There is an 1895 poem by Joseph Malins entitled A Fence or an Ambulance. The poem recounts two opposing perspectives on what to do about a perilous cliff that had caused injury to many. Some said, "Put a fence 'round the edge of the cliff;" others, "An ambulance down in the valley."
One hundred and twenty years later the debate between prevention and treatment still rages, but in the US healthcare system, the ambulance is winning -- and by a sizable margin. A recent article in the New York Times ("A Sea Change in Treating Heart Attacks") by Gina Kolata is wholly emblematic of our nation's focus on treatment over prevention.
The article opens with a review of the many factors that contributed to a 38 percent decline nationally in the death rate from coronary heart disease between 2003 and 2013. These include better control of cholesterol and blood pressure as well as reduced smoking rates.
However, as is often the case when discussing health in the U.S., the article focuses on improvements in treatment. Although the story features Camden, New Jersey -- one of America's poorest and most dangerous cities -- where "heart disease risk factors abound..." and where "[o]besity is rampant, as are high cholesterol levels, high blood pressure and smoking," it only examines the clinical successes of Camden-based Our Lady of Lourdes hospital -- the ambulance down in the valley.
Photo courtesy ep_jhu (CC BY-NC 2.0)
An Obsession with Treatment
While the article is certainly valid and accurate in its own right, its singular focus is representative of our nation's obsession with medical innovation and invention. It is representative of our quick fix culture -- where a pill is preferable over real behavior change. This approach comes at a cost, though. Nearly half of all U.S. medical spending can be attributed to about 5% of the population, with 1% accounting for one-fifth of all spending.
When treatment is episodic and quick, the system works. A patient can show up at the doctor's office with an infection, receive treatment, and likely be cured. The costs and care were contained. Today, with chronic disease like asthma, heart disease, or diabetes much more prevalent and 60 percent of our adult population obese, care is continuous-and the bills start adding up. Nonetheless, as a nation, we continue to value, if not celebrate, treatments over prevention.
Addressing What Really Makes Us Sick
Like in Camden, New Jersey, most of what makes people sick has to do with where they live, how active they are, what they eat, and their daily stress levels.
While prevention is often oversimplified to a conversation about individual choices, those choices are made in a broader context. They are shaped and compounded by factors outside of any one person's control -- high concentrations of alcohol and tobacco outlets and advertising; mold, insect and rodent infestations in rental and low income housing; "food deserts" with no access to fresh meat, fruits, or vegetables; exposure to high crime areas; and no or limited access to parks or playgrounds.
While more people in the US may have health insurance than ever before as a result of the Patient Protection and Affordable Care Act (ACA), little has been done to help people actively manage their health, improve their activity levels, or regulate their diets.
Photo courtesy Simon Yeo (CC BY 2.0)
A Balance Between Prevention and Response
In other fields, where lives are at stake, we recognize that a more balanced approach between prevention and response is appropriate.
Earthquakes, like heart attacks, happen. They are devastating realities of our world. However, our approach to earthquakes is not limited to clean up and repair. We work to prevent negative consequences through policy, such as changes to the building codes, and educational campaigns that can shape personal, behavioral choices, like securing bookcases to the wall and not hanging heavy objects over beds.
In other fields, bombs are diffused, air bags deployed, and smoke detectors installed. All of this is done to manage the known risks of everyday life. In the US health system, on the other hand, the focus is all too often on improving treatments while failing to prioritize prevention. One explanation may be the unique payment structures that drive the US healthcare system.
Incentivizing Sickness
In the article, the head of the Our Lady of Lourdes hospital's cardiovascular disease program, Dr. Reginald Blaber, acknowledges that "Heart care is the hospital's specialty, and without its revenue... Lourdes would have to close its doors." This quote is a stark reality and illustrative of how treatment is incentivized.
The entire medical industrial complex relies on the small percentage of society that require extensive medical intervention for its continued existence. This is the result of a system in which reimbursement is based largely on illness.
Imagine a system in which hospitals and medical providers are incentivized to partner with local public health agencies and community organizations to ensure the health of the overall population. While progress is slow, payment structures appear to be evolving in this direction.
The movement toward Accountable Care Organizations (ACOs) and, more broadly, Accountable Care Communities is a start. These healthcare organizations offer a payment and care delivery model that ties reimbursements to quality metrics and reductions in the total cost of care for a group of patients. New entrepreneurial endeavors are also developing, like Dr. Farzad Mostashari's firm Aledade that will assist independent primary care providers form ACOs.
While payment structures begin to change, it is important to look to those who aren't waiting, who see the value of partnerships between health care and public health and what they can accomplish together.
The Practical Playbook, a joint project of Duke University Medical School's Department of Family and Community Medicine, the de Beaumont Foundation, and the Centers for Disease Control and Prevention, is documenting partnerships between primary care and public health across the US that prioritize prevention by altering community level factors that contribute to disease.
The 18 BUILD Health Challenge awardees are also working to understand how hospitals, public health, and community leaders can work together to change their communities and improve health.
Photo courtesy ep_jhu (CC BY-NC-ND 2.0)
Without Prevention AND Treatment, Nothing Can Change
A Fence or an Ambulance presents a complex situation as a dichotomous choice, but we know it isn't.
We actually want both -- we want the preventive measures up front, as well as the access to medical innovations or new treatments when needed. Kolota's piece focuses on the part of the healthcare system that the US does exceptionally well: treatment. If you are sick and in need of treatment, there's no better place to be. However, treating greater numbers of people at increasing costs is not sustainable.
Bad things happen. It's a reality of our world, but we have a choice. We can sit passively by and wait for disaster, or we can work together to try to stop it. This will require a reprioritization that starts to focus on and fund prevention. We already have great ambulances. Now we need to build better, more effective fences.
- A Sea Change in Treating Heart Attacks (The New York Times), 6/19
- What the New York Times overlooked about heart attacks (The Daily Briefing via The Advisory Board Company), 6/23
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Brian Castrucci is the Chief Program and Strategy Officer at the de Beaumont Foundation. Prior to joining the Foundation, Brian spent a decade working in state and local health departments. Brian is also pursuing his doctorate in public health leadership at the University of North Carolina at Chapel Hill Gillings School of Global Public Health.