Abraham Verghese is a skeptic – The Myth of Prevention The article reacts to the now famous Gawande article. He argues that prevention does not save money.
Yet, we know that high quality primary care does save money. I believe Verghese is making the classic mistake of defining prevention only as primary prevention. Those who study epidemiology and health services research understand that the real value occurs in secondary and tertiary prevention.
Time for some prevention definitions:
- Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
- Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms.
- Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.
The value of good comprehensive care is in decreasing costs and improving value once you have disease. The major health care advances in my career come in tertiary prevention. Some examples should make this concept clear:
- ACE inhibitors for patients with CHF decrease hospitalizations, improve quality of life and improve mortality.
- So do appropriate beta blockers
- Statins decrease progression of coronary artery disease
- Antibiotics decrease recurrent spontaneous bacterial peritonitis
- Home oxygen improves COPD mortality and morbidity
- ACE inhibitors or ARBs slow progression of proteinuric CKD, as does aggressive blood pressure control
Most physicians can add to this list. The reason that I want universal coverage is to provide care to those with disease, not for those who are healthy. We provide value if we prescribe appropriate medications which patients can afford and willingly take. Those medications generally save health care dollars through decreasing hospitalizations and emergency department visits.
One final criticism of this provocative paper. The main value of EMR will result when a universal medical repository provides information on previous imaging studies, and allows us to avoid repitition. They also should decrease medication errors – a big financial and health care cost.
So I disagree with the premise of this paper. What do you think?
{ 9 comments… read them below or add one }
I enjoyed this thoughtful post. I hadn’t thought of “prevention” in these categories before reading it.
Most of the prevention you hear talked about in health care reform or at the employer level is of the ‘primary’ type.
The typical discussion is: 70% of our costs go to pay for the costs of preventable disease, caused by things like lifestyle. If we can get people to get rid of those unhealthy lifestyles, we will save a great deal of money.
It makes logical sense. The problem is that studies show that programs designed to get people to live these healthier lifestyles cost more than they save because not everyone you think will get the disease actually does.
I am hardly advocating against such primary prevention efforts. To the contrary, I think we should have more of them than we do now. But we should have them because they do something good for the people whose lives they touch, not because we imagine they will save us huge amounts of money.
Cost isn’t the only important issue. See: The Health Care Costs of Smoking, NEJM Volume 337:1052-1057
I do not disagree with your arguments, however, I believe that Dr. Verghese is being quoted out of context. His exemplifies his concerns with the use of coronary calcium scores, PSA and other interventions applied to populations that would derive little benefit from treatment. Even Steven Nissen and Eric Topol warned against the “oculo-stenotic reflex” but despite these warnings and multiple studies it is yet brisk in several of our colleagues.
I understand that our interventions are in part determined by an innate drive in physicians to do good. However, how often is the drive spurred on by their own financial good?Reduction in compensation for doing and an equivalent increase for thinking and caring may be an approach.
Remember, the government, health insurers and the like only are able to proceed as they do because we as physicians countenance their behavior. Should we not determine change and is the saying “physician heal thyself” not more relevant now than at any time?
I don’t think your comments come close to actually criticizing Dr. Verghese’s positions.
It seems that the definitions of secondary and tertiary prevention can very well be definitions of disease treatment, along with the examples you cite regarding beta-blockers, ACE-inhibitors, etc. I don’t think that Obama, or most people, are thinking about preventive health care as “secondary or tertiary preventive” care but rather as staying healthy, or catching conditions/disease/risk factors early (PSA’s, cholesterol, etc that Dr. Verghese cites). I am willing to bet that most physicians and the public don’t see the examples you cite as simply preventive care, but rather treatment of disease. If we use the secondary or tertiary definitions of prevention, then in essence all of medicine is preventive care. Furthermore, you’ve cited examples of good medical practices, but not necessarily practices that save money, if that is what you mean by value. In fact, the best way to save health care dollars is to have people avoid seeing physicians and having people die at home. Part of Dr. Verghese’s point is that the more you want to get doctors involved in people’s lives, the more health care money spent. Which means that services will have to be rationed. You may disagree with his premise, but the arguments presented are weak.
