Priority: prevention

By decreasing the incidence of chronic diseases, we can reduce costs and improve care

February 18, 2010|By E. Albert Reece and Edward Miller

If our nation's leaders truly want to cut health care costs while expanding health care coverage and ensuring the future viability of Medicare and Medicaid, prevention must be the cornerstone of health care reform - not just a piece of it. They can do this not only by significantly increasing access to primary care for the nation's uninsured and underinsured populations but also by linking such coverage to incentives for patients to change their health care behaviors.

Some in Congress are questioning the cost and appropriateness of funding preventive measures within legislation that is largely focused on expanding coverage. Unless Congress makes prevention a central tenet of health care reform legislation, it will merely be putting out brush fires, while a raging inferno of chronic disease threatens to consume our precious health care resources, and particularly our two greatest health care safety nets - Medicare and Medicaid.

The U.S. Centers for Disease Control and Prevention (CDC) reports that 133 million people have at least one chronic condition. The cost of their care accounts for more than 75 percent of the nation's annual health care expenditures of $2 trillion. By 2025, more than one in four Americans are expected to have two or more chronic illnesses, and most will be among the Medicare and Medicaid populations. In fact, Medicare spending is dominated by spending on the chronically ill.

Chronic diseases are an even bigger burden on Medicaid, accounting for nearly 80 percent of its expenditures. The Congressional Budget Office's conservative prediction is that, unless action is taken, total spending on health care will increase from 17 percent of GDP today to 49 percent in 2082, and federal spending on Medicare and Medicaid will mushroom from 4 percent of GDP now to almost 20 percent.

The good news is that most chronic diseases are highly preventable, and preventing some can even have a multiplier effect. If, for example, we were to launch an aggressive, incentive-based national effort to prevent or significantly reduce diabetes and obesity, it also would significantly reduce the incidence, medical costs and incredible human suffering associated with heart disease and stroke. Taken together, these four mostly preventable illnesses account for approximately three-quarters of a trillion dollars in health care costs per year.

Some experts suggest that the savings from preventive measures would be negligible or take too long to accrue. However, the available data dispute such claims. For example, a 2005 study published in the Annals of Internal Medicine found that a federally funded program to prevent diabetes in people with "pre-diabetes" produced significant cost savings in a relatively short time, particularly for people between 25 and 44. A large-scale diabetes prevention program in Finland produced similar findings.

In addition, multiple studies have demonstrated that providing consumers with information and guidelines about self-management - in combination with modest interventions and incentives - can lower the rate of use of medical services by nearly 20 percent. Safeway has had such an incentive-laden prevention program in place since 2005 and reportedly has been able to keep its per-capita health care costs flat, while most American companies' costs have increased almost 40 percent.

Academic health centers such as the Johns Hopkins University and the University of Maryland in Baltimore can play a major role by conducting incentive-based outreach screening and prevention activities. Doing so will get high-risk people into the health care system earlier and at a time when it is far easier and less costly to treat them. Although some of these programs already exist on a limited basis within our institutions and elsewhere, a major nationwide effort with appropriate reimbursement built in is needed to truly begin to get health care costs under control in this country.

If incentive-based prevention is not an intrinsic part of health care reform, the consequences for our health care system, particularly Medicare and Medicaid, will likely be catastrophic.

Dr. E. Albert Reece is vice president for medical affairs at the University of Maryland, dean of the University of Maryland School of Medicine and an internationally recognized diabetes researcher. His e-mail is Dr. Edward Miller is chief executive officer of Johns Hopkins Medicine and dean of the Johns Hopkins University School of Medicine. His e-mail is

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