By Emily P. Walker
November 30, 2007 -- Despite medical advances that have enabled doctors to unclog fat from arteries and prescribe tumor-killing medications and radiation, public health officials are hoping the future of health care will be focused on preventing the nation's most expensive and deadly diseases from ever happening in the first place.
"It's a perfect storm of health care costs increasing and baby boomers aging. These things have made us realize that prevention is important. It's time to create a culture of wellness," said Kathleen Toomey, director of the Coordinating Center for Health Promotion at the Centers for Disease Control and Prevention (CDC).
According to the CDC, the United States spends more than 70 percent of its health care dollar on providing care for those with chronic diseases such as cancer, heart disease, high blood pressure, and mental illness, causing some to dub the nation's health care system "sick care."
The World Health Organization recently ranked the United States behind 40 other countries based on health statistics. But "we can outspend everyone else blind," said John Clymer, president of the Partnership for Prevention. The United States spends about 16 percent of gross domestic product on health care, compared with 8 to 10 percent in most major industrialized nations.
"We need to do a better job to make people realize that chronic conditions are preventable," said Janet Collins, director of the national center for Chronic Disease Prevention and Health Promotion at the CDC. "You can have an angioplasty, but it doesn't equate to the same quality [as preventing heart disease]."
The current health care debate has recently been dominated by presidential hopefuls touting new payment plans so more Americans can get coverage for things such as cancer screenings, check-ups, medication, hospitals stays, and surgery.
Democratic candidates Sen. Hillary Rodham Clinton of New York, Sen. Barack Obama of Illinois, and former North Carolina Sen. John Edwards, and Republican candidates Sen. John McCain of Arizona and Arkansas Governor Mike Huckabee, all include steps for preventing chronic diseases and encouraging healthy lifestyles, said Ken Thorpe, founder of the Partnership to Fight Chronic Disease and chairman of the Rollins School of Public Health at Emory University.
Aside from national plans, individual states have the potential to spur major changes in the health of their residents, said Ross DeVol, director of the Center for Health Economics at the Milken Institute during a Friday Milken Institute–sponsored briefing on the economic burden of chronic disease. DeVol lauded the initiatives in the state of Vermont, which he called "the most comprehensive health care reform in the country." Vermont provides incentives for patients with chronic illnesses to "self-manage" their condition at home, which helps alleviate the strain chronically ill patients put on primary care physicians and hospitals.
An entire state also can promote a healthier culture by encouraging physical activity to combat obesity, like Arkansas did when it built a massive walking bridge over the Arkansas River connecting Little Rock and North Little Rock. Arkansas is consistently ranked one of the unhealthiest states in the nation, but has enacted some major reforms such as healthier school lunches and bonus payments for state employees who avoid unhealthy behaviors, according to Arkansas' Surgeon General Joseph Thomas, who spoke at a CDC summit on prevention held earlier this week in Washington.
At the community level, local health centers can reduce the prevalence of chronic disease by closing the loop between preventive testing and follow-up by placing public health workers in hospitals, said Collins. These workers would get the information of people who tested poorly on diagnostic tests such as blood pressure screenings, and contact them with for follow-up. Collins added that incorporating electronic medical records into the health system would help eliminate the problem of losing patients in follow-up.
Public health experts call the collaboration between national, state and local levels, and business and schools a "health systems integration" model and say without such a system, a push toward prevention-based care would be impossible.
Implementing a prevention-based approach to health care, especially one that would cut obesity and smoking rates, would translate to a $200 billion savings in treatment costs by 2023, DeVol said.
While paying for preventive services remains an issue, experts said, some private insurance companies are recognizing that paying to prevent a disease is far cheaper than paying for decades of disease management down the road, and are rewarding their policy holders for healthy lifestyles. Some even cover expensive preventive screenings such as a colonoscopy and bone density tests.
Medicare, meanwhile, could do a better job at covering preventive services, according to Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services who spoke at the summit about the "prevention gap" in Medicare.
While Medicare does cover some disease screening and certain adult immunizations, introducing more preventive services, like smoking cessation assistance, would require national legislation. Currently, Medicare covers smoking cessation only if a smoker is exhibiting symptoms of a chronic smoking-related disease, Weems said.
Some states are paving the way in prevention-focused health insurance by providing their employees with lower deductibles and bonuses for maintaining healthy lifestyles. For example, in West Virginia, state employees can sign an agreement to avoid disease-causing activities and receive extra coverage for things like smoking cessation and chemical dependency support, according to Weems.
One CDC official balked at the notion that money should even enter the discussion about disease prevention.
"We need to change the discussion about prevention so we don't have to prove that this will save money," said Edwin Trevathan, director of the National Center on Birth Defects and Developmental Disabilities at the CDC. "It should be worth the investment to never have the disease and go through the pain. Why do we have to prove that it saves money?"
If a CDC report released this week about stagnated obesity rates is any indication, collaborative, integrated anti-obesity campaigns may be working. The report found that after a quarter century of rising obesity rates, the number has finally flat lined.
One-third of the U.S. population is obese—or has a body mass index of 30—which puts much of the country at risk for cardiovascular disease, certain types of cancer, and type 2 diabetes. Still, the fact that obesity rates have not risen since 2003 is encouraging, said Collins.
Collins says the flat lining of the nation's obesity rates is partly due to the CDC putting obesity prevention on the top of its preventive agenda.
"We are actively working in partnership with state and local public health agencies, the nation's schools, community organizations, businesses, medical systems, and faith communities to promote and support healthy eating, physical activity, and healthy weight," Collins said.