I do not think that EMR will necessarily avoid repetition nor avoid medication errors. Most of what people say EMR will do is anecdotal. I think Dr. Verghese is correct in his ambivalence on whether it will save money or not, and his skepticism on how this hope for savings will pay for itself. I am not sure that repetition will be avoided. I also work at a VA, and I will tell you that many things are repeated, because of the “garbage in, garbage out” nature of that EMR system. Medication errors, when made in the EMR system, are amplified. EMR is not all what people want it to be, but I don’t think it is as bad as other people say. I see switching to EMR like the switch from horses to cars for travel. It is going to happen because EMR may make some things in life easier (billing, etc), but saying it will save money or avoid error may be like saying that there will be less pollution with cars because there will be less horseshit on the road.
Only final note. How does providing universal coverage to reduce cost equate with excellent care that you generally advocate in your blogging? I think that advocating excellent medical care is different that advocating care for everyone in hopes of reducing costs. It is far from obvious that providing care for everyone will result in excellent management of disease or excellent management of the patient. It is by definition impossible (excellent care for everyone is like Garrison Kiellor’s Lake Webogon where everyone’s above average), but I am willing to let that slide. It seems that if you want to save health care costs, then the performance measures you are very adamant against using to define excellence (or at least to use to tie to physician re-imbursement) need to be used. If using Ace inhibitors and beta blockers in CHF, statins in CAD, antibiotic prophylaxis to prevent SBP, O2 in COPD, and ARB/ACE-I in proteinuric CKD save money, they why are you so reluctant to have these things measured? I’ve found your arguments in the past against performance measurements uncovincing (and always arrogant in their dismissal of “beancounters”. Adherence to performance measures based on well accepted, defined, and evidence based guidelines may not identify an excellent doctor, but it will certainly identify a poor one.
The best way to improve quality of care is to provide it to all. It seems intuitively obvious (to the degree that one can trust intuition) that people who are uninsured will not get their blood pressure checked or treated. So by making blood pressure checking affordable and accessible and medication for it free one improves access to treatment and improves quality, adherence, and outcomes.
So universal insurance is the first step to guaranteeing quality. Buying a Primatene mist MDI in the drugstore because one does not have insurance for acute asthma does not provide quality.
It is hard to see how insured people would have access to secondary and tertiary preventive care.
One can provide excellent care to most people. The average level of care can be higher. If you read Gawande and his observations of India and the triage that has to take place, then by that standard someone in a developed country has excellent care. Something that is excellent can be better.
Having worked in an inner city county hospital, I can categorically state that one would have trouble finding excellent care there on a regular basis. When I found patients with disease that had not been diagnosed despite multiple visits because the patient never had a proper history, never had a proper exam (no clothes removed), then by that standard someone who had care in a normal institution had better, good, or very good, or excellent care in comparison.
On the other hand, if you mean by universal care Medicaid, then one would have to agree. That does not agree excellence. I recently heard on the news that Medicaid was meant to be inferior since it would be dealing with the poor and the black. So inferiority was built in.
I guess with insurance there is no guarantee that your care will be excellent. But without insurance it is almost impossible to obtain excellent care. That becomes an issue of equity and social justice.
Bohdan A. Oryshkevich, MD, MPH
In response to Dr. Oryshkevich:
No, universal coverage is not the way to make quality medicine. The mantra of advocating for universal care means nothing, as the devil is in the details. How exactly is that universal coverage going to be delivered? After all, Medicare is universal coverage for the elderly, and it is nearly bankrupting this country. You can argue whether or not Medicare is providing excellent care for the elderly, but one thing it is not doing is providing a model for a sustainable health care system. While it is intuitive to some that being underinsured will not provide quality care, it is equally intuitive that universal coverage will lead to overutilization.
When you think about what quality is, it begins and ends with the physician/patient relationship/partnership. I think we physicians have failed our patients because we have not done our homework. For a variety of reasons, we are ordering too many tests, doing too many procedures, flogging too many people, and fail to see patients as humans rather than disease. Perhaps it is because we are not confident in our assessments (I’ll need to order an echo to rule out CHF, even though I am sure the edema is because the patient is obese; the radiologist who sees a spot in the U/s of the kidneys suggests a CT, then when CT is done suggests MRI, then when that is done, thinks the U/S is needed), we don’t know how to interpret the tests we’ve ordered (why exactly did I order that ANA? I’ll order a BNP every morning in a patient with CHF even though there is no value in doing so), we want to cover our asses (I’ll get CT of the lung for the 2mm nodule for years to come), or we are not taking enough time. Internist, Pediatricians, and General Surgeons, who should be standing in the middle of healthcare, are pushed aside (or perhaps more than willing to stand aside) by subspecialist. We’ve become part of a system where the principles of medicine taught in school are different than those we use in practice.
