A Pound of Prevention

Early intervention may be the Rx that cures the nation’s health-care woes.

by Matt Getty

April 1, 2009

Treasure Walker '04, fourth-year medical student, takes a shift in the emergency room.

An ambulance siren screams across the hospital parking lot. Red and blue lights splash against the brick walls and the stark white “Emergency Room” sign above. When the tires squeal to a halt, two EMTs leap out and circle to the back of the ambulance, their chiseled faces etched with concern.

“What do we have?” shouts a gray-haired doctor coming out to meet them. His eyes dart between the two EMTs and then come to rest on the confused middle-aged man on the gurney who, aside from being overweight, looks healthy and unharmed.

“White male, late 30s, 40 pounds overweight, hasn’t had a checkup in five years,” says one of the EMTs as he jerks up the guard on the side of the gurney. “His wife called it in. Caught him lying on the couch eating a bag of potato chips.”

“All right,” the doctor says with a sigh. “We’ll do what we can. We also have a woman six months pregnant who’s never seen an ob-gyn, knows nothing about prenatal nutrition, and two teenagers who recently started smoking. Then we have an entire family of six, not a single vegetable in their refrigerator … It’s going to be another long night.”

Most nighttime TV medical dramas sound nothing like this, but according to many of the nation’s health-care experts, it might be better if they did. With medical costs projected to double during the next decade and the U.S. life expectancy dropping to 46th in the world, doctors and policymakers have a new rallying cry—if an ounce of prevention is worth a pound of cure, think what we could do with a pound of prevention.

“Between recent academic articles and what we’re hearing out of congressional leaders and President Obama, there’s clearly an acknowledgement that our health-care system is turned on its head,” says Courtney Taylor Piron ’89, who heads the health-care policy department at the public-affairs firm APCO Worldwide. “We do so much to treat people once they’re sick, but we haven’t done much to try to keep people healthy.”

Shaping Up Health Care

Today, the public and private sectors have begun the long struggle to turn the system right side up. In the last decade, 33 states have taken on cancer with laws banning or limiting smoking in bars, restaurants and other public places. Employers are increasingly turning to wellness programs to fight rising insurance premiums with free fitness classes. Both state and the federal governments recently have begun to stanch bleeding budgets by investing in everything from bike-lane construction to community health centers offering free nutrition programs. As the new, trim president eyes comprehensive health-care reform in a country with a 30-percent obesity rate, this trend looks likely to grow.

“It just makes sense,” explains David Sarcone, assistant professor of international business & management and the coordinator of Dickinson’s health-studies certificate program. “Access to medical care makes up a very small portion of why people are healthy—some say as little as 10 to 12 percent—but personal decisions and behavior account for approximately 50 percent. So if the goal is to improve health, to focus solely on medical care ignores one of the greatest opportunities for improvement, which is changing behavior.”

No More Tinkering

Behavioral health advocacy dates back to at least the 1920s when doctors first championed seat belts, but the watershed moment for preventive health care came very recently. In 2007, explains AcademyHealth Vice President Enrique Martinez-Vidal ’79, a groundbreaking report in Health Affairs revealed that 75 percent of all health-care dollars are spent on chronically ill patients—many of whose conditions could have been prevented by proper diet and exercise. Since then, Martinez-Vidal, who helps states develop health-care reform strategies as the director of the Robert Wood Johnson Foundation’s State Coverage Initiatives program, has seen more states looking toward primary care and prevention as a way to cut costs.

“In the past, everyone tried to do it by tinkering around the edges without really getting to the underlying cost drivers,” he explains. “It was a question of how do we manage our benefits to reduce the premiums or how do we cut back benefits? It was all about higher co-pays, higher deductibles. This research really showed everyone a major cause of the problem. Today, most of the states that are on the forefront of health reform are saying we need to invest in delivery-system redesign, payment reform, care coordination, wellness programs and education programs.”

Cost Control

It’s hard to argue with the math. Last year Andrea Sisko ’04, an economist with the Centers for Medicare & Medicaid Services, co-authored a government report estimating that health-care cost increases will easily outpace inflation during the next 10 years. Spending, she predicted, will swell by 6.7 percent annually, doubling by 2017 when medical costs could account for nearly 20 percent of the nation’s gross domestic product. When it comes to state budgets, Sarcone reports that health care currently accounts for 15 to 22 percent of all expenditures. Add to these numbers what looks to be a sustained economic crisis, and preventive health care moves from looking like a good idea to looking like the only idea.

“If enough work is done to push for prevention, the amount of money that could be saved is enormous,” says Kjell Enge, an associate professor of anthropology who has worked on several preventive-health programs in South and Central America. “The factor in terms of cost is at least 1-to-10. For every dollar you spend on relatively simple preventive measures like education and primary-care outreach, you save $10 on the high-tech cure.”

Uphill Battle

But the road to recouping those savings in America looks far from easy. One of the biggest obstacles is the medical work force.

