During recent years, there has been a growing recognition throughout the world that more and better prevention is needed to reduce human suffering, enhance the quality of life, and contain medical expenditures (Fries et al., 1993). There are two major reasons for this conclusion: the inadequacy of treatment-oriented strategies and the potential benefits of prevention.
The Inadequacy of Treatment-Oriented Strategies
A therapeutic-oriented medical system devotes most of its funds towards curing diseases after they occur. Medical resources are therefore focused on diagnosing disease and eliminating it through pharmacology, surgery, radiation, or related technologies, which are relatively expensive. The prevailing medical doctrine is that better diagnosis and therapeutics will yield better health.
Therapeutics is the dominant strategy for health care partly because when many groups are competing for relatively scarce financial resources, generally the most dire needs are met first. People dying of heart disease or cancer today are a higher priority than groups who might get the disease 20 years in the future. Consequently, the majority of nations currently direct most of their medical resources towards implementing a therapeutic or curative strategy.
However, in recent years some medical researchers have questioned the effectiveness of relying almost entirely on the therapeutic strategy for maintaining health. For example, Thomas McKeown (1978) explained:
Modern medicine is not nearly as effective as most people believe. It has not been effective because medical science and service are misdirected and society's investment is misused. At the base of this misdirection is a false assumption about human health. Physicians, biochemists, and the general public assume that the body is a machine that can be protected from disease primarily by physical and chemical intervention. This approach, rooted in 17th century science, has led to widespread indifference to the influence of the primary determinants of human health-environment and personal behavior-and emphasizes the role of medical treatment, which is actually less important than either of the others. It has also resulted in the neglect of sick people whose ailments are not within the scope of the sort of therapy that interests the medical professions. (p. 60)
Robert J. Haggerty (1990) stated:
There is not much evidence that illness care (which is what most medical care consists of) reduces mortality or morbidity very much. When well organized, it can reduce utilization of expensive facilities such as hospitals and emergency rooms and can reduce other costs such as laboratory and pharmacy without any measurable difference in health status. In other words, the effect of illness care after a point produces only marginal gains in health. (p. 113)
Some research supports this viewpoint. Fuchs (1972, 1974, 1979) and Newhouse, Phelps, and Schwartz (1974) concur that therapeutic care appears to be only a minor factor in producing national health. Multiple regression studies on general health inputs and outcomes further support this conclusion. These studies include those by Letourmy (1975). Fuchs (1979) summarizes the results of these studies: "The basic finding is: when the state of medical science and other health-determining variables are held constant, the marginal contribution of medical care to health is very small in modern nations" (p. 155).
Evidence for the ineffectiveness of almost total reliance on therapeutic medicine (at present, 98%-99% of health sector spending has been devoted to treatment and 1%-2% for prevention) in producing health is the virtual leveling off of the adult mortality rate in the U.S. from 1955 to the present. Since the end of World War II, the GNP devoted to medical spending has grown from less than 5% to an estimated 14% of GNP in 1993. Yet there have been no corresponding improvements in mortality and other health measures.
C.T. Stewart, Jr. (1971), empirically evaluated the contributions of treatment, prevention, information, and research in improving health as measured by life expectancy for all the nations in the Western Hemisphere. With regard to the comparison between treatment and prevention, Stewart (1971) concluded:
Readily available empirical data suggest that until recent decades in the United States, and even today in nearly all underdeveloped nations, health improvement as measured by increased life expectancy has been almost entirely the result of improvements in prevention. (p. 111)
The therapeutic strategy has apparently reached the point of diminishing marginal utility in most nations, including the United States. This suggests that our continued massive investment in this expensive approach is unwarranted. Further spending might help a relatively small number of people in the short term, but the general population does not appear to benefit significantly in terms of increased life expectancy or reduced morbidity in the long term.
The therapeutic strategy is exhibiting the symptoms of an obsolete technology, namely, level to decreasing marginal returns. It may now be time to consider alternative strategies.
The Possible Benefits of Expanded Prevention
The prevention-oriented strategy is based on the realization that "an ounce of prevention is worth a pound of cure." In implementing this strategy, a public health organization attempts to identify and promote the determinants of good health and to eliminate factors that threaten health. Usually public health officials prevent disease through community interventions that improve water purity, hygiene, vaccination, sanitation, nutrition, and air quality and other environmental factors. They also attempt to foster healthier lifestyles through programs that aim to improve dietary habits, lower cholesterol, reduce drug abuse, decrease smoking, encourage regular exercise, decrease alcohol consumption, increase prenatal care, introduce stress management, and otherwise enhance health in the individual and society. Unlike clinical medicine, public health attempts to avert medical problems before they arise.
In 1979, the United States government called for more prevention in Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Later, in Healthy People 2000: National Health Promotion and Disease Prevention Objectives (1990a), the Department of Health and Human Services (DHHS) identified specific prevention-oriented goals and delineated plans for attaining those goals. Both these documents operationalized prevention in terms of eliminating behaviors that increase disease risk. Secretary of Health and Human Services Louis W. Sullivan (Health and Human Services, 1990a) explains the U.S. government's perspective:
First, personal responsibility, which is to say responsible and enlightened behavior by each and every individual, truly is the key to good health. Evidence of this still-evolving perspective abounds in our concern about the dangers of smoking and the abuse of alcohol and drugs; in the emphasis that we are placing on physical and emotional fitness; in our growing interest in nutritional practices; and in our growing concern about the quality of our environment. . . . We would be terribly remiss if we did not seize the opportunity presented by health promotion and disease prevention to dramatically cut health-care costs, to prevent the premature onset of disease and disability, and to help all Americans achieve healthier, more productive lives. (p. v & vi)
In spite of extensive recognition of the need for more prevention, governmental funding has not increased significantly in this area. Historically the United States has spent 1%-2% of its health sector expenditures on prevention. It is possible that more funding for health promotion and disease prevention research and interventions in the United States would yield significant improvements in health and well-being that would simultaneously reduce national medical expenditures. This funding, however, must be well directed; not all prevention and promotion programs are effective (Russell, 1986).