The government is not going to fix this. It can’t even fix the “problem” of having to have someone admitted for 3 days before Medicare Nursing home coverage kicks in which leads to unnecessary hospitalizations just to get someone placed; it makes obtuse rules distinguishing a referral from a consult; doesn’t have a code to pay for acute outpatient dialysis in someone who may have a reversible cause of renal failure, forcing either in patient hospitalization, or forcing units to give away dialysis. The government does not know about the delivery of health care, only the payment of healthcare. The VA likes to think it provides great care to the vets, but the dirty little secret is that many vets with insurance have “civilian” docs who will get them their scopes, knee replacements in a timely manner (the VA where I am at is book out 6 months, because apparently they cannot hire people who know how to clean the OR suites in a timely manner, wasting time), and non-formulary meds when the VA fails. I could not get them to pay for one of my patient’s PT for severe myositis who lived 90 minutes away because of their service connection rules; they wanted him to make that drive twice a week when he would have driven by dozens of places who could help him.
Excellence is created from the ground up, not top down. Government intervention will only help in fixing the payment problem, which is only exacerbating the current problem, because Medicare created that problem by overypaying for procedures and neglecting cognitive care. Fixing the payment system will not fix medicine. It is not simply a matter of proving “primary practitioners” more time with patients and paying for it, it is a matter of those “practitioners” being the brightest bunch, continuing their medical education in a meaningful way, and being leaders for their patients. We really can’t really on the politicians to do this for us, as it is hard for public to understand the “payment problem” when many physicians are in the top 5% income bracket. There will be a civil war amongst physicians, unless the subspecialist start asking themselves what they would want if they got sick—a well trained internist who develops a differential diagnosis and the surgeon who’ll get up in the middle of the night to examine your belly and take out your inflamed appendix, or the internist one who’ll put you in the merry go round from one specialist to the other, and the surgeon who’ll wait for the CT scan the radiologist doesn’t know how to read (it seems surgeons know how to read Abd CT scans better than radiologists, perhaps because they have clinical and surgical correlation). The best way to provide excellent medical is not simply providing it to all, but by making better doctors and letting them practice.
Currently Medicare does not pay for the preventive medicine CPT codes. Medicare does pay for pneumonia and flu vaccines, but most preventive medicine is done the discretion of a primary care doctor during a regular office visit. Many insurance companies limit preventive medicine/annual physicals on male patients between 18-40 to every 2-3 years, even though some of the patients close to 40 would like to come in for BP/chol etc screening. Screening is often denied under the current system.
The reality is that Medicare is a peculiarity in many ways. Once you offer universal insurance you have to design it well. Execution is as important as the objective.
But without universal insurance you have 50 million without insurance so on a scale of 10 their care may be 2 or 3 or 4 but not 9 or 10. You need tactics to get to your objective of high quality care for all. You need the cooperation of physicians and of its leadership. As I stated you have to have universal health insurance to be able to compete against the quality standards of countries with 100 % coverage.
One person one vote does not mean that every time the population will elect the best candidate. But you will not have a democracy without one person one vote. Sure you could state that you can only vote if you have an IQ over 110 but that would eliminate sixty percent of the people. You could stat that those forty percent vote in a quality manner. But if you had only 40% of the people voting would that bring about a better system? We could stat that we have the best care in the world because the people in Olmstead County in MN or the people in Utah live very long. But that would not include the denominator of the whole 300 million Americans. We could state that we are ecologically responsible against global warming because the people in Davis California all ride bicycles.
But you must realize that the AMA as Dr. Varghese points out resisted Medicare and only the fees drew them in. So Medicare was in many ways stillborn. Because Medicare pays a lot for procedures does not mean that the doctor has to fall into temptation and do the procedure. If medical schools on purpose put doctors into debt so that they are money driven, that is a problem. That is exactly what medical schools did in this country. So there was internal sabotage of Medicare.
