Prevention

HEALTH CARE: Of Carrot Cake and Oreos

Joanne Kenen — Fri, 23 Oct 2009 17:19:00 -0400

Dr. David Kessler, as you've probably heard, is out with a terrific best-seller called "The End of Overeating: Taking Control of the Insatiable American Appetite."

The cover grabs your attention: very pure white glossy background with a carrot cake and carrots.

I don't like carrot cake. But as I told Dr. Kessler, if the cover picture were an Oreo, I wouldn't be able to have his book in my house.

I got to know Kessler while I was covering tobacco back in the late 1990s, but hadn't seen him in quite a few years until he spoke at a conference of health writers I attended last week.

He was the luncheon speaker: the healthiest of the box lunch options, the one I chose, was vegetables -- drenched in salad dressing -- on a white-bread roll, an apple, and two chocolate chip cookies in plastic wrap. I didn't want to eat them until Kessler began talking about how smells triggers cravings and my friend Ivan sitting next to me unwrapped his cookies. But, concentrating intently on the dress I wanted to wear at a college reunion this weekend, I ignored Ivan and the cookies, and listened to Kessler. Luckily, they weren't Oreos.

Anyhow, David happened to be heading to Washington this week, and we ended up having a longer and more provocative conversation about fat, policy, parenting, Oreos and social norms than either of us expected. (I took him to a place where only the tea was supersized.)

Normally I avoid writing about books until I've finished reading them (which is why we have only given a passing shout-out to T.R. Reid's excellent The Healing of America... I will tell you just how excellent it is when I get past page 50... which will probably be after this weekend's college reunion). But while I'm only about halfway through Kessler's book, I wanted to share some of our conversation while it is still fresh in my mind.

"The End of Overeating" is not about health reform or health insurance, or even about how health reform will improve the care and management of obesity-related diseases like diabetes and heart disease (although that will help). Nor is it just about the social determinants of health or steps like kids getting more exercise at school and healthy school lunches and walkable neighborhoods and all that. The book isn't about government regulation (although better and more useful labeling, he told me, is essential -- and the Froot Loops "Smart Choices" flap may help lead to better public awareness.)

His book is about our bellies. And our brains.

About how and why our brains tell us to keep putting large quantities of bad food in our bellies. And how we become wired to want more and more of the bad food that gives us a quick fix and still leaves us wanting more. Why I can't have Oreos in my house, and why the top layer of my wedding cake in my mom's freezer "talked" to her so loudly and insistently that she gave it away while I was on my honeymoon. And how and why the social norms in contemporary America have changed. We used to eat food. Now we eat processed stuff. Stuff engineered by food companies that know exactly what they are doing. A dash of fiber and a bit of fortification buried under layers and layers of sugar, salt and fat.

And it's everywhere. And we eat it all the time. And it's getting worse and worse.

Kessler writes:

Foods built layer upon layer to stimulate our senses. Foods high in sugar, fat and salt, and the cues that signal them, promote more of everything: more arousal... more thoughts of food... more urge to pursue food... more dopamine-stimulated approach behavior... more consumption... more opioid-driven reward... more overeating to feel better... more delay in feeling full... more loss of control... more preoccupation with food... more habit-driven behavior... and ultimately, more and more weight gain.

We don't just have palatable food. We have hyper-palatable food. We don't have habits, we have conditioned hyper-eating, driven behavior. Conditioned driven behavior isn't exactly the same thing as an addiction to a drug or nicotine... but it's a close cousin.

The result, in his view, is an obesity epidemic so severe that it has emerged as the biggest public health challenge of our lifetimes. This comes from a former FDA commissioner who did about as much as anyone on earth to combat tobacco. And who has also been involved in the fight against HIV/AIDS.

We're already spending $147 billion a year on obesity -- twice what we spent a decade ago. And it's only getting worse. Reversing the obesity epidemic, he told me, is also "harder than anything we've ever done in public health."

I look around and see what he means. Too much. All the time. Everywhere.

