There's no easy or cheap way to transform an ailing system into one that promotes health and wellness. At every level, from the way doctors are trained to the way they're reimbursed, the importance of prevention is overshadowed by a focus on treating illness and a reliance on expensive medical technologies and procedures.
As a young cardiologist, Steve Devries noticed a disturbing pattern: His patched-up heart patients kept returning for repairs. Devries decided there must be another way to advance patients’ health.
Today, his Chicago practice focuses exclusively on preventing disease, and Devries is far more likely to counsel patients about diet, sleep habits and exercise than to prescribe high-tech scans or cholesterol-lowering drugs.
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Motivated by a growing sense that America’s health-care system is broken, doctors such as Devries and public-health experts are turning to preventive medicine for a potential fix. And lawmakers, eager to curb runaway health-care costs, are paying close attention.
Every serious health-care proposal includes measures to promote healthier lifestyles and minimize the burden of disease. The federal government last month earmarked $650 million in grants — the largest sum ever — for community programs designed to reduce tobacco use, increase physical activity and improve eating habits.
But there’s no easy or cheap way to transform an ailing system into one that promotes health and wellness. At every level, from the way doctors are trained to the way they’re reimbursed, the importance of prevention is overshadowed by a focus on treating illness and a reliance on expensive medical technologies and procedures.
“Health reform gives us a great opportunity to shift the focus,” said Mike Barry, executive director of the American College of Preventive Medicine. “Instead of pulling out a prescription pad, we want to see physicians prescribing lifestyle changes.”
Extensive research documents the potential impact. In an April article in PLoS Medicine, an international peer-reviewed journal, researchers estimated 191,000 fewer Americans would die each year if they had more physical activity; 216,000 deaths forestalled if people were a normal weight instead of overweight or obese; and 467,000 deaths averted if people gave up smoking.
Less clear is the effect on health-care costs. Although some forms of prevention save money, others require a significant upfront investment and can prompt increased spending, said Louise Russell, chair of the division of health policy at Rutgers University.
3 forms of prevention
Doctors practice primary prevention when they administer flu shots or immunizations, check a patient’s blood pressure or cholesterol and perform cancer screenings such as mammograms.
Secondary prevention occurs when physicians help people with illnesses such as heart disease, asthma or diabetes manage those conditions and avoid possible complications. About 75 percent of health-care spending is driven by people with chronic illnesses, according to Jeff Levi, executive director of The Trust for America’s Health.
A third form of prevention focuses on places where we live, work, play and learn. This strategy recognizes it’s difficult for people to change behavior without safe, convenient places to walk and exercise; fruits and vegetables in school lunchrooms; and restaurants where tobacco smoke doesn’t drift across tables; among other social supports.
“If we lower the barriers to making healthier choices in the community, then we can create a culture of health in this country,” said Partnership for Prevention President Robert Gould.
A recent report in the Archives of Internal Medicine found that people who live in “healthy” neighborhoods — areas with plentiful opportunities for physical activity and eating well — had a 38 percent lower rate of Type 2 diabetes than those in “unhealthy” neighborhoods.
Although the analysis doesn’t prove cause and effect, “altering our environments so that healthier behaviors and lifestyles can be easily chosen may be one of the key steps in arresting and reversing these epidemics,” wrote researchers from Northwestern University, Drexel University and several other institutions.
Similarly, a new Institute of Medicine report has concluded that smoking bans — an increasingly common prevention strategy — reduce heart-attack risk in smokers as well as nonsmokers by limiting exposure to secondhand smoke.
But messages about relationships between health and social factors often provoke controversy, impeding prevention efforts. Many people resent the government telling them what to do, including how to stay healthy.
University of Michigan researchers found a partisan divide: Republicans were less supportive of prevention strategies after news reports suggested that diseases are related to social or economic factors, while Democrats became more supportive, according to the report, published online this month in the American Journal of Public Health.
Insurance policies that pay doctors handsomely for performing medical interventions but not for counseling people about healthier lifestyles present another hurdle. Many policies cover stomach-reducing surgery for obese patients, for instance, but don’t pay for weight-loss programs or nutritional counseling.
To promote prevention, insurance policies need to be restructured “to create the right kinds of incentives,” said Dr. A. Mark Fendrick, co-director of the Center for Value-Based Insurance Design at the University of Michigan. What is needed is a link between how much health is produced and how much the nation pays for medical care, he said.
Under the current health-care bills, Medicare, the government’s health program for seniors, would take a step in that direction by waiving co-payments for older Americans who seek preventive care and rewarding doctors for delivering recommended preventive services. Businesses also could impose stricter penalties on employees who smoke or are overweight.
But if we’re to become a healthier nation, change needs to start even earlier, in the halls of medical education, argues Dr. Andrew Weil, founder and director of the Arizona Center for Integrative Medicine. “American medical doctors are functionally illiterate about nutrition and unable to counsel patients about improving their eating habits,” he wrote in his new book, “Why Our Health Matters.”
Because of economic incentives, too many doctors become medical specialists and too few become internists, family doctors or pediatricians — physicians most needed to oversee the overall health of patients and deliver preventive services, Weil said.
Encouraging behavior change may be the toughest obstacle of all. A health scare usually is needed.
Adele Simmons, 68, recently discovered she had high blood pressure and a slightly blocked artery, and she dreaded the thought of giving up ice cream, brownies and regular Coke. After meeting with Devries, however, the Chicago woman changed her diet, went on a natural statin called red yeast rice (best used under the supervision of a qualified doctor) and became more vigilant about incorporating exercise, meditation and breathing into her day.
Her blood-pressure and cholesterol levels have dropped into the normal range. A happy bonus: She lost 10 pounds.
“I thought I’d feel like giving up, but in fact, it was easier than I expected,” Simmons said. “When I changed my diet, my taste buds changed, too, so some of the things I found irresistible, I just don’t like anymore.”