An Ounce of Prevention
True healthcare reform: Healthier lifestyles can reduce disease and cut costs.
By Lisa James
If there is one thing that everyone in our national healthcare debate can agree on, it’s that we spend a lot of money on health. According to the federal government, US medical expenditures were roughly $1 trillion in 2006, or $4,078 a person. That’s more than 15% of our gross national product.
We’re not getting what we pay for. Our average life expectancy of 78 ranks 29th in a recent World Health Organization survey. What’s worse is that our healthy life expectancy—the period of time we can expect to feel fairly spry—is 70, 28th on the list.
These figures indicate that in fighting over who should pay for healthcare (something Congress was still debating as this issue went to press) we may be missing the point. The real question is how we can prevent disease instead of treating it—so we don’t have to spend such vast sums in the first place.
What makes our current healthcare system unsustainable? “We lay in wait for symptoms to appear,” says Len Saputo, MD, author of A Return to Healing (Origin Press), “and then focus on overkill treatments.”
Prostate cancer is a good example. Treatments range from watchful waiting, which costs a few thousand dollars for periodic testing, through surgery to such therapies as a radiation protocol called IMRT, which can cost $50,000. But no one is sure which works best—and under the current fee-for-service system, high-tech approaches such as IMRT are becoming more common.
Saputo believes this emphasis on costly treatments is wrong. “We need to reward doctors and other healthcare practitioners for the good things that they’re doing, for the money that they’re saving when they keep somebody well,” he says. “The business of medicine has handcuffed us so that we can’t do what we need to do in looking out for people’s welfare.”
But the “business of medicine” is only part of the problem. The other is an unwillingness by many people to take responsibility for their health. “The belief is, ‘I can overeat, someone down the road will save me. I can be sedentary, I don’t have to move, I’ll do it later,’” says Jill Evenson, ND, president of the Wisconsin Naturopathic Physicians Association. One study has estimated that poor health behaviors account for more than 40% of all sickness and death in the US (Health Affairs 11-12/05).
To avoid being swamped by healthcare costs over time, we need to focus on prevention now. “If you look at childhood cholesterol levels, body fat levels, the amount of atherosclerosis, it will frighten you,” says Barry Bittman, MD, medical director of the Mind-Body Wellness Center in Meadville, Pennsylvania. “We see cardiovascular disease as preventable and it’s now believed that a great deal of cancer is preventable as well. Wouldn’t it be better to make an investment now for a healthier future?”
How much could we expect to save? “We’re looking at lifestyle-based care returning four dollars for every dollar invested within two to four years. It would save about 75% of our healthcare costs,” says Saputo. “We’d all be happier and healthier, too.” According to the Prevention Institute (www.preventioninstitute.org), a 5% reduction in disease incidence in California alone could result in an annual savings of more than $1.6 billion.
First Things First
Going from subsidizing sickness to promoting health is going to require individual initiative encouraged by societal support. “We need to incentivize wellness,” says Evanson. “We need to give people the power, and have faith that they will actually choose, to take care of themselves if given the right information and tools.”
Bittman believes that people should get a chance to live healthier—or pay higher insurance premiums if they refuse to take steps such as smoking cessation or weight control. “I think every human being deserves an opportunity to improve their health,” he says. “I also think that everyone has an obligation to take care of themselves. You can’t have a healthcare system that provides everything for everyone regardless of their choices.”
Making good choices isn’t just for individuals. “We aren’t having a discussion on how to build walkable communities, about having clean air and safer water,” says Georges Benjamin, MD, FACP, FACEP, executive director of the American Public Health Association (www.apha.org). “We have to make sure there are healthy choices in vending machines in schools, that cafeteria food includes healthier choices.” And Benjamin believes in getting the business community involved in public health. When a restaurant goes smoke-free, for example, “we know that healthcare costs go down for workers. People have to understand the business reasons why this is a good idea.”
Supporting wellness will also require a different approach to the practice of medicine, one in which conventional and complementary practitioners work together smoothly. “What I would like to see is seamless respect for the other discipline, and for people to know when they need to refer,” says Evanson. “We have to say, ‘What is best for the patient? If I’m not, can you help? If I am, let me give you insights into what I’m seeing.’”
There are signs that people are at least starting to take charge of their own well-being. According to the National Institutes of Health, 83 million adults spent nearly $34 million on complementary and alternative medicine in 2007. And supplement sales rose nearly 5% a year from 2001 to 2008, a figure industry sources expected to increase in 2009 even amid an economic downturn.