Today, at a college snackbar, I saw "macaroni and cheese pizza." (It's just what it sounds like.) Yesterday morning, as I wrote part of this post in an airport departure lounge, I saw a coffee stand at each end of the corridor, but they weren't serving what we used to think of as "coffee." This coffee is loaded with syrups and flavors and chocolates and garnishes and whipped cream. There was a diner at one end of the corridor, (fries, fries fries) and a dubiously greasy-smelling seafood place offering breakfast at another (I didn't dare look). In between, there was no shop for me to pick up a cheap watch to replace the one I dropped rushing out of the house for my plane. But there's a pizza place, an Arby's, a California Tortilla, McDonalds (with really really long lines), a Chinese take-out place, a Quiznos, and yes a place for me to buy a newspaper and a bottle of water -- but the woman in front of me in line was getting a Coke and a candy bar for breakfast. And the bigger-than-it-used-to-be bag of M&Ms on the newsstand counter had a logo about fighting breast cancer.

So a lot of what David Kessler and I spent an afternoon talking about wasn't so much about the Baucus bill or the Waxman bill, or medical homes or more nurses. It was about social norms, and how to change them. He has some ideas in the book, but much of that is still a conversation going on in his head. We changed the social norms for smoking, even before the laws he fought for were enacted. And we're going to have to change the social norms for food. Kids used to say, "Daddy please don't smoke," Kessler recalled. How do we get them to say, "Daddy, please don't buy me fast food." Because without significant changes in what we eat, how we eat, when we eat, and why we eat, the costs -- both economic and physical -- to ourselves and our nation will be overwhelming. Way bigger than any Oreo.

HEALTH CARE: Practicing What We (Ouch) Preach

Joanne Kenen — Tue, 06 Oct 2009 22:07:00 -0400

Hmm. New America is doing a flu shot clinic (seasonal, not swine) at the office this week, I believe for the first time.

Apparently, only two of us in the health policy program (you know, the ones who write about prevention and wellness) have signed up for this free service.

Maybe everyone else already got theirs.

QUALITY: US Leads Industrialized World In Preventable Deaths

Meredith Hughes — Tue, 06 Oct 2009 20:21:00 -0400

We've mentioned soaring U.S. health costs many times before, but a recent Commonwealth Fund report puts into perspective '"what we pay for" versus "what we get" from our health system. In comparison to other industrialized nations, according to The Washington Post, the U.S. is one of the top spenders on health care -- $2.4 trillion annually -- but we rank near the bottom in preventable deaths.

The report, Reducing Preventable Deaths Through Improved Health System Performance, found the US had the highest rate of preventable deaths, with 110 out of 100,000 dying in 2002-2003. For example, controlling for age and whether death is preventable from certain conditions, the study found women under the age 75 died from health care-amenable causes at a rate of 96.41 per 100,000 in the U.S., versus 68.15 in Canada and 57.40 in France. Though all countries made progress in lowering rates of preventable deaths between 1997 to 1998 and 2002 to 2003, the United States made the least progress, dropping from 15th overall in preventable mortality to 19th, said a similar study in Health Affairs.

The U.S. ranks very low on premature deaths caused by illnesses such as diabetes, stroke, ulcers, and pneumonia. Complicated cancers, AIDS, and most forms of heart disease were not considered preventable in the definitions used here (ie once someone gets these conditions, medical treatment can't always stop a premature death). Gun and automobile accident fatalities were not a big contributor to the preventable death rate either.

"Chronic illnesses are a much bigger driver of health-care costs than trauma cases such as vehicle crashes and gunshots," Robert Shesser, head of emergency medicine at George Washington University, told the Post. "Because of our wacky system, some people are bankrupted or avoiding care and some are getting too much care."

The Commonwealth Fund suggests several health reform strategies as a path to lowering preventable mortality in the United States, including extending affordable insurance to all Americans and realigning financial incentives to enhance value and achieve savings. The report said,

We also must reform our payment system, as fee-for-service incentives reward more services and not necessarily better care. Good preventive care, for example, requires not just a screening test, but also services that are not currently reimbursed such as outreach and follow-up when a test is positive.