Government and private organizations attempt to promote health and prevent disease mainly by disseminating information on lifestyle improvement. Prominent individuals help this endeavor by expounding the virtues of healthy behaviors; for example, on Feb. 5, 1992 (Des Moines Register, 1992), President Bush urged citizens, "Let's change the behavior that costs society tens of billions." Such exhortation strategies appear to have had only limited impact: they have yielded minimal results as measured by morbidity and mortality rates. Most people find it difficult to change their behavior. For example, there have been numerous smoking cessation campaigns in the U.S., and consequently, almost all adult smokers in the country know that their habit increases the likelihood of their dying prematurely from lung cancer, coronary heart disease, or other diseases. Ninety percent of those who smoke would like to stop, but only 15% will attempt to quit each year. Of those who try to end their habit, only 10% will succeed. John G. Bruhn (1988) explains why behaviors are difficult to change:
Compliance is difficult to achieve when health produces little or no rewarding physical feedback, e.g., reduction of pain, and typically elicits only minimal or short-term acknowledgement and support by family, friends and employer. . . . People are reluctant to alter patterns that represent powerful, predictable, and immediate sources of gratification which are deeply ingrained in social and cultural contexts. One possible impediment may be the lack of a comprehensive national health policy and the mixed messages the public receives about the health risks of certain substances. These inconsistencies may reinforce the ambivalence and resistance to change among many people. Furthermore, there is an apparent lack of real commitment to the concept of healthier living. The government continues tobacco subsidies, while the Surgeon General takes a strong stand on the health risks of smoking. Similarly, certain foods and alcohol are promoted by the mass media, while the health sector warns about their abuse. Perhaps one of the greatest barriers to change may be the "live for today and don't worry about tomorrow" attitude prevalent in our country, coupled with the high expectations that the sophisticated technology of medicine can mend any health malady that might occur. There is little incentive for individuals to assume responsibility for their health or adopt a Spartan pattern of living (Milio, 1981). (p. 79)
In 1974 Marc Lalonde, Canadian Minister of National Health and Welfare, issued a working paper called A New Perspective on the Health of Canadians, which challenged many of the current assumptions in the health care field, such as "more medical therapeutics means better health." Lalonde stated that the Canadian government would give the same priority to environment and lifestyle that it gives to medical care organizations. Only a small fraction of Minister Lalonde's recommendations for prevention were implemented, however. Sixteen years later, Milton Terris (1990) again urged Canadians to adopt more healthy behaviors:
Perhaps the biggest failing of the Canadian program is a defect it shares with most of the world's developed nations: its enormous expenditures for medical care have left very little money for preventing disease and injury.
Illness and death from lung cancer continue to rise in Canada-at an alarming pace in women, for whom the death rate doubled from 1970 to 1979. Chronic obstructive lung disease, another major killer caused mainly by cigarette smoking, is also on the rise in Canadian women. Cirrhosis of the liver, primarily from heavy drinking, increased by 31 percent in men and 21 percent in women during the 1970s. . . . All these problems are preventable, but even now, 15 years after the Lalonde Report, decisive action has yet to be taken. (p. 32)
A possible deterrent to funding research on innovative prevention strategies is a perceived doubt that health promotion and disease prevention are cost effective. Pelletier (1991) points out that research assessing the cost effectiveness of health promotion interventions is urgently needed:
Unequivocally, the question most frequently asked by decision makers prior to implementing comprehensive health promotion and disease prevention programs is "What is the data regarding the health and/or cost benefits?" Failure to provide compelling evidence documenting these benefits is the most pervasive deterrent to the implementation of programs. (p. 311)
According to two reports by the Office of Technology Assessment (1989, 1990), Medicare does not pay for most preventive interventions in the elderly because there is no evidence to justify these programs as being effective and affordable. These reports add that the failure to produce strong evidence is usually related to research design problems that foil the accurate measurement of potential expenditure savings. The problem is not necessarily a lack of potential results, but the lack of well-designed and properly implemented research. Unfortunately, in America prevention research has been a low priority; it has been overridden by more popular projects such as AIDS and genetic research.
Finally, interventions must also succeed in changing the potential patient's perception of his or her own health status, in addition to improving physical health. The reason for this is that health improvement alone is unlikely to reduce utilization. A study by Buczko (1986) indicates that the key determinant of physician utilization for the general population is perceived health status. Buczko (1986) explained the results of his regression analysis on various possible predictors of physician utilization:
As in prior studies, health status variables were the strongest predictors of both physician visit utilization and expenditures. Perceived health status was the best predictor of number of physician visits and physician visit expenditures, and it was also a significant predictor of the probability of a physician visit. (p. 25)
Thus to decrease medical utilization and expenditures, a health-promotion intervention must improve both physical health and psychological status, because both of these factors affect medical care expenses.
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[The International Health Care Cost Crisis]
[The Need For Prevention: Identifying New, Cost-Effective Strategies]
[The High-Cost Case Phenomenon: A Way to Leverage Medical Expenditure Savings through Prevention]
[The Proposed Strategy]
[Conclusions and Future Research Directions]