The problem with prevention

Blue Cross and Blue Shield of North Carolina, and groups funded by the insurer, like to claim that wellness will save our health care system. Politicians also love this line. State lawmakers are so convinced that wellness will save money — without any evidence to support their position — that they might yank the coverage of overweight and smoking state employees and leave them and their families uninsured.

But the truth is that prevention is only a small piece of the health reform puzzle. Some types of prevention are cost effective — like some smoking cessation programs and vaccinations for children. Other types of prevention probably don’t save much money but add to quality of life, or, in some cases, save lives, like flu shots for adults, Pap smears for cervical cancer, and colon cancer screenings.

If we can keep people at a reasonable weight and stop them from smoking then it will certainly improve public health. But wellness can’t be the cornerstone of cost control in health reform. Of course, Blue Cross and elected officials don’t want to deal with the hard work of actually controlling costs. Controlling costs will upset powerful special interests like insurance companies, drug companies, doctors, and hospitals.

The truth is that a small percentage of the population eats up a huge percentage of health care spending. About 20 percent of the population accounts for 80 percent of spending, and about 5 percent of the population accounts for almost half of health care spending.

Expensive patients usually have multiple chronic illnesses. Some of those illnesses could be prevented by jogging and eating more vegetables, but many are the result of aging. Dying in the United States is expensive and involves many stays at the hospital and many specialist visits. No amount of wellness will change that fact.

Instead, if we want to start saving money in health care we will have to get more efficiency from hospitals and doctors. We will have to get more coordination of care. We will have to offer competition for private insurance companies to reduce administrative costs.

And we will absolutely have to improve end-of-life care.

So when you ask a politician or insurance company spokesman about controlling costs in health reform and they start talking about prevention, start asking more questions. Wellness is a dodge, not an answer.


  1. Paul Slobodian

    July 7, 2009 at 5:39 pm

    Bravo! Excellent perspective. Here are a couple of added thoughts:

    Yes, end of life care does consume large amounts of funds…but this has relatively little to do with the cost of private insurance. Why? Because the vast majority of the expensive end of life care is paid via Medicare (the taxpayer) which is the main payor for those 65 and higher. So this needs to be dealt with as part of Medicare reform….not as the main part of private health insurance reform.

    Private (pre 65) care is too expensive because of the practice of defensive medical practice for fear of lawsuits….and because almost all care is covered by insurance….. the patient bears little cost….so patients seldom ask “is this MRI (or whatever) really needed doctor?” Thirdly, since most big insurers set price caps on docs and hospitals, the providers have a financial interest in too many tests and procedures.

  2. Adam Linker

    July 7, 2009 at 7:20 pm

    I would agree that Medicare is paying the bill for expensive end-of-life care, but the reason end-of-life care is expensive is largely because of the way our health system is organized. Medicare reform will certainly help tackle that issue, but larger health reform will have to encourage doctors to practice in larger, more efficient groups and hospitals to work in systems.

    I know that many docs insist that defensive medicine is the reason for overtesting, but that’s only part of the problem. As Dartmouth researchers have shown repeatedly, care varies widely within small regions — regions where doctors are all under the same malpractice regime. That means something else is going on.

    I think the larger problem is doctors working as independent operators without enough information — so they rely on experience and what other doctors in the community are doing, which is sometimes right and sometimes not.

  3. Middle Road

    July 8, 2009 at 9:18 am

    I’m not sure I follow how the health reform packages being considered in DC will “encourage doctors to practice in larger, more efficient groups and hospitals to work in systems.” Paying them less will force greater cooperation between specialists?

    The track record for that approach isn’t good. In the early to mid 90s, there was a trend toward consolidation into larger, multi-specialty practices, largely in response to the growth of managed care organizations that wanted to pay flat, capitated rates and let physician groups manage the money. The results were disastrous. Physician practice patterns changed little and most of these IPAs tanked quickly and spectacularly.

    Keep in mind that for generations, medical schools have tended to attract bright, confident and highly independent people. California and some Pacific Northwest states have been able to attract doctors with salaries positions where incentives are very different. But that approach has gone nowhere in NC, and indeed in much of the country.

    True, prevention doesn’t always save money (especially in the short term). But changing the tens of millions of poor lifestyle choices had better be a part of any reform effort, or we’ll never get costs under control.

  4. AdamL

    July 8, 2009 at 10:43 am

    That’s a fair point that simple capitation payments and lower reimbursements aren’t going to get us very far.

    But I doubt you can walk from one Starbucks to another in DC these days without hearing about how reform needs to encourage global capitation, medical homes, and accountable care organizations. These ideas will be incorporated into any reform package.

    The ACO idea doesn’t put doctors on salary at an HMO or hospital but does create networks of physicians centered around hospitals who are all accountable for patient care.

    And I promise that prevention will be a major part of reform. But that’s the only cost control politicians and insurance companies want to discuss, much like specialists only want to discuss malpractice reform. Jonathan Oberlander would call prevention, like electronic medical records, “faith-based” cost saving measures.

  5. Paul Slobodian

    July 9, 2009 at 6:44 am

    Prevention sells well to the public, but I agree completely that it is “faith based.”…..I’m aware of no serious study that supports it as a cost saving idea.

    The prevention idea is behind many of the major public health interventions: mammography, prostate testing, statin use, cardiology intervention (angioplasty etc), and colonoscopy.

    These prevention programs cost billions, actually harm some, and save surprisingly few people. North Carolina’s Nortin Hadler MD presents the analysis that show this convincingly in his book Worried Sick.

    I also agree with “Middle Road” that I haven’t seen the case made that supports the hypothesis that larger groups/systems save money.

  6. Steve Minnick

    July 9, 2009 at 1:22 pm

    When I met with Representative Shuler last month with the Consumers Union forum, I got the lecture from him regarding our overweight, underexercised, unhealthy American population and how we need to stress “wellness (meaning diet and exercise)”.

    This of course has nothing to do with accessible affordable health insurance for all American citizens, but it is a good way to obfuscate.

  7. Paul Slobodian

    July 10, 2009 at 6:44 am

    How about this?
    NC pays for all golf rounds as long as you walk instead of taking a cart (hey, it is great exercise)….this has the added benefit of an economic boost for the golf clubs….. the costs would be offset by the long term health cost savings (and the alcohol taxes at the 19th hole)!

  8. Betty Church

    July 13, 2009 at 1:28 am

    This makes sense to me. I have noted the propaganda vilifying obesity when growing scientific data shows chemicals termed “obesegens” are likely responsible for most of the obesity for which the insurance cos. and poison pushers would prefer to blame the victims. The real way to prevent much of modern disease would be to stop the poisoning, but this would curtail the poison manufacturers and their heavy investors, the insurance industry’s profits. Simply prohibiting MSG, certain fats, targeted pesticides and other obesegens would go far in reducing obesity as well as cancer, Alzheimers, Parkinson’s, and any number of modern chemically affiliated diseases.

  9. […] wrote a post recently about how wellness and prevention are not the most important aspects of health reform […]

  10. hoodia gordonii

    August 29, 2009 at 12:29 am

    Nice but i think something is missing.

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