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Preventive Medicine Incentives

One of the major goals of healthcare reform is to make preventive service more available. During a recent telephone conversation with new member David Katz, MD, MPH, we discussed how the HPfHR system could promote preventive services.

Dr. Katz, who has published extensively on preventive services in the medical and lay press, sent me a couple of interesting pieces that discuss the under-utilization of preventive services.

In 2006 he wrote:

Most of us surely agree, in theory, that when it comes to disease, an ounce of prevention is worth a pound of cure. But a new report entitled “Priorities for America’s Health: Capitalizing on Life-Saving, Cost-Effective Services,” released last week by the non-profit Partnership for Prevention, suggests that our actions are often at odds with this philosophy.
The report indicates that many vital preventive services are seriously underutilized. The consideration of aspirin to prevent heart disease, for example, is often appropriate in men over age 40, women over age 50, or anyone with heart disease risk factors; yet the topic is only discussed with about 50% of these at-risk individuals. For someone who smokes, quitting is among the best things they can do for their health, and available evidence suggests that physician counseling is a helpful inducement. But only about 35% of smokers receive this professional guidance.
Screening for colon cancer by any of several means has life-saving potential in anyone over age 50, yet is provided to only 35% of this population. The pneumococcal vaccine can prevent one of the most common forms of bacterial pneumonia, and is advisable for all adults age 65 and older; but nearly half of this population is unimmunized. Screening young women for the common sexually transmitted infection, Chlamydia, can prevent further transmission, along with both serious illness and infertility- but 60% of sexually active women under age 25 are unscreened.
The report characterizes not only which preventive services are under utilized, but which, when used, offer the most “bang” for the buck. Beginning with the scrupulous assessments of the utility of preventive services compiled by the United States Preventive Services Task Force, this new report assigns priority scores for 25 preventive services based on their health impact and cost-effectiveness. Each of these is on a scale from 1 (lowest priority) to 5 (highest priority), and the two scores are summed.
Discussion of aspirin use to prevent heart disease, screening and counseling for tobacco use, and childhood immunizations all received a score of 10, making these top priority items. Screening for colon cancer, monitoring blood pressure, flu vaccine, pneumonia vaccine, screening and counseling for alcohol abuse, and vision screening for older adults were close behind with scores of 8. The full list is available at www.prevent.org/ncpp.

In 2007 he added this:

The leading causes of disability and premature death in our society are overwhelmingly preventable. There is consensus among experts that applying what we know now would enable us to prevent 90% of diabetes, 80% of heart disease, and up to 60% of cancer.
What if we dedicated funds to insuring every person in the country (or a given state), but then required them to put that coverage to good use? The United States Preventive Services Task Force (http://www.ahrq.gov/clinic/prevenix.htm) is a non-partisan group of medical experts who conduct exhaustive reviews of the evidence supporting clinical preventive services, such as immunization, cancer screening, and counseling for healthful eating, exercise, and weight control. The reviews of the Task Force illuminate a whole list of services we know not only to promote health and prevent disease, but also to be cost-effective. And other groups have taken this effort further, examining the impact of preventive services relative to one another. Former US Surgeon General Dr. David Satcher lead a group called the National Commission on Prevention Priorities that rank-ordered preventive services on the basis of bang for the buck. Topping their list are aspirin to prevent heart disease, childhood immunization, and counseling for smoking cessation (see http://prevent.org/content/view/49/99/ for the complete list).
Since we have cost-effective means of preventing advanced disease, why not impose on ourselves the responsibility of using them?
How about this: you are guaranteed health insurance only as long as you are substantially in compliance with recommended clinical preventive services? No need to require perfect compliance, but a minimum of, say, 80% of recommended services for your household during any 3-year period, might be reasonable. Published reports indicate that at present, clinical preventive services are substantially under-utilized.
The advantages of people receiving clinical preventive services are considerable. Lives will be saved, cases of advanced disease prevented by virtue of early detection and treatment, and costs reduced. If all clinical preventive services were used as advised, hundreds of thousands of lives could be spared each year, and health care expenditure reduced by $100 billion or more.
A recent report in the NY Times (To Save Later, Employers Offer Free Drugs Now. by Milt Freudenheim. NY Times. 2/21/07) indicates that some companies will provide medications to their employees for free to treat chronic disease. This is advantageous to the employers because well-treated chronic disease is less costly than poorly treated chronic disease. Co-pays reduce an employer’s drug costs, but the evidence is clear and consistent that they drive up total healthcare costs by reducing medication use. So paying the pharmacy bill to ensure that employees actually take drugs as prescribed turns out to be good business, as well as good medicine.

After reading and discussing the HPfHR plan, he suggested that we might be able to encourage preventive services for everyone by (public) financing Tier 2 coverage for those who show more than 80% compliance with their Tier 1 preventive screening services.
I personally think this will be a great addition to the plan and will dove-tail well with our aim to improve the health of the entire population.
Please let me know if you have any other thoughts or comments.
Gil

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July 20, 2008 - Posted by | Uncategorized

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