Over at GoozNews, Merrill Goozner has written an excellent piece on Senator Hillary Clinton’s proposal to create a “Wellness Trust”—a fund that would consolidate the dollars that both public and private insurers now lay out for preventive health services, and then spend that money in a way that gives us the biggest bang for our buck.
In his October 14 post, Goozner explains: “The new Wellness Trust would be run by 7-member board appointed by the president and approved by the Senate…in its first year of operation it would commission and then issue reports on the best way to supplement the existing health care workforce with certified ‘prevention health workers’; establish new reimbursement systems that would ‘align incentives’ with health promotion and disease prevention goals; and analyze current expenditures on prevention, which the bill estimates at 1 to 3 percent of health care costs or $20 billion to $60 billion.”
When Clinton talks about creating reimbursement systems that “align incentives” I believe that she, like the Medicare Payment Advisory Commission (MedPac), is talking about the need to pay health care providers for the quality of their care—not the quantity. In other words, we want to pay for preventive care that actually leads to better health. Some call it “paying for value,” and argue that this must be the centerpiece of health care reform.
Goozner stresses: “Some prevention interventions lower costs, and some
cost far more than they are worth—just like health care
interventions…By centralizing all the money spent on prevention in a
single agency, the government could deploy those limited resources in
the most cost-effective manner.
“A lot of the services that generate a lot of cash for a lot of doctors
and clinics—like prostate cancer screening for old men—do not make it
onto the U.S. Preventive Services Task Force recommended list,”
Goozner notes. “Presumably they wouldn’t make it through a Wellness
Trust screen. “ As we have discussed on HealthBeat in the past, neither
the U.S. Preventive Services Task Force, the American Cancer Society
(ACS) nor the National Cancer Institute (NCI) recommend routine PSA
testing of average-risk men over 55 because, as the National Cancer
Institute puts it “there is no evidence that early detection and
treatment alters the course of the disease.”
In the second year of the program, Goozner explains, the trustees of
the Wellness Fund “would then begin collecting all payments made by
Medicare, Medicaid and insurance companies for existing prevention
services. The agency would then designate its own ‘prevention
priorities.’ These would include community-based strategies like
tobacco and alcohol counseling or diabetes prevention education, as
well as the usual clinical services like the colonoscopies, mammograms
and vaccinations that most people associate with preventive care. With
these priorities and money in hand, the Wellness
Trust trustees would enter into contracts with certified prevention
providers to deliver the services deemed the highest priorities
"without regard to the insurance status of such individuals." This would be an important, affordable step toward providing essential
care for everyone, including the uninsured. Read Goozner’s entire post
here,
scrolling down to October 14. He does a great job of explaining who
will be opposed to this proposal—and why we should ignore them.
On the subject of “preventive medicine”, I also recommend Dr. Gilbert Welch’s recent op-ed in the New York Times,
in which he warns against: “screening [of well patients who exhibit no
symptoms] for heart disease, problems in major blood vessels and a
variety of cancers…These interventions do prevent advanced illness in
some patients,” Gilbert adds, “but relatively few. Any savings from
preventing those cases is dwarfed by the cost of intervening early in
millions of additional patients. No wonder pharmaceutical companies
and medical centers see preventive medicine as a great way to turn
people into patients — and paying customers.”
Why? Because once you are “diagnosed,” he points out, you will be
treated. “Early diagnosis may help some, but it undoubtedly leads
others to be treated for ‘diseases’ that would never have bothered
them. That’s called overdiagnosis.”
“Early screening is like the ‘check engine’ light in your car,” Gilbert
writes. “It can alert you to problems that need to be fixed, but too
often it picks up trivial abnormalities that don’t affect performance,
like one sensor’s recognizing that another sensor isn’t sensing.
“And if we look hard enough, we’ll probably find out that one of your check-engine lights is on.
“It’s hard to ignore a ‘check-engine’ light,” Gilbert acknowledges.
“Some mechanics reset them and see if they come on again, but often
they lead you to a repair. And you may have had the unfortunate
experience that a repair makes matters worse.
“If so, you have some feel for the problem of overdiagnosis. Almost
everybody with a diagnosis undergoes treatment. And all of our
treatments have some harms. From 1 to 5 percent of patients die after
major surgery, and as we are all increasingly aware, prescription
medicines carry real risks.”
Keep in mind that Gilbert is talking about finding something wrong with
people who appear well and exhibit no symptoms. “For those who are ill,
the potential benefits [of screening] typically overwhelm the potential
harms. But the calculus is different for those recruited to consume
preventive medicine: those who are well. They are the ones at risk for
overdiagnosis — and overdiagnosed patients can’t benefit from
prevention, because there is nothing to prevent. Instead, they can only
be harmed.”
Just a personal reaction, but it would be so wonderful to have an overdiagnosis problem.
Maggie
THANKS FOR LINKING TO MERRIL’S PIECE AND FOR ADDING YOUR OWN GOOD THOUGHTS
Here is what galls me!
The IMMORALITY of many health care economists stating publically that prevention is too costly because people might live longer!
The hard cold economics might be true (“death is cheaper”)but at what moral loss and and loss of humanity as a nation?
Dr. Rick Lippin
Southmpton,Pa
ralippin@aol.com
Rick and Paul–
Thanks for your comments.
Rick– Yes, effective preventive care does mean people live longer, and so we don’t save money.
But since saving money is Not the goal of healthcare, this argument is, as you say, beside the point.
