Investing in Prevention
By: Greg Vigdor/WHF President & CEO
"An apple a day keeps the doctor away". "An ounce of prevention equals a pound of cure". You probably know where I’m going with this. If trite sayings and old wives’ tales were how we made our decisions on directing investments in our health care system, there is little doubt that we would be doing something differently - investing in prevention, for one.
Sadly - that is not now the case. The health care system has developed through the prism of science and clinical expertise aimed primarily at treating illness or injury; things such as cancer, broken bones, heart attacks, kidney failure, and the ravages of infectious diseases. To its credit, the health care world has made incredible progress in figuring out how to better treat or even cure the devastation of these diseases and injuries over the past 50 years. It has also figured out better and less invasive ways to diagnose these health care problems. We are surely fortunate to enjoy the benefits of these advances.
However, this success comes at a price. It has cost a tremendous amount of money to achieve this progress. Once a small fraction of the American economy, health care rose to account for eight percent of the gross domestic product in the 1970s. This was a statistic that many found troubling. Some even suggested that we needed to put a lid on this cost growth before it pushed out other critical elements of the American economy. Others maintained that health care was an economic sector to be desired in this Nation - and that additional money should be invested in it.
Whether by design or by the inability to control health care cost pressures, what is certain is that the societal investment in health care has grown dramatically over the years since. In most years, we saw double digit increases in our investment. Over time, the investment in health care moved from large to massive, with health care now making up nearly 17 percent of our economy. Most experts believe it will grow to more than 20 percent within the next five years - even with health care reform.
While it remains the case that health care is a "good" thing for many people, the tremendous cost of it has become a national crisis. We know this by listening to the frustration of the people that pay the bills (such as businesses and governments), and also from regular people who are paying more and more of these bills out of their own pockets. Polling shows that people see the cost of service as the compelling problem of health care, far more so than access or quality concerns. It has been this way for more than a decade, probably much longer.
The numbers bear out the public concern with health care costs; there are trillions of dollars at play. For those who see our Nation now competing in a global economy, the numbers are even more troubling. We spend double on health care per person than most other industrialized nations and 1/3 more than the second highest spending country on the world list (Norway). All while the health care system clamors for even more, activating this call with enormous political campaign contributions to make sure that policy makers continue the flow of money to this sector.
With so much white noise surrounding this issue, it is hard to focus attention on the need to invest more in prevention, even if it makes practical economic sense to do so. How can we put more money into this aspect of health and health care when we have this overwhelming cost problem to tackle?
Well, if only we actually were tackling the health care cost problem; we certainly need to do that. But how? One way might be to substitute our investment in medical care for larger investments in those social determinants of health that offer more promise to actually improve our health. That is, things like education, housing, greater individual responsibility for health and the like. These are a handful of the social determinants that contribute well over half of what can be done to produce health in this Nation. While medical care contributes no more than 8-10% toward creating health, we currently invest more than 97% of our vast health care resources to it. So, we should constrain how much we spend on medical care and move it to other more valuable health investments - such as K-12 education.
The call for more investment in prevention should also address how the medical care system spends its 97%. A small but important chunk of that 97% goes toward medical services that are preventive in nature. These services include medications, screening tests, counseling and other health care interventions that have proven to be worthwhile. The list of the recommended services is developed and published by the United States Preventive Services Task Force, based on their ‘best evidence’ review. Our own Healthiest State Report Card provides a composite listing of some of these services so that we can judge how well we do in these areas when compared to different states. Despite the science, the list, the benefits, and the reality that most are very low cost interventions, there is far more money to be had for treating the diseases or illnesses once they occur than these proven clinical preventive services.
Why is this? Well, for one, there is no constituency to say “enough” on the part of those who are receiving dollars from the current investment patterns in health care in this Nation. These folks may be marginally okay with putting more into prevention if it is coming out of someone else's pocket but not their own. And part of what they consider their own is the view that they will require more money in the future, not just what they are currently earning.
One would think that budgeters in the government and private sectors would be fast to make the argument that more prevention would be a good thing in terms of distributing costs and benefits in this society. Trouble is that most prevention investments will save money over much longer time periods than most governments and businesses can conceptualize (or are willing to tolerate), so prevention is treated as an additional short term cost rather than what it should be; a long term investment that will translate into lower costs far into the future.
Prevention also suffers from ignorance as to what it entails and how much better we need to be at it. Witness a comment from a health care executive about this at a conference a couple of years ago. When asked by a news reporter about investing more in prevention, this insider commented that "we just don't know what to do to invest in prevention", citing conflicting newspaper stories about different diets and the like. Apparently, this executive was unaware of the work of the U.S Clinical Preventive Health Services Task Force. This health care leader created the impression that the industry would do more prevention if only those on the inside knew what to do. Well, they do.
In this state, and probably in others, many are also willing to be ignorant of the realities of how poorly we are doing in providing clinical preventive services to our people. Our Healthiest State Report Cards have shown that our state lags behind most others in delivering clinical preventive services. We have shared this data-based observation time and time again with health care executives, government health leaders and others. Yet, it has been almost universally ignored, as it conflicts with the preferred story line that casts Washington state as a national leader in delivering health care services. Hard to imagine how that can be the case when we rank 32nd in receipt of clinical preventive health services!
Those are just a few of the obstacles as we look to change our health care investment patterns toward prevention. So, there is much to do in helping to drive that change. And making sure that change happens is one of the keys to making us the Healthiest State in the Nation (or the Healthiest Nation in the World!). There remains little doubt that it must be done. To get it done, we will need to convince those who are vested in the status quo to take a broader and less self-interested look at the question of prevention. Daunting – yes, but we will continue the fight to make sure this issue is heard - heard above all the prevailing health care cost chatter. That’s because when it comes to prevention - “silence is not golden!”