Heath & Rehabilitation

One of the major concerns of health care reform in the United States is whether its cost will balloon out of control or whether the version envisioned by President Obama will actually end up saving money. President Obama envisions saving great amounts of money by concentrating on prevention. The question I have is, “Can prevention efforts save money?”

According to a June 12, 2009 article in the Wall Street Journal titled “Prevention Efforts Provide No Panacea on Health Costs,” there is no clear evidence on whether clinically directed prevention provides significant savings. According to the article there have been no broad scientific trials to ascertain if savings would be significant if physicians concentrated more on prevention than acute care. A study of diabetes prevention stated that “screening all 65-year-olds for diabetes would cost $590,000 for every healthy year of life it adds over just screening people that age with high blood pressure.” In the same article it stated that colorectal screening for cancer in men over 60 is cost effective.

Some screenings in the primary care setting are quite cheap and cost effective. A study by Medicare of brief interventions by primary care physicians with patients who are heavy drinkers found that there is significant cost savings. The article, “Brief Physician Advice with Problem Drinkers in Primary Care Setting,” found that there was an average savings of $1151 per patient, with 46% of the savings in emergency room costs or hospital care. The remainder of the savings was in crime prevention and drunk driving offenses.

The Wall Street Journal article quoted previously stated that there was no substantial savings in one study for targeted prevention measures for patients with chronic diseases. In the study most of the patients were diabetic or had congestive heart failure. Nurses phoned patients to be sure they were following doctors orders, packets were mailed to patients about their diseases and patients were informed about healthy living classes in their area. Hospitalizations, ER visits and deaths were not significantly impacted, according to this study. Another study of which I am aware finds significant savings in the primary care setting for chronic care patients if the Wagner Chronic Care model is employed. In an article by Truls Østbye in the May/June 2005 edition of the Annals of Family Medicine it was shown that a patient with uncontrolled hypertension had on average 12 visits per year to his physician. A patient with controlled hypertension only visited his physician on average twice a year. This model is currently being advocated in the Patient-Centered Medical Home model.

It seems, then, that saving costs through prevention as a medical service depends upon the disease being screened and the method being used. Undoubtedly, in my opinion, significant savings can be realized with the right approaches. Not only will savings be significant but patient lives will be dramatically improved.

Most of what has been covered in the news about prevention has centered on clinical approaches. Little has been said about prevention as a community, state or national activity. At a recent local presentation to health care providers focusing on the progress of a local nonprofit organization made in its efforts to reduce regional health care costs with the aid of a grant from the Robert Woods Johnson Foundation a speaker stated that it takes community involvement to make significant changes. Unfortunately, from my own observations, there did not seem to be many attending other than health care providers. It seems that no matter what the venue, disease prevention is considered a function of the medical community.

There are quite a few examples of significant changes in lifestyle habits that prevent many serious medical conditions and deaths through large scale interventions at the local, regional, state or national level. I am sure that many of you are aware of some and realize that they are cost effective. If you want proof that this can be done, just look at the percentage of adults and youth using tobacco. In the 1950′s over half of the adult population smoked cigarettes. Through effective media campaigns, screening by primary care physicians and tobacco cessation clinics offered by a variety of healthcare providers and insurers the percentage of adult smokers stands at approximately 23% today. That is a decrease of 60%!

I have a client who works in the prevention of the misuse of alcohol and other drugs in the high school setting. At one school over a two year period the percent of students who have used alcohol in the past 30 days has decreased 19.1%. The percent who have used marijuana in the past 30 days has decreased 17.3%. Binge drinking has dropped 16.6%. These drops in the misuse of illegal substances has resulted in significant decreases in negative outcomes, such as getting into fights and arguments as well as driving under the influence.

National media reported the efforts of Sommerville, Massachusetts to reduce weight gains among their school children in grades one through three. The results were very good. The children in Sommerville gained one pound less per student in a year than children in surrounding communities, thus reducing the BMI of the students. The remarkable success was due to largely inexpensive efforts by broad segments of the community. Schools served twice as much fruit and vegetables and greatly restricted access to unhealthy foods, such as ice cream. The mayor became a leader in the effort; he had crosswalks in the town repainted so they would be clearly visible and encouraged people to walk more. More children walked to and from school. Restaurants switched to low fat milk and smaller portion sizes. The accumulated effect of these and other efforts was a significant improvement in the health of the children. Details of this program can be found in an issue of the medical journal Obesity and in the May 10, 2007 edition of the Wall Street Journal.

Although most think of clinical approaches when thinking of prevention it seems that a clinical approach combined with community-wide prevention programs based upon proven strategies is best. Using proven clinical models such as the Wagner Chronic Care model and the Sommerville approach will undoubtedly realize significant health care savings over the long term. I hope that our Congressman will provide and reward such approaches. I hope that the medical community and prevention community, such as MADD and local coalitions, combine their efforts and encourage local community wide prevention campaigns, whether these campaigns focus on alcohol and drug misuse, obesity in youth, focus on the family campaigns, or one of the many other prevention campaigns that improve the lives of community members.

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