Most of the well-thought-out “solutions” to our health care crisis include the recognition that to the extent possible, we should be dramatically increasing our investments in prevention.  This can include reducing the incidence and prevalence of disease, injury, and disability in the first place (“primary” prevention).  Estimates are that anywhere from 50% to 80% of all causes of sickness care use and expense can be prevented.  The prevention effect may arise from immunization and other medical means, or via preventing or reforming risky behaviors that tend to cause sickness.

It also includes early detection of both actual sickness and conditions that may become or cause illness, with subsequent control or reversal of these conditions so that more advanced and expensive forms of disease are prevented, existing disease cured or controlled, and risk conditions do not cause or become diseases (“secondary” prevention).  This may be the way to prevent as much sickness and its care as primary prevention, if widely adopted and successful.

The third kind of prevention is the management of diseases and injuries in ways the limit the development of crises and complications thereof, perhaps even “reverse” them to the point where healthy behavior, alone, will keep them under control (‘tertiary prevention”).  This form has perhaps the greatest short-term potential for saving money, as well as improving the lives of patients who currently suffer from chronic diseases and injuries.  But if these same diseases and injuries could be prevented in the first place, the savings would be even greater than what can be achieved by managing them well after the fact.

Prevention = Changing Payor, Provider and Patient Behavior

The biggest challenges involved in achieving the full potential of prevention is that of altering the behaviors of the employers, insurers and governments that pay for health care, that of the professionals and organizations that provide it, and of the individuals who use it, as well as adopt and persist in either healthy or unhealthy behaviors and lifestyles.  And naturally, the question of how best to achieve the widespread, if not universal changes in behavior is the key element in this challenge.

The two most popular approaches to altering behaviors seem to be either to make it economically more advantageous for all such stakeholders to adopt and persist in healthier behaviors, or to require them to do so by law (which can be economically more advantageous as well, since it can enable people to avoid paying fines or serving unpaid time in jail by behaving better).  Both have been suggested by many health care reform gurus and political aspirants.

Making healthy behavior mandatory, or at least unhealthy behavior more difficult, expensive, and potentially a reason for jailing people, has been used frequently, though for a limited number of such behaviors.  Recent jailing of people with tuberculosis, either because it is untreatable, or because the patient refuses to comply with treatment, and historical cases of forced quarantine of individuals and populations are examples of this form of “punishing the sick”.  One presidential aspirant recently called for making it mandatory that individuals both have insurance coverage, and get preventive care, including all forms of prevention.  While this plan would cost up to $120 billion a year, it might easily save that far more, at least in the long run. [“Edwards Backs Mandatory Preventive Care”.]

The second approach is for payors to pay providers and individuals to behave in the desired way, across as many of the three types and hundreds of possible examples of providing preventive care and adopting healthy behaviors are worth paying for.  This would presumably be one set of services and behaviors for insured but unemployed populations, where savings would come from reducing sickness care costs alone.  It would be quite different for employed populations where not merely sickness costs but workers compensation and disability expense, absence and productivity losses, quality and service performance and revenue as well as cost consequences of sickness and health behaviors or conditions that impair performance would be important.

Both methods would cost money, for “behavior police” and systems for enforcing mandatory behaviors and punishing providers or patients for unhealthy behaviors.  Of course, these costs could be covered by taxing, fining, or increasing premiums and out-of-pocket payments for those guilty of uncooperative behavior.  Such taxes, fines and other penalties could increase the proportions of the provider and patient populations that adopt and persist in desired behaviors, though experience shows clear limits to the effects of punishment in wiping out behaviors that people find some enjoyment or other pleasure from.

Offering incentives and paying rewards can add significantly to the costs of prevention efforts.  These costs may be greater than the amount of sickness care savings achieved through the desired behaviors, making the result a net increase in total sickness and health expense.  Experience also indicates that extrinsic rewards often lose their effect after a while, when they apply to continuous, rather than one-time or infrequent behavior.  In other words, it might work well in promoting providers to deliver and patients to get annual immunizations and disease/risk screenings, but not work as well in promoting lasting dietary or exercise change or daily compliance with medications.

For continuous healthy behaviors, particularly for as often as daily cooperation in healthy lifestyles or medications, and to reduce the costs of incentives, there is always the potential that there will be sufficient intrinsic rewards in healthy behaviors and lifestyles to promote their widespread use and persistence.  To achieve the maximum effects of such intrinsic rewards — the natural and idiosyncratic impacts that healthy behaviors have on the health and life quality of individuals and households – reformers and often payors and providers as well may have to exert time and effort, and incur costs.

This requires that interventions aimed at promoting healthy behaviors among providers and patients first make sure such behaviors deliver significant and noticeable value to both.  This should probably go beyond a report of reduced risks of disease and injury and a longer life expectancy for patients, for example, though these may serve as significant intrinsic value for providers, who enter their professions at least partly because of the opportunity to do good while doing well.  Intrinsic benefits are better if they are immediate, and promote something of value that is important to the individual concerned, not merely to payors, providers or society.

There are four “As” that should be part of efforts to include intrinsic value as motivation for provider and patient behavior change then maintenance:

1.  Promote their awareness of changes that their behaviors have brought about – in terms of clinical metrics, health status, life impact, job performance, etc. among patients, since these can promote a sense of pride and accomplishment, perhaps intrinsic monetary gains, rather than direct rewards
2.  Promote their appreciation of the personal and family consequences, including protections for other family members through shared improved diets, smoking cessation and second-hand smoke effects, etc.
3.  Promote their attribution of positive changes and their value to their own but also providers’ and payors’ help in achieving them
4.  Promote their anticipation of persistence or improvement in all the positive changes that healthy behaviors and cooperation with providers or payors in achieving and maintaining them will continue to deliver in future, and their corresponding anticipation of loss if their cooperation and relationship with provider or payor ended.

It is likely that some mix of these three approaches to promoting all forms of prevention will be needed to optimize the adoption and repetition of all three types of prevention among providers and patients.  The mix is likely to differ for different populations and individuals, and for different preventive behaviors.  While espousing and championing a simple, single “solution” may be more attractive and politically expedient, it would be a deliberate and dangerous myopia to choose only one of these without at least testing all.