In Canada where they have universal insurance procedures are paid much less. Let us say, $100 for endoscopy with ten slots a day per gastroenterologist. There are 15 people who are sent in for GI evaluation and/endoscopy in the afternoon for the next day and the gastroenterologist must decide that day who really needs the endoscopy the following day. The others have to wait until the next day. If they make the top ten they can get the endoscopy but otherwise they have to wait again. They can go to another gastroenterologist for a second opinion. But he also may find them below the top ten that need the endoscopy. So patients are turned away because of queues. That is built in prioritization which serves the system and the patients well in most cases. The doctors make the decision who needs what based upon the rational availability of resources. In the UK or the Netherlands the general internist decides who needs the endoscopy and the patient is sent to a nurse who does the procedure. The general internist does not make any money for the referral or the procedure and the nurse is paid a salary. The procedure is ordered by a cognitively oriented internist or primary care physician.
So the queue serves a valuable function. It puts an upper limit on the number of procedures that can be done.
In Canada, they have fee for service but they have no “private practice”. The doctor cannot set up an imaging facility and refer to himself. Simple technology can exist in the office but generally with some exceptions in Alberta, etc. you cannot own your own imaging device and self refer or have friends refer to you. Expensive technology is developed on a regional basis. In Japan, MRIs are reimbursed at a very low level so the tech companies have developed very cheap MRI machines. If reimbursements for MRIs fall in this country, MRI centers will import the cheap machines from Japan and do in volume what they now do for huge fees.
If you end up being a high volume physician (on a quarterly basis) in Quebec your fee schedule goes down to zero if you reach your quarterly cap. You can continue to work and see your patients but you will not be paid since you have reached your cap. Not all physicians reach this cap. But some do. You can then take a week or two off until the new quarter kicks in or you can continue seeing your patients for no reimbursement. Or you can work less intensely and see no new patients, etc. This is possible with a single payer.
If you dealing with one insurer only for your whole professional career) as in Canada, you know that they know that you are high volume MD and so that is a restraining influence. You cannot switch to another insurance company and start all over again. If you are a high volume outlier, they know your profile.
We have built in all sorts of excesses into the fee for service system: medical student debt, most doctors entering procedural specialties, high procedural fees, multiple insurance companies (no single payer), self referral, right to own your technology and hospitals, etc. So we have created a very skewed version of the fee for service system which is nothing less than institutionalized abuse of patients.
I am a board certified allergist. You can make comprehensive aeroallergy diagnosis with ten, twenty, at most thirty skin prick tests. ACP in 1988 or 1989. I am also trained in cost effectiveness medicine (HSPH) with Daniel Federman now head of the Institute of Medicine. So I have studied in this extensively over nearly thirty years. In Canada we did about twenty skin prick tests in a university referral practice. In New York City board certified allergists working in an academic settings would do 150 skin tests regularly on children (four or five years old) in both skin prick and intradermal tests. As the chairman of the internal medicine department told me at this medical school, “We cannot afford to do evidence based medicine.” Our system pays for this year in and year out.
There is nothing wrong with universal insurance. It is the way we set the rules and the fees and the rewards to physicians. We have worked to overbill Medicare so we have made it unsustainable. We have found a goldmine and scraped every last sliver out of it.
So Dr. Varghese’s points come from an Indian trained physician who is telling truth to power.
We are in an era of American glasnost and hopefully with successful perestroika.
Bohdan A. Oryshkevich, MD, MPH
There are primary care doctors in my communities who see 50 patients a day, and there are ones who only see around 25 a day. Both sets work from around 10-5 with an hour for lunch. Medicare and the private insurance can’t figure out the 15 minute visits codes are not possible at 7-8 patients an hour. Some of these same 40-50 patients a day doctors are known to liberally prescribe high quantities of narcotics and see a lot of car accident/work comp patients for the lawyer. Under a national health system a quota would be a good idea, similar to what is mentioned from Dr. Oryshkevich. The current system encourages a maximum number of patients and a maximum number of reimbursable procedures to make maximum income, which together do not necessarily equal quality health care. Providing subpar care is contributing to the wastes in the healthcare system.
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