The promise of preventative healthcare in the U.S. is unfortunately not being fully realized. When the government began promoting these programs in 1984, it promised to prevent disease. Preventative care was also supposed to reduce healthcare costs.
Some thirty years later, the two leading causes of death in the U.S., heart disease and cancer, continue to claim more lives than ever with no sign of any significant decline. On reducing the cost of healthcare, while there is some debate in this area, a recent article in the New York Times makes the case that while preventative care does improve quality of life, it does not, in fact, reduce healthcare costs for providers, payors or consumers.
The CDC, however, reports that chronic diseases that may be avoidable through preventive care services account for 75 percent of the nation’s healthcare spending and lower economic output in the U.S. by upward of $260 billion a year. Reducing something as prevalent as hypertension by just five percent a year could save some $25 billion, according to the Surgeon General.
Prevention versus Detection
Preventative measures such as vaccines, low-dose aspirin therapy, weight reduction and smoking cessation do reduce the incidence of certain diseases. But much of what the healthcare community defines as preventative medicine is better described as early detection of disease.
Early detection is really an attempt to ward off the human and financial costs of chronic disease as early as possible in the disease progression. As a result, providers spend far more time, money and resources on detecting and treating disease than actually trying to prevent it. This may sometimes result in over-testing of patients, which generates additional costs without necessarily adding a corresponding improvement in patient quality-of-life or life-hours gained. And since many of these procedures are not reimbursable by private or public payors, they either are not done in a timely fashion or are not done at all.
A good example of detection over prevention is heart disease, the number one killer in the U.S. To help prevent it, a healthcare provider may recommend cholesterol checks over the age of 40; obesity screening and counseling if a patient starts to gain weight; and routine blood pressure screenings for patients over the age of 20 to detect when blood pressure gets too high.
Another example is cancer, the second leading killer in the U.S. To help ’catch’ certain cancers early, doctors usually recommend colorectal and breast cancer screenings for patients over 40 or 50, respectively. Most guidelines indicate holding off on these screening tests until these ages, because this is when the best chance of detecting evidence of these cancers exists. These are generally all recommendations designed to detect and treat asymptomatic disease at a time when the disease is likely to show up.
Is it time for a shift in focus?
The use of antibiotics provides an example of how a shift in focus to true prevention could benefit patients and providers alike. Antibiotic prescriptions in the United States are among the highest in the world. One often ignored side effect of antibiotics is the reduction in the population of good bacteria in the gut. Certain antibiotics may also reduce the amount of calcium and iron available for use in your body. Insufficient good bacteria in the gut may result in increased risk for heart disease, cancer, obesity and many other diseases. Insufficient calcium and iron may lead to heart problems and other health disorders. But rather than avoiding this risk by appropriately testing the population of remaining good bacteria after a long course of antibiotics, or for calcium or iron deficiency, most doctors instead screen for the diseases caused by the deficient minerals, vitamins and gut bacteria. And then they focus on treating the disease itself.
Another example of where detection currently takes precedence over prevention is nutrient deficiency. Research indicates about 80 percent of adults in the U.S. get too few of critical nutrients such as vitamin C, which can result in increased risk of heart disease, cancer and obesity. Yet neither vitamin C level tests, nor testing for many other critical nutrients needed to stay healthy, are on the list of recommended primary preventive screening tests.
Screening tests for gut bacteria and nutrients are far better methods of preventative care than testing for the disease. By not having true preventative healthcare, the healthcare community may have inadvertently created a healthcare problem that now requires billions to address.
Preventative Care is Underutilized
Experience does show that true preventative care can prevent disease and increase the probability of a patient staying healthy. And it is commonplace and routine in many other areas of our lives.
Consider aviation, for example. The risk of death from a single inflight malfunction is so astronomically high, that airlines generally take true preventative steps to identify and correct potential problems before they happen or before warning signs are expected to manifest themselves. The human body is equally complex and the risk of death or disability from untreated disease is just as high. However, given the current dynamics of the healthcare system, the general practice continues to focus on early detection of disease, not prevention.
And despite studies that may show otherwise, the Rand Corporation reports a two-to-one return on investment (ROI) on preventative health programs in the workplace. And another report by the CDC shows that preventative care can generate up to a four-to-one return on investment. Yet, despite these numbers, true preventative care continues to be underutilized. In fact, one study indicates that only about 44 percent of healthcare providers ask about health lifestyles and steps patients take to ward off disease.
Healthcare Providers Can Play a Leading Role
Healthcare Providers, given their mission to protect community health, can do a lot to develop, promote and make true preventative care a real possibility. And they may also reap benefits by seeing a positive impact to their bottom line. For example, they may minimize expensive re-admissions, reduce non-emergency and unreimbursed visits to the ER, address the spiraling costs of preventable diseases such as diabetes and obesity and garner community goodwill.
Steps providers can take now may include:
- Community Education: Lack of education leads to bad decisions, which leads to disease and more — greater spending to treat disease rather than on preventing it in the first place. Providers should engage or expand existing efforts in community health-building that give people the information and tools they need to get and stay healthy.
- Workplace Health: Providers can set an example by developing new or enhanced workplace wellness programs to include elements aimed at helping employees educate and raise healthy kids. Studies shows that healthy children tend to become healthy adults. They also show that parents with unhealthy habits tend to raise children who will follow in their footsteps. Providers can help break the cycle.
- Provide Screening: Screen whole populations but focus on less-expensive but equally-effective techniques and procedures where possible. For example, in their colon cancer screening programs, certain capitated organizations typically lead with pre-screening through mail-in stool tests. Positive “occult blood” results on these may reliably turn up in the small percentage of the population that could benefit from a colonoscopy. Some 5 percent of those may actually have colon cancer.
- Work to Expand Coverage: Given the ROI on preventative care, work with payors and government authorities to expand coverage to better include preventative care services aligned with the US Preventive Services Task and CDC recommendations.
- Improve Targeting: By reaching vulnerable and higher-risk populations, providers can improve the ROI (both human and financial) of preventative care programs.
Remember prevention is always better than a cure. But it requires both patient, healthcare professionals, and policy makers to work together.