Outreach and follow-up care are facilitated when patients have a medical home that serves as a regular source of care and coordinates care for people. Medical homes that are paid per patient can encourage preventive care by sending electronic reminders of screening visits-reminding patients that it's time for their cholesterol check, for example.

In health care, "prevention" can mean different things, from encouraging overall healthy lifestyles to avoiding certain diseases, to using medical checkups and screenings to catch disease early. As the Post points out,

...as many as 80 million Americans are uninsured or underinsured, which means they have little access to a regular physician, checkups, preventive services, affordable prescription drugs, dental care or screening tests.

Without health reform that provides everyone with quality, sustainable, affordable health care coverage, many Americans will continue to struggle to stay healthy, and access the preventative health services that could end up saving their lives.

QUALITY: More Getting Primary Care From Community Health Centers

Meredith Hughes — Tue, 29 Sep 2009 17:13:00 -0400

A growing number of Americans rely on federally qualified health centers for care, reports The Wall Street Journal. Last year, community health centers, as well as migrant and homeless health centers, served approximately 18 million people. That number is expected to hit 20 million this year, according to the WSJ and the National Association of Community Health Centers.

A disproportionate number of patients seen at the centers live in such low-income or underserved communities as inner cities and rural areas. According to the NACHC, 70 percent live at or below the poverty line. But with unemployment levels high, more middle class, college educated people are falling into the safety net of community heath centers, reports the WSJ. Loudoun County, VA Community Health Center operating chief Stephanie Kenyon told the WSJ the center's waiting list ballooned from 20 to 500 in just a few months.

Support for federally funded health centers (also known as Federally Qualified Health Centers or Community Health Centers) increased both during the Bush administration and more recently in the Obama administration through the American Recovery and Reinvestment Act (better known as the stimulus bill). By the end of the Bush administration, there were about 1,200 clinics nationwide, and this year's stimulus package provided $2 billion in funding to clinics. (That's $1.5 billion for infrastructure and another $500 million for operations -- and it represents a lot of money in the world of community health centers). Under the provisions in the pending House health reform bill, community heath centers could see an additional $38 billion over the next 10 years, although the specifics of the various congressional bills are still in flux.

Both Democrats and Republicans have seen the value of community health centers -- not just for the care they provide to millions who need it, but how they can help contain health costs by providing primary and preventive care in a community setting. According to the NACHC, the clinics save the U.S. health care system billions of dollars every year by providing preventative care that helps patients avoid costly trips to the emergency room. The centers are able to provide patients with comprehensive primary care services, including physical, dental and mental health. Patients pay for the visits based on a sliding scale, anywhere from $0 to $20 to $100 or more. According to the WSJ, the average cost of a visit to the health center in Loudoun County is $145 -- that's a lot cheaper than the national average for trips to the ER, which tend to run about $1,000 for a single visit.

Community health centers can also become a vital component of care coordination and disease management. As we've written before, Denver Health in Colorado has been a model of bringing community health clinics into an integrated system. And they've been a pioneer in the use of health information technology. The network of community health clinics, a 911 ambulance and trauma system, school-based clinics, the local hospital, an HMO, and the county public health department all use health IT and electronic medical records so that doctors can communicate more easily -- with each other and with their patients. That helps them create efficient coordinated care plans, and help patients adhere to their treatments.

Colorado, where community health clinics have been ahead of much of the nation in adopting health IT, also has a program called Connected Care to expand telehealth resources for patients in remote, underserved rural areas. The program, a partnership between the state of Colorado, UnitedHealthcare, Centura Health and the Colorado Rural Health Center, aims to allow health centers and other providers to use timely and efficient electronic information so that clinicians can coordinate care, improve quality, and lower cost.

Community health clinics don't get a lot of attention in our national health care conversation. But with their focus on affordable primary care and chronic disease management, many of these clinics are at the forefront of the move to lower costs while improviding the quality of health care.

