There have been some dramatically optimistic estimates of how much our national sickness care bill could be cut by improving how such care is delivered. By moving all providers toward greater adherence to evidence-based medicine “best practices” and eliminating wasteful practices and errors by both hospitals and physicians, estimates have been that as much as 50% of total expenditures could be avoided. These are clearly highly optimistic, tantamount to achieving the impossible situation attributed to children in Lake Wobegon, where every provider is above average.

A recent optimistic prediction of what could be achieved through prevention of just seven chronic disease and risk condition categories described a far less drastic reduction needed to save as much as $8.5 trillion between now and 2023, of which $1.6 trillion would be in avoided sickness care costs, and $6.9 trillion in avoided absenteeism and presenteeism. While this is an enormous amount of money, it comes with the avoidance of an equally enormous amount of sickness and negative impact on the lives of individuals and families. And the amount of change required to achieve it is nowhere near as dramatic as a 50% reduction in sickness care by improving provider quality and efficiency. [R. DeVol & A. Bedroussian “An Unhealthy America” Santa Monica, CA The Milken Institute Oct 2007 (www.milkeninstitute.org)]

The amounts of savings estimated as achievable come mainly from either avoiding increases in the prevalence of risk conditions and behaviors, or “rolling them back” to recent levels, not dramatically reducing their current levels. Instead of the predicted 29% to 62% increase in the seven chronic conditions addressed (cancers, hypertension, mental disorders, heart disease