As happens occasionally, prevention has become a buzzword in healthcare—at least temporarily. The Patient Protection and Affordable Care Act includes several provisions boosting preventive health services. Employers, insurers and providers say they want to emphasize prevention. Emerging delivery and payment structures—accountable care organizations, patient-centered medical homes and bundling of payments—provide powerful incentives to stop expensive diseases before they start.
Three recent studies illustrate the complexities of prevention. In January, the Agency for Healthcare Research and Quality reported that 1% of patients represented 20.2% of all healthcare expenditures in 2008; 5% of patients represented 38% of the total. On Feb. 23, a New England Journal of Medicine study confirmed that colonoscopy reduces colorectal cancer deaths and is more effective than sigmoidoscopy or stool testing, especially in detecting precancerous polyps. But another study in that issue found that patients were more willing to undergo stool testing than colonoscopy.
It doesn't take a rocket scientist to figure out why. Colonoscopy preparation involves consuming only clear liquids for at least a day and ingesting unpleasant-tasting laxatives that leave patients communing with nature in the bathroom for hours. As Dr. Sidney Winawer, one of the authors of the colonoscopy effectiveness study, said, “Sure, it's a pain in the neck. People complain to me all the time, ‘It's horrible. It's terrible.' ”
It is not surprising that AHRQ found that in 2008, only 60% of white Americans and 55% of African-Americans over 50 had been screened for colorectal cancer; only 44% of Latinos and 37% of Native Americans had.
The same story can be told about mammograms, prostate cancer screening, endoscopy and other preventive procedures.
Why is it so difficult to get people to put up with some degree of discomfort or inconvenience when it could save their lives?
One reason is patients' reluctance to submit to what they believe is an awful experience. Women don't enjoy having their breasts mashed in a machine, and men don't enjoy having their genitals digitally examined. Being told that a colonoscopy or endoscopy is equivalent to being burned at the stake provides a perfect excuse for someone who didn't want to undergo the procedure in the first place.
In addition, many patients fear what screening might reveal. And some immigrants, people who speak little or no English and those with poor health literacy may be ignorant of the value of these tests.
Also, access to screening can be constrained for Medicaid and even Medicare beneficiaries because of provider reluctance to accept them. And that's assuming the Medicaid program covers all preventive services.
For patients without insurance, access is even more difficult. Tests are not cheap, and there are long waits to get them for free. The Commonwealth Fund found that in 2011, people who were uninsured at least part of the year were less likely to undergo blood pressure testing (52% vs. 80% for insured persons), cholesterol checks (35% vs. 64%), Pap tests (49% vs. 66%), mammograms (32% vs. 66%) and colon cancer screening (10% vs. 50%).
How can the situation be improved?
Coverage for prevention should be broader. There is both opportunity and threat in the federal government's decision to give states latitude in configuring “essential health benefits” under reform. If Medicaid benefits design is any indication, many states could ignore some preventive services. The federal commitment appears ambivalent as well; in order to pay for postponing the looming Medicare fee reduction for physicians, Congress cut $5 billion from the ACA's prevention fund.
The opportunity is that if all payers are required to cover proven preventive services, utilization should increase. Indeed, coverage for some services should probably be mandated for everyone, even the otherwise uninsured. Incentives for providers to increase outreach wouldn't hurt, either.
Also, the best way to counter the horror stories is to make unbiased, understandable information widely available.
A longer-term solution would be to familiarize children with preventive services, so that when they are grown, prevention will just be part of life. Also, provider, pharmaceutical and medical device groups should try to find easier ways to check for colorectal cancer than making patients consume nasty stuff and spend hours on the toilet, and then denying them food and water. There are countless jokes about how mammograms would be designed if men were subject to them. Reconfiguring these procedures to make them less obnoxious could make a huge difference.
Speaking of his study on colonoscopy, Winawer, conceding that some aspects of the procedure are less than enchanting, added, “But look at the alternative.” We should be considering alternatives on both the payment and delivery sides.
True prevention almost always means swimming upstream. It's difficult to push exercise and low-fat, low-salt diets in a society in which people are chained to their computers all day, fast food is ubiquitous, and a guy can star in a television series by eating his way through the most gigantic restaurant meals imaginable. Getting everyone screened for common cancers, diabetes and other conditions is a tall order. But if we make the commitment, it could be the most effective means yet of bending the cost curve.
Besides, the life you save may be your own.
Emily Friedman is an independent health policy and ethics analyst based in Chicago.