least this time there is growing consensus that the system should change; unfortunately no one can agree on exactly what should be changed, how it should be changed and who should change it. Ultimately, Congress will make these decisions.

All too slowly we have arrived at the realization that our health system is broken. I think this conclusion has been made possible by a fundamental agreement that the system - taken as a whole - is a poor performer and a poor value.

Value is defined as quality/cost. We have a high-cost and low-quality system. The United States spends more per person on health care than any industrial nation, and yet lags other nations in important health indicators such as how long we live and infant mortality rates. Access to care is not equally or fairly distributed. Uninsurance rates are unacceptably high and exceed 30 percent in the 20-25 year old age group.

Health disparities are all too common and African Americans fare much less well in many comparative population health studies. Nor is the need for health-care services equally distributed in the population; 10 percent of our population uses 60 percent of the resources, and chronic conditions are at epidemic levels.

The media coverage of the reform proposals has focused on insurance exchanges, employer and individual mandates, a public option, subsidies for the poor, guaranteed insurability, taxes, others aspects of health insurance and the funding of health care in general. All these schemes focus on bending the cost curve and rearranging the flow of funds within the medical-care system.

Important issues to be sure. But over the past 100 years, as other countries have done better investing and cultivating their health systems, America has fallen behind. We did not get where we are by taking a single wrong turn.

We are infatuated with science and believe that the rapid adoption of high-tech services will allow us to treat diseases more effectively and more efficiently. Certainly improvements in understanding the pathophysiology of disease, the development of new medications and advances in imaging technology have led to better diagnosis and treatment. But our rush to fund individual medical-care services has caused us to neglect an important process: Population Based Prevention.

Direct medical-care services account for over 98 percent of health care spending. Less than 2 percent is spent on trying to prevent the very diseases we are now treating. In our rush to adopt new treatment, we have failed to use common sense and to make appropriate policy choices that take into consideration the root causes of the chronic diseases our system now spends wildly to treat.

Our national policy consistently undervalues the effect of health literacy, social circumstances, environmental conditions and behavior choices on health outcomes. Mounting evidence suggests these are important factors are correlated with poor outcomes (and higher costs) and are themselves modifiable.

Behavior choices like smoking, over eating and lack of exercise all have an effect on our health. Community based anti-tobacco programs aimed at children may be a better buy for our health dollar than medications for emphysema. And there are 1.5 million pregnancies each year as a result of unprotected sexual intercourse. This also causes 12 million new cases of sexually transmitted disease, as well as illness and deaths from Hepatitis B, HIV/AIDS and cervical cancer.

Choices and behavior make a difference.

About 40 percent of all U.S. deaths are from causes modifiable through population-based prevention efforts. We should invest in the infrastructure to promote healthy communities, yet we consistently spend too much of our resources at the wrong end of the problem. More of our resources should be spent upstream on community health programs and on population based interventions that help individuals make better choices about the factors that contribute to their health. We should also spend more on education efforts to make patients better health care consumers.

Big box hospitals and big box managed care systems have been allowed to consume resources at an alarming rate, much as a fire sucks the oxygen out of the air.

This current shortsighted national policy leaves too little for community health and prevention efforts that could improve the quality of life for Americans. I am concerned that in our zeal to cut costs, we will again undervalue prevention and community health programs. Prevention is a powerful tool and should be an essential ingredient of reform. I do not believe we can treat our way out of the health-care crisis, but we may be able to substitute better prevention capacity for some marginally useful high technology treatments and improve America's health status.

It will be up to individual citizens to influence their senators and representatives. As special-interest lobbyists swarm Washington to make their case and push our legislators to see the reform process from where they sit, I have high hopes, but low expectations.

William L. Kincaid, MD, MPH, is interim director of the Health Policy Division at Saint Louis University. He has experience in the St. Louis area as a local health officer, hospital board member, managed care medical director, and mental health and children's services tax board member. Dr. Kincaid serves on the board of directors for such nonprofit organizationsas  Community Health Charities of Kansas and Missouri, the St. Louis Diabetes Coalition, the St. Louis Regional Asthma Consortium and the Maternal, Child, and Family Health Coalition.