“Primary-care physicians play the most significant role in helping us prevent illness, and yet we see fewer and fewer physicians going into primary care or staying in that field,” says Ruthann Mamrak Russo ’80, a health-care consultant and the author of 7 Steps to Your Best Possible Healthcare. “Their Medicare dollars and insurance dollars decline every year. What they get paid for a patient visit today is significantly less than what it was a couple of years ago … It’s no wonder they’re leaving.”

To help solve this problem, Russo suggests that the federal government provide financial incentives for medical students to enter primary care and, at the same time, craft laws to expand the field. While the National Institutes of Health recently validated the effectiveness of several alternative-medical practices, many doctors of alternative medicine, who could help fill the primary-care void, are barred from the field by outdated licensing laws that vary from state to state.

“There’s an opportunity for the federal government to step in and expand our definition of primary-care physicians,” says Russo.

Patient, Heal Thyself

But this shortage of primary-care physicians also means that individuals need to take greater personal responsibility for their own health, says Russo. Through her work with HealthMap, a system she developed to help people plan their own approach to preventive health care, Russo has found that most individuals put far less effort into planning health care than planning a party.

“We’ve been trained in this country to turn over the role of keeper of health care to our physicians,” she says. “That way we sort of wash our hands of it and do what they tell us to do rather than be proactive.”

Ironically, health insurance itself also may be partly to blame. Because medical insurance originated as hospital insurance, which covered catastrophic illness but left individuals to pay for their own health-maintenance costs, expenses related to maintaining health have always received less coverage.

“Look at pharmaceuticals, for example. It’s probably the least insured benefit in health care,” says Piron. “People pay the most out of pocket for drugs—much more than they pay for a hospital visit or for an outpatient visit. That has led people to stop taking medicine when they feel financial pressures and that, of course, leads to some adverse health consequences that are going to be much more expensive for the system.”

On top of these challenges, much of the cost savings promised by more preventive health measures require costly long-term investments.

“The payoff for these things is very long term; you have to take a 15- to 20-year view,” explains James Hoefler, professor of political science. “But politicians tend to think in four- and eight-year terms. So it’s really going to take a lot of political courage.”

Wellness at Work

That’s one reason employers have already begun to take the lead through wellness programs that encourage healthy lifestyles. Dickinson, one of the first private, liberal-arts colleges to establish such a program, has been offering faculty and staff members on-campus fitness classes, health screenings and health-education seminars since 2006. According to Steve Riccio, who oversees the program as the human resource services staff development coordinator, the college already is reaping some of the benefits.

“Our health-care renewal [increase] last year was just 4 percent,” he reports. “It was one of the lowest that we’ve had in several years. Now, can you say that was all because of the wellness program? Not necessarily, but if you look at our utilization, there were very few high-cost claims related to poor cardiovascular health, for instance, and that makes a big difference.”

Fitness vs. Freedom?

For some, however, there’s a troubling side to the nation’s momentum toward more preventive health care. As employers, community health centers and the government look to reduce costs and improve health by shaping behavior, personal health rubs up against personal freedom. Talk of a “junk-food tax” and recent measures such as New York City’s banning of trans fats give rise to debates over whether an unhealthy lifestyle should be protected as a natural-born right.

“There’s this sense that public policy and the translation of public policy into regulatory activity shouldn’t make a judgment on people’s behavior,” says Sarcone. “But there are laws about gambling, laws about smoking, laws about seat belts. All those are really designed to modify behavior that is seen as destructive. So, historically, it’s not beyond the regulatory power of the public sector to move into managing behavior.”

We’re in it Together

The key, Sarcone and Hoefler say, is that in each case there needs to be a convincing argument that the regulated behavior damages more than the lone individual. The movement to ban smoking in public places, for instance, has been aided by the Environmental Protection Agency’s research revealing that second-hand smoke causes health problems for nonsmokers. In the case of many other unhealthy behaviors, Sarcone and Hoefler explain, it gets more difficult—but not impossible—to make a similar argument.

“We’ve got a very individualistic culture in the United States,” says Hoefler, “But one thing people are starting to realize over time is that every health issue impacts the whole society. Take the helmet law, for instance. Even if you have private insurance, if you crack your head open when you fly off the motorcycle, the entire risk pool is affected. My insurance will go up next year if a bunch of other guys out there do that. So in health care it’s not a public or private thing anymore. We’re all in this pool together.”

Slow Going

Considering that only 20 states have helmet laws for all motorcycle riders, Sarcone and Hoefler expect more preventive health measures to move forward at a slow pace. For that reason, as well as the myriad of other challenges facing this trend toward early intervention, most agree that continued progress will be slow and incremental but steady.

“It’s like turning around an aircraft carrier,” Hoefler says. “We’re changing course; it’s just going to take a long time.”

So while more employer-provided wellness programs, statewide smoking bans and initiatives to fight childhood obesity may be on the horizon, don’t expect tense evening soap operas about nutrition counseling sessions to replace those hospital dramas any time soon.