I once read this quote from a former Trauma Chief of Surgery in Hospital: An Oral History of Cook County Hospital that always stuck with me, and so I’ll repeat it now:
To me, there’s something fundamentally wrong with an attitude of mind that says, “You’re sick, pay me.” The ancient Chinese had it much better–they said, “When you’re well, you pay the doctor; when you’re sick, the doctor pays you.” That’s a much better system–now you’re talking prevention.
The concept turns medicine on its head, and radically changes the way a doctor’s role is defined: keeping a person healthy, as opposed to healing a person that’s fallen ill. And it radically warps the incentives doctors have, as well; I’ve always been more than a little bothered by the fact that hospitals serve Burger King, Pizza Hut, and McDonald’s in their cafeterias. It’s a paranoid hypochondriac’s perfect conspiracy theory–the cardiologists keep the fast food joints around to ensure a plethora of business. (Okay, the cardiologists, and the stroke service, and the radiologists reading arthritis x-rays of obese patients, and the endocrinologists taking care of the diabetics, and the so on.) And props to Kaiser Permanente; their cafeteria food seems to be at least somewhat healthier, and their cafeteria vending machines offer juices, bottled water, and healthier snacks like granola bars, baked potato chips, and carrot/celery/peanut butter packs. More on Kaiser later.
This prevention doctor wouldn’t really work with the way that medicine is rooted in diagnosis, however. It usually requires a symptom (or some other strong piece of evidence) for a doctor to start to evaluate a patient, and for a patient to even go see a doctor. There’s also a statistical piece–you only want to do tests on people you suspect might have a certain disease, because of high numbers of false positives and risks associated with all tests. You wouldn’t want to do colonoscopies on all healthy 22 year-olds. (And I’ll guess that no healthy 22 year-olds want colonoscopies, either.)
But I’m not ready to rule out this alternate view of medicine and use of prevention. What if there’s a role for another person in the health care system–the health prevention professional. (I know, there are public health folks and prevention medicine physicians, but they usually act on a community or society level. Hear me out.) Imagine people saw a health prevention expert twice a year. This person would do some basic screenings, figure out risk factors, and give patients goals–and help to achieve them. Maybe they’re also a nutritionist, so they can suggest healthier foods. And they have practice managing diabetics. And they do vaccinations, check cholesterol levels, and refer for treatment, smoking cessation, all that jazz.
I know what you’re thinking–what kind of socialist, hippie world does this idealistic medical student think we live in? But what if this health prevention is mandatory: for insurers and for patients. What if all health insurance companies had to provide these appointments to patients… and what if patients had to go?
News flash: insurers often don’t provide coverage for some types of preventative care. Great examples for diabetes here. And to a company controlled by shareholders and bottom lines, this makes economic sense, unfortunately. I’ve read that because people change jobs so often, and because jobs are tied to insurance, the average American will bounce between multiple health insurance companies during their lifetime. For insurers, this means that they don’t have a reason (in the short-term) to provide preventative care–the mildly sick patient now won’t be a member of Company X when they’re the very sick patient. Insurance companies do everything they can to minimalize how many older, sick patients can join their coverage, but if they’re all trying to do that, I’d imagine on average they all have X many sick patients who’ve gotten worse during the years, bouncing from insurer to insurer. So if we require all insurance companies to provide this preventative care, it’ll be an investment in their bottom lines in the coming decades. (Kaiser Permanente of Northern California offers relatively better preventive care; since Kaiser is specific to a region and not a company, odds are if you have Kaiser insurance at one job, you might have Kaiser insurance at another job. They therefore have an incentive to keep their patients healthy.)
But maybe patients need a kick in the pants to get them into prevention, too. Consumer health plan advocates say that patients don’t know about health care prices, and that’s why they spend, spend, spend. But what if it’s not about prices. What if it’s just about taking responsibility? What if you had to see your preventionalist twice a year, as a part of your health insurance plan? What if insurers could drop coverage for patients who don’t go to their bi-annual visits (but couldn’t deny care for pre-existing conditions)? Requiring patients to see a “preventionalist” would send a number of important messages:
- Doctors don’t have magic pills. We can treat some things, but other diseases–many of the toughest we’re facing today–develop over decades.
- Patients have to take an active role in their health, and the everyday choices they make influence their health. The cheeseburger you eat today, and the one next week, and the week after that, put you at risk for a heart attack.
- Patients have control, and can change the course of their health, if caught early enough. Even if caught late, in some cases.
- The medical system is here to help patients improve their health; it recognizes that it’s hard to change behaviors, but it’s devoting a lot of time, money, and energy to helping people do better.
This is just meant to be a framework. This is not meant to be a white paper, or an implementation, so any nit-picking will be promptly ignored. It’s supposed to be a new concept in how health–and health care–work.