Failure to focus on disease prevention means that healthcare costs will continue to spin out of control. “Social transformation and personal responsibility are absolutely central,” says Saputo. “Until that happens we’re dead in the water.”
More Opinions from Our Experts on Prevention
Benjamin on the role of complementary and alternative medicine (CAM): “When I talk about CAM I point out that many of the things that we think of as state-of-the-art medical science today were in the realm of alternative medicine yesterday. We’re just not as smart as we like to think we are, in terms of things some cultures have used for years to stay healthy. Those two worlds are going to come together as we know more about how the body works and how these approaches work.”
Barry Bittman on hidden medical costs: “We routinely do health-risk assessments [at our clinic]—questionnaires that look at healthy lifestyle practices plus measurements of blood sugar, body fat, cholesterol and so on. We’re surprised at how much money could be potentially saved by each person. We think of the $80,000 it costs to deal with a heart attack, but not about how much it’s going to cost to take care of this person the rest of their life.”
Bittman on cost as a driver of change: “People are complaining about taxes on sweetened beverages; they are saying, ‘How can you do this?’ It’s similar to smoking; with every cost increase in cigarettes there’s been a reduction in the number of smokers. There had to be a charge applied to it. There has to be a consequence for not changing one’s behavior.”
Bittman on why people don’t care for themselves: “It’s the law of entropy; if you stop putting energy into a system it goes into disarray. It’s easier to not take care of yourself than take care of yourself. Relatively few individuals take the necessary step of having an annual physical, even if their healthcare plan pays for it. We have to change attitudes and beliefs.”
Bittman on people’s ability to change: “When a person is highly motivated and is supported the changes they can make are incredible. We’ve seen people lose enormous amount of weight, keep it off and really improve their lives. I’m convinced that if we were a fit America we wouldn’t have a healthcare crisis.”
Jill Evenson on asthma as an example of saving via prevention: “We have all the tools to dramatically lower the cost of our healthcare. The bulk of what I see in my practice is chronic disease. We have models to prove that if you can act on things like exercise, diet and sleep, those are things that reduce symptoms and lower healthcare costs overall. If I can work with the family to identify the trigger for a child with asthma—animals, mold, dust, a food the child’s eating—when we can take away those triggers or reduce the reaction, we can save four to five trips to the hospital every year.”
Evenson on physicians’ lack of time: “What may be a healthy lifestyle for me may not be for you. Learning what works and what doesn’t takes time, and time is not something doctors have a lot of. And they’re frustrated by that. I know perfectly ethical, beautifully gifted MDs who can’t practice the way they want to because of time. And that’s the insurance model.”
Evenson on CAM’s role in healthcare: “We need to be realistic; with our limited numbers, we’re not going to go out and storm primary care. But we can help fill the primary care gap. The medical model has added nurse practitioners—we should be on the same tier.”
Evenson on health relationships: “The relationship between doctor and patient is the primary relationship. But in the interest of that patient, you have other relationships that affect their healthcare. It’s like a target: The core is the patient and the doctor, the next ring is the other practitioners, other rings are family, work environment, hobbies and so on. Those are all things that are affecting that person’s health. Even their financial consultant consult may pay a role, if stress over money matters is affecting their health.”
Len Saputo on the US medical industry: “We don’t have medical freedom in the US. There’s an unlevel playing field that rewards the medical industry as opposed to other healthcare disciplines. What we’re talking about is trying to fight the medical industry, the insurance industry and Big Pharma. You’re talking about waging a war against people who have all the guns. We should be ashamed of ourselves that we’ve allowed this to happen.”
Saputo on effects of drug advertising: “People don’t take care of themselves; they’re being brainwashed by direct-to-consumer [drug] ads. They’re eating things that are no longer food. Until we change how we operate as a culture in term of lifestyle we’re going to be sick.”
Saputo on the proper use of conventional medicine: “I would never throw away the magic of conventional medicine but I wouldn’t use it as the primary approach. Sometimes it can do amazing things; examples are gene therapies and stem cell treatments. But it’s way out of balance. [Health] begins always with lifestyle. Then you go to non-invasive medicine—homeopathy, herbalism, Chinese medicine. Then get aggressive with supplements to change the biology. If that doesn’t work, go to your doctor.”