Monday, March 21, 2011

Healthcare cost savings from expanded access to preventive medicine could be dead on arrival

Enormous, and enormously unrealistic, hope is being placed on preventing illness and its complications as a means to improving health outcomes and containing healthcare costs.

A major criticism of the U.S. fee-for-service healthcare model is that it rewards the treatment of health problems over their prevention. Much of the effort at reform is aimed at revising incentives to motivate providers to deliver preventive medicine.

The logic is that if physicians and other providers are compensated for a focus on prevention, and patients have access to affordable primary care, then people will be motivated to use that care and do the things needed to stay healthy. The reality, however, may be quite different.

The impediments to preventive medicine and health maintenance may lie less with our healthcare system than with the psychological make-up of the patients it's meant to serve.

For all that patients may talk about wellness, it is actually very difficult to socialize or coerce them into greater proactivity or compliance. As a general rule, people want to see the doctor only when they're sick. That's why the people least likely to miss their medical appointments are those who are already very sick.

People who know the right choices to make for their health -- diet, exercise, annual physicals -- often fail to make them. Fear, denial, and other psychological forces keep us from facing our vulnerabilities and embracing steps that might extend our longevity but in ways we can't generally measure or know.

Many of us with prescriptions to prevent various life-threatening conditions are, for a variety of reasons, notoriously reluctant to take them, or take them regularly. The problem of insufficient adherence and persistence with drug therapies has unmeasured implications for the health status of our population but clear implications for the revenues of the pharmaceutical industry.

Complicating things further, any public debate about the merits of a particular therapy or test becomes rational grounds for people to abandon preventive or early intervention behaviors.

A case in point is the drop in rate of yearly mammograms among women over age 40 after the revised U.S. Preventive Services Task Force guidelines were announced in November 2009 saying that women in their 40s at average risk for cancer do not need annual mammograms.

Even before the Task Force issued its conclusions, and in spite of American Cancer Society endorsement of yearly screening, only 50 percent of women in their 40s were receiving annual mammography (and only 54 percent of women between 50 and 64, the group for which there is greatest evidence of, and agreement about, mammography's value).

Kocher & Sahni suggest in The New England Journal of Medicine that accountable care organizations (ACOs) should focus on the 10 percent of patients responsible for 64 percent of all U.S. healthcare costs by offering "better and more efficient management of chronic conditions," for example, by calling high-risk patients to return for timely follow-up care.

Unfortunately, even patients at high risk of future health problems are not necessarily easier to coax or coerce into dutiful prevention behaviors than anyone else.

Not long ago, I received a message from my physician's office telling me that my internist had renewed my prescriptions (a proton pump inhibitor for GERD, an ACE inhibitor/diuretic combination for hypertension, and five medications for asthma) and reminding me to schedule my annual physical. I haven't. I know I should. And I'm willing to bet that I'm one of the more compliant patients my physician has.

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