QUALITY: Prevention Works

Meredith Hughes — Mon, 21 Sep 2009 19:57:00 -0400

As you know, there's been a ton of argument about whether prevention saves money -- and one of the issues has been how narrowly we define "prevention," whether we treat it as a synonym for "screening for early detection of disease" or whether it's something bigger.

Today, a report by the Trust for America's Health (TFAH) and The New York Academy of Medicine (NYAM) comes down firmly on the side of prevention (broadly defined) as a money-saver.

The report, Compendium of Proven Community-Based Prevention Programs, is a comprehensive review of studies which document community-based disease prevention from all around the world. Specifically, the report looks at programs aimed at decreasing smoking, increasing exercise, and improving healthy eating. The goal of these programs is not just to detect disease early, but to prevent it altogether.

Community-based prevention programs work to reach out to the population as a whole, and address common health problems. These programs:

Work to reduce rates of obesity, high blood pressure and high cholesterol, and encourage people to exercise and eat healthier, which can lower risk for cardiovascular disease, stroke, and diabetes.
Getting people to stop smoking (or never start) can lower the risk of cardiovascular disease, and many types of cancer -- especially lung cancer.
Asthma can be managed by proper diagnosis, care, and management, reducing the hospitalizations and absenteeism that asthma causes, particularly in school-age children.
Community-based intervention programs to prevent the elderly from falling, which is a leading cause of injury, traumatic brain injury and death for those 65 and over.
Programs that encourage the use of condoms and safe sex practices can lower the rates of sexually transmitted infections, including HIV.

Some of the initiatives described in the report were as simple as walking more each day, but they had a positive impact on local communities. For example,

Researchers at Ohio State University recruited 60 women in their forties for a 12-week walking program on the college's campus. At three months, the intervention group saw a one percent decrease in body mass index (BMI), a 3.4 percent decrease in hypertension, a three percent decrease in cholesterol, and a 5.5 percent decrease in glucose levels.
The New York State Healthy Neighborhoods Program conducted an asthma intervention in which outreach workers conducted home visits and provided education about asthma, referrals, and controls for asthma triggers. During the program's 1997-1999 funding cycle, the average hospitalization (hospital admissions and ER visits) rate decreased by 23 percent.
A worksite intervention program targeting approximately 800 high-risk employees who smoked provided them with cardiovascular risk factor screenings, individualized counseling and related services. At 3.7 years, the intervention group realized a 12.6 percent decrease in the amount smoked, a 3.3 percent decrease in diastolic blood pressure, and a 7.8 percent decrease in cholesterol, meaning an overall reduction in their risks for developing cardiovascular disease.

On a call announcing the release of the report, leaders from the Trust for America's Health, The New York Academy of Medicine, and The California Endowment expressed concern that prevention programs are overlooked by reformers looking for savings. Trust executive director Jeff Levi, PhD, disagreed with the CBO's estimations on the amount of savings that prevention programs bring. He hopes that nonclinical prevention programs, like those examined in the report, will find a place in current health reform legislation. According to a TFAH report released in July 2008, an investment of $10 per person in community health could result in health care savings of $16.5 billion over five years.

Levi, writing in the RWJF Users Guide to the Health Reform Galaxy Blog, also pointed to what we can learn about prevention and community health from the $650 million in stimulus money being made available in the Communities Putting Prevention to Work initiative. He called it "an important down payment on the road toward real health reform that will help make Americans healthier." The initiative will make money available to 30 to 40 communities or states to "built or expand upon programs that prevent chronic disease and obesity by addressing physical activity, nutrition and tobacco use."

"At the end of the day," he wrote, "these programs will be the laboratory for showing what results we can have if we invest more heavily in wellness and prevention." Healthier, higher quality lives.

IN THE STATES: Indiana Leads the Way on Prevention

Allison Levy — Fri, 11 Sep 2009 16:29:00 -0400

We all know you can earn rewards for frequent flying. But what about for routine trips to your doctor?

Emphasizing primary care and preventive services is a key goal of health reform and many contend the savings from such programs can help finance a health care overhaul (and make us a healthier country). Yet, the details of how these savings might be realized are less clear.