On the other hand, largely ineffective preventive care–the type Gilbert takes about–is not only a waste of money, but causes great harm to many patients.
Paul–
I’m not sure it would be so wonderful to have an overdiagnosis problem. In the case of early stage prostate cancer, 20 out of 100 of men regularly tested via PSA and biopsy will eventually be told they have prostate cancer.
But only 17 will ever experience symptoms before they die of something else. Three out of 20 will, however, die of the prostate cancer.
Which three?
Should the 20 men
be treated? Another problem: We have no medical evidence that any of the treatments currently available alter the course of the disease–in other words, we have no evidence that these treatments even slow it down.
Though they may –in individual cases.
We do know that if you undergo one of these treatments there is a fair chance you’ll wind up either incontient or impotent.
So do you go ahead with the treatment? Or do you hope you’re one of the 17 out of 20 who will never experience symptoms, and go with “watchful waiting”??
Would you really want to be faced with this decision?
“Yes, effective preventive care does mean people live longer, and so we don’t save money.
But since saving money is Not the goal of healthcare, this argument is, as you say, beside the point.”
It’s fine and appropriate to argue that effective preventive care allows more people to live more years of healthy life. It’s also the right thing to do. It is not appropriate to try to sell preventive care politically on the grounds that it will save money because it won’t over the long term. To claim otherwise is both disingenuous and wrong.
Conversely, minimizing inappropriate or cost ineffective preventive care is not only the right thing to do, it also saves money. In a world of finite resources, we need to be mindful of costs, no matter how annoying and inconvenient that may be to some.
Barry–
Exactly, I agree completely.
Let me add just one phrase–which also confirms what you are saying:
When you write ” Minimizing inappropriate or cost ineffective preventive care is not only the right thing to do, it also saves money”
and, I would add, “spares
patients from the unnecessary risks of being exposed to ineffective preventive care.”
Barry–
Yes exactly.
And eliminating ineffective preventive care doesn’t just mean saving money; it means that patients are spared the risks assoicated with being exposed to ineffective preventive care.
Take a look at Gilbert’s article. He argues that both presidentialy candidates have been hyping the wonders of “preventive care” without really differentiating between preventive care that helps, and preventive care that merely adds to costs and leads to over-diagnosis.
This is understandable: neitherr candidate is a health care expert. And perhaps the message is too subtle for a campaign.
But our next president needs advisors who understand the difference.
Maggie,
But see:
http://www.medhumanities.org/2008/10/on-conceptions.html
http://www.medhumanities.org/2008/10/health-wonk-rev.html
Daniel–
Thanks to the link
I actually had seen medical humanities on this and totally agree.
I didn’t link to it in this post because I plan to write a longer post about prevention, and the need to view prevention in terms of Public Health (just as Med humanities suggests– there I plan to quote the blog and going into the work he refers to.
After the election, I plan to write about how we need a cabinet post focusing on public health–
A Department of Public Health (not unlike the Dept. of Health, Education and Welfare that we once had.)
If Obama wins, I’m going to suggest that he appoint Hillary Secretary of Public Health . .
Hey Maggie,
Sorry for the shameless advertising, but it is quite frustrating to see so much discourse — not just by candidates, but even among policy scholars, who in my view ought to know better — about a kind of prevention that really isn’t the conception which enjoys robust support in the evidence base.
Prevention was not traditionally and ought not be reduced to screening, the connection of which to health is at times tenuous at best.
Daniel-
I’m sorry when I was replying I didn’t realize that you Are Med Humanities. (I half-recognized the name, but didn’t know why.)
Anyway, the blog is on my “favorites” list and I had already put the post in the file I’m keeping on “preventive” with an eye to writing a post about it.
I think we’re probably on the same page . . .
Why are we still talking about “preventing” illness rather than promoting health?
Prevention has been discussed and lighly promoted for at least half a century, and it still has not caught on. Let’s go forward to another level, namely, REAL wellness for quality of life enhancement. REAL wellness could extend health status and human functioning beyond a prevention orientation. It could boost personal and organizational effectiveness. Five major areas of focus would be
1. A foundational knowledge of the practical applications of critical thinking skills;
2. An understanding of basic discoveries from positive psychology about human happiness;
3. A wide range of explorations intended to promote new discoveries about meaning and purpose;
4. A better understanding of science, along with a related appreciation of wonder, gratitude and commitment to reason and free inquiry; and
5. A raised interest in ethics and explorations concerning the nature, sources and applications of common decencies.
Three major obstacles to a gradual shift from prevention to REAL wellness for quality of life enhancement should be evaluated.
The whole point of a Wellness Trust should be to promote/facilitate and otherwise lead the way to self-directed boosts in quality of life.
Maybe I’m reading something out of context, but don’t we already have an overdiagnosis problem? Is it just in our family that everytime my husband saw a physician he was diagnosed with something new and given a new prescription? Was it just in our hospital…Maggie didn’t you write about your friend needing eye surgery…and it turns out he didn’t? Isn’t overdiagnosis a subject in your book? I realize that’s not what this thread is about but that caught my eye.
Lisa–
Good to hear from you.
Yes– we do overdiagnose.
And you are entirely right about the connection between overdiagnoses and ineffective preventive care.
Too much of our so-called “preventive care” is about expensive tests that then finds something else that needs to be treated–even if this is not the patient’s real or major problem.
Obama said “this year all new insurance plans will be required to offer free preventive care”?
Describe a new insurance plan please.