Should we pay for prevention? Making health the goal of health care (5/24/12)
Making Health the Goal of Health Care
How much do practitioners get paid to prevent illness and regenerate people’s health? Most of the time – zero. How much do doctors get paid to treat long standing, chronic illness? Depending on health insurance – which prefers some illnesses to others – the sky’s the limit.
Why do we pay so much to treat a bad result but not to prevent that result?
Go Walk With a Patient
In the 5/22/12 NY Times, health economist Dana Goldman tells a story of a physician treating a patient with chronic disease. He wants to take a walk with a patient, rather than simply provide drugs and standard, “evidence based” treatment.
But no one will pay him to do that.
Such things do happen in health care “systems” where the goal is the overall health of the population. Goldman talks of paying doctors for prevention rather than paying for extraordinarily expensive end of life care – even if prevention causes a population bulge of long lived, healthy elderly.
But health insurers in America claim there’s no profit incentive to keep people healthy. Large corporations change their insurers every couple of years. If you make people healthy ten years from now, someone else gets the credit – and the money.
Sadly, doctors are generally not well set to explain to people how to regenerate their bodies and stay healthy. Doctors are taught to deal with sick people – one at a time. They see more and more sick people – and are trained to get each of them “unsick.”
The result is that American physicians are paid according to an impoverished definition of health – the “absence of disease.” How many times does your internist tell you “your numbers are fine” when you’re still hurting?
The WHO definition of health is “complete physical, mental, and social health”. They’re talking about populations, not individuals. Worse, in many cases physicians are incentivized not to try and treat the “full” patient. With increasing technical specialization, they work instead on one or two “problems.” Money comes in for diagnosing and treating such specific “problems” – and not for keeping people well.
Psychotherapists generally have a more expansive view of “patient care.” But they cannot pay full attention to the many other aspects of life – from physical illness to environmental issues – that strongly affect health.
Health is a much bigger issue than health care.
The Three Propositions
With health care presently eating up 18% of U.S. GDP, it’s worthwhile to repeat three propositions:
- Health care should be about health. Preventing an illness is vastly more effective and cheaper than treating it, even if those measures involve little or no specific “medical” expertise. Lifespan in the last century increased greatly in the last century due to sanitation, nutrition, education and vaccination – much more than provisions of medical care.
- A healthy economy requires a healthy population. People don’t work well – or creatively – when they’re sick.
- A healthy population requires a healthy environment. Put people in a toxic environment and lots more of them get ill.
Health Is Far More than Health Care
Let’s look at two issues that should be regarded as national health issues – but often are not.
First is the unity of FEW – food, energy, and water. The whole population needs safe drinking water not filled with carcinogens, drugs, heavy metals, pollutants, and microorganisms – and should be able to get it from public sources, not expensive bottled water. Farmers need lots of water to create crops. Oil and gas drillers and nuclear plants need huge amounts of water to produce energy – especially through practices like fracking.
Fracking can radically change the quality of drinking and agricultural water.
We want safe drinking water. We want nutritious, cheap food. We want domestic energy supplies that produce less pollution. Natural gas is better that way than coal, but only if the drilling methods control methane offgassing and don’t wreck the usable water supply.
Drinking, cleaning, food and energy production all require vast amounts of water. Yet is water use viewed as a health issue where food, clean water and energy must all be balanced against the overall health of the population and the economy?
Go look for that in the policy debates.
Next up is another major health issue – adolescent obesity and its result – diabetes. With reports that up to a quarter of adolescents will eventually prove diabetic or prediabetic, is this framed as a national health issue?
Rarely. Instead it becomes a debate about nutrition, or high fructose corn syrup, or sodas in the schools. But many more factors go into adolescent obesity – including cell phone use and sleep (sleep less, weigh more); lack of PE classes in schools; increasing use of cars and buses to transport kids rather than self-transport; energy drinks and their effects on rest and regeneration; the new forms of social networking; and perhaps most problematic, food advertising to children.
Are these different issues put together when we talk about adolescent health? Or are they tackled – if at all – on a one to one basis?
Putting it Together
A healthy population does not just live longer – it performs better. People feel more alert, alive, empowered. They also get more done, including economic production.
The American health care “system” is almost singularly unconcerned with producing health – the well-being of the population. According the CIA World Factbook, the US ranks 50th in the world in lifespan – one measure of health – and pays out about twice as much as other comparable countries.
What a deal.
If health care is to justify its outsized costs, we need to see health care’s stated goal as health – the well-being of the population. Otherwise, people will get wise to what other countries have known for decades: health care is often ancillary to the public’s health. Your water, air, food supply and national lifestyle may not be as sexy or “bottom-line profitable” as new hospital wings. They just affect the well-being of the population far more.
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