Indiana is one state to find some answers. Contributing to a statewide effort to improve population health, Managed Health Services, one of three Medicaid plan administrators in Indiana, now offers the CentAccount Healthy Rewards Program. Participants accrue dollars on a CentAccount Mastercard debit card as a bonus for participating in appropriate preventive care services -- in the appropriate care settings. LIke the doctor's office, not the E.R.

For example, a patient will earn $15 for seeing a primary care physician within the first three months of joining, and can get additional money if they get certain screenings, for instance for cervical cancer or chlamydia. (which can cause complications in pregnant women and their newborns.) They earn $10 each time they take their newborn baby to the doctor's office for a recommended checkup.. The money on the card can then be used to pay for health-related items at participating grocery and convenience store, including over-the-counter medicines, diapers, and bottles.

Pat Rooney, president and CEO of Managed Health Services, recently told the AP, "What we're trying to do is promote the healthy behavior and make sure the people are getting the right things that they need." Rooney contends that "Just getting people in to see their primary care doctor is always a challenge with this population."

Realigning incentives is a central goal of reform. As we've written before, small changes can have a big impact on personal behavior, health, and system savings. Often, the return on investment from primary care and prevention depends on how you define these programs. The results from Indiana's initiative expand our definition and refine our discussion of such efforts.

HEALTH CARE: Prevention, Way Beyond an Apple a Day

Joanne Kenen — Fri, 17 Jul 2009 14:44:00 -0400

I was about to recommend Minna Jung's thoughts on preventive care at the RWJF's Users Guide to the Health Reform Galaxy blog, when I realized she ended her post by recommending mine.... But the points we both made, about the need to understand that prevention is broader than giving people screening tests to detect disease, and that its economic benefits may not be easily measured in the short-term windows of federal budget policy, are illustrated in the real world at the Cleveland Clinic.

TIME took a look at the preventive health and wellness programs that the Cleveland Clinic is running for its own employees in its recent special edition on health. (Since this is a prevention post, we could explain that it took us nearly a month to read the article and photo essay because we swim more in the summer, and treadmill more in the winter, and we can't read magazines in the pool. But we digress.) The clinic, internationally renown for its technologically sophisticated medicine, is now putting at least some of its energy into things like hiring chefs to teach its workers how to fry food with less oil -- or better yet, to grill. No longer will helpful ER personnel offer to send out for food for a family waiting for test results -- and produce Kentucky Fried Chicken.

The clinic wants to improve health. It also wants to prove that wellness pays:

The Cleveland Clinic's own experience suggests that [chief wellness officer Dr. Michael] Roizen's confidence in prevention's payoff is well founded. The hospital's chief human-resources officer anticipates that after growing between 4% and 8% each year over the past six years, employee premiums will not increase in 2010. That's in part due to savings from employees with chronic illnesses who are making lifestyle changes to keep themselves from getting sicker. This saves the clinic between $5,000 and $10,000 a year per patient on claims they would have otherwise filed for treatments such as dialysis, angioplasty or bypass.

The wellness teams at Cleveland are thinking well beyond short-term savings in premiums. They are thinking that wellness, properly done over the long-haul, can not only prevent disease, it can reverse it. And then we'd have a health care system that wasn't about sickness, but about health.

HEALTH CARE: The Choice for Surgeon General

Joanne Kenen — Tue, 14 Jul 2009 15:22:00 -0400

I was at a conference yesterday and couldn't post about President Obama's nomination of Dr. Regina Benjamin to be surgeon general. Today I'm reposting what I wrote last September when she won a MacArthur "genius" grant,"

I met Dr. Regina Benjamin only once but she's not easy to forget. She took the time to travel to Missisippi in the spring of 2007, about 18 months after Hurricane Katrina, to talk to a small group of health care journalists. We weren't writing about her that day, we were just learning from her, and she was fine with that. Dr. Benjamin is a family physician in the tiny shrimping community of Bayou La Batre in southernmost Alabama. It is racially and ethnically mixed, including an influx of Vietnamese who were drawn to its shrimping fleet, probably the only thing in the fictional home of Forest Gump that was familiar to them...

News articles about Dr. Benjamin's award point out that her clinic was destroyed by Hurricane Katrina, but she rebuilt it -- only to have it burn down just as they were ready to reopen. What the articles omitted is that she had to rebuild as well less than a decade earlier, after Hurricane Georges in 1998. Each time, the grateful community rallied around to help her, as she has helped them, putting the bills on her own credit card when she had no other choice. When her clinic is out of commission, she treats patients out of her beat up old pick-up truck (if this sounds like a story of inspiration ready for Readers' Digest, you're right.) She also finds time to serve on all sorts of health-related and nonprofit boards, and in her "spare" time, she mentors and teaches younger doctors how to provide quality care to underserved communities in rural America.

Her job, in short, is to help us be fitter, healthier, more health-literate nation. Reducing health disparities is another priority of the U.S. Public Health Service, and emergency response is also part of their brief. In case you are wondering whether her background, however inspiring, is the right administrative fit -- she also has an MBA from Tulane.

HEALTH CARE: Making Primary Care Pay

Joanne Kenen — Mon, 29 Jun 2009 16:42:00 -0400

Business Week takes a look at the medical home model, and finds that, lo and behold, primary care docs can provide high quality coordinated care and boost their income to boot.

Improving patient centered primary care—which means care coordination, prevention, wellness and management of chronic conditions—is a key theme of national health reform, supported across ideological lines. A medical home can take various forms. It can be a large group practice or a solo one like Dr. Peter B. Anderson's in Newport News, Virginia, profiled by Catherine Arnst in the Business Week story. (Or this doctor profiled last year in the Washington Post, a slightly different model). As Cathy writes:

The "home" is the office of a primary-care doctor where patients would go for most of their medical needs. The general practitioner would oversee everything from flu shots to chronic disease management to weight loss, and coordinate care with nurses, pharmacists, and specialists. A 2004 study estimated that if every patient had such a home, the resulting efficiencies might reduce U.S. health-care costs by 5.6%, a savings of $67 billion a year.

She described how Anderson and his team of four nurses (three fulltime and one parttime) take plenty of time to counsel patients about things like weight control, nutrition and smoking. People with chronic conditions get frequent checkups to keep their illnesses under control. And because of the way the doctor and nurses divide and coordinate care, and their successful incorporation of electronic medical records, they see more patients a day than doctors typically do. Abderson's practice sees 30 to 35 patients a day, compared with 20 to 25 for a more typical primary care doctor.

There's a lot of support in Washington for paying primary care doctors more, and shifting the incentives in the system to improve care coordination and prevention. Anderson, 56, has actually made the medical home model work for him and his patients even in the current system, where the incentives are for more specialty care and procedures, and the results are often fragmentation and overutilization.

Before he switched to the medical home model five years ago, he worked 50 to 60 hours a week and wasn't able to pay his bills. Now, he's working fewer hours, seeing more patients, making more money and "delivering the best care I've ever done."

HEALTH CARE: Just What Do We Mean By Prevention?

Joanne Kenen — Fri, 26 Jun 2009 15:08:00 -0400

At a meeting we attended about health reform the other day, one side of the room was saying of course prevention saves money and the other side was saying with equal certitude that of course prevention doesn't save money. (Forget the irony that we were having this discussion over a pizza lunch. With no salad.) A lot of other people are having this debate, and we attended a helpful panel discussion recently sponsored the Alliance for Health Reform.

We'll grant that if you look, you can find good solid economic arguments that prevention (depending on how it's defined, but more on that in a minute) doesn't save money. At least it doesn't save money in the five- or 10-year budget windows that Washington is used to talking about (and which legislation must be measured against). Economist Louise Russell has been writing about this for years, and her widely cited article earlier this year in Health Affairs (and a shorter version on the Hastings Center blog) makes that argument. Note she is not saying prevention isn't a good thing; she's saying it isn't a "money-saver," strictly defined.

But you can find good solid arguments, too, that prevention and wellness does save money, and can save it quickly. A number of major corporations—Intel, Pitney Bowes, IBM, to name a few—report a high return on investment within a few years (sometimes sooner). They have taken a variety of steps—incentives for diet and exercise, tobacco-counseling, health screenings, no-copay screenings—that are producing a healthier workforce at lower cost.

As they say on Facebook... It's complicated. Let's break it down.

How are we defining prevention?
Does prevention mean medical screenings for everybody that lead to uncertain or ambiguous findings that lead to more tests for things that (for most patients) will turn out to be nothing? Mammograms starting at age 40? Or at 50? Until when? Colonoscopies from 50 through old age, or one colonoscopy between the age of 60 and 64? Diabetes screenings for everyone at 65, or only for people with certain risk factors?
Genetics and other advances in personalized medicine may eventually help us target screenings better. In the meantime, it is true that some of these interventions across an entire population will cost money because we are screening everybody, not just the relatively small number who will eventually get sick. But it will also save lives.
Or is prevention something other than screenings? Is it immunizations? Schools that get rid of soda machines and serve fruit with lunch? Anti-smoking campaigns? These steps can save money.
Is it medical homes and a robust primary care system that can take time with patients so they can stay well, or detect diseases at earlier manageable and sometimes reversible stages? That can save money.
Is it making sure we have healthy schools and healthy neighborhoods, so kids get time to run around during recess, and communities have sidewalks and bike paths, and grocery stores open in poor neighborhoods that currently have little access to healthy fresh fruits and vegetables. The Robert Wood Johnson Foundation's Commission to Build a Healthier America (which we've written about several times over the past year) has made recommendations for a healthier society that reaches well beyond health insurance. Screening can be important, but it's not the only way we keep well.
Are we confusing prevention and disease management?
Keeping an 80-year-old with five chronic conditions out of the hospital is not "wellness." It's "less sickness." We need to learn how to do this better—it's where most of our health dollars go. But let's not confuse managing disease toward the end of life with preventing disease at the beginning (or middle...)
How are we defining savings?
Is it a number that shows up within a five- or 10-year budget window that CBO can score? What about savings that will show up 20 or 30 or 40 years from now? If you stop a child from getting fat, or a teenager from smoking, it may not save money next year or the year after that, but it can make a huge difference down the road. Bill Frist, of all people, has made this message a current mission of his.
What if the savings aren't found only in the health care system?
How about if they reduce absenteeism and increase productivity in the private sector work force, as some businesses have found? Or if an intervention, like having a nurse educator work with high-risk families during the first years of a child's life ends up saving the juvenile justice system money 15 years down the road? It isn't saving Medicare or Medicaid money, but it's certainly saving money. (And improving lives.)
Will the obesity crisis change the math?
The jury is still out, but we are getting so fat, so fast, so young, that the costs (of diabetes and cardiovascular diseases) are rising so fast that it might change the prevention cost calculus sooner than we'd like. Dr. Steven Woolf of Virginia Commonwealth University, at a recent conference on prevention and cost sponsored by the Center for Health System Change, cited estimates that the obesity epidemic, linked to diabetes and cardiovascular disease, could raise health spending by some 30 percent.
Why do we ask prevention to prove its worth, but we don't ask whether certain brand name drugs, or high-cost tests and surgeries save money?
In fact, if we even talk about studying or comparing cost benefits, we get a screed about government bureaucrats and socialized medicine. (We aren't bothering to link, you've heard it...But if you have somehow not noticed, you can start with the Wall Street Journal editorial pages or those Republicans, mostly but not only in the House, who recite Frank Luntz's talking points.)
The last point we want to make here—When we discuss prevention, should we be talking less about savings and more about value?
The public strongly favors prevention (maybe telling a pollster they want to spend money on wellness assuages the guilt of a couch potato nation). Health reform isn't only about financing. It's about better health. And that is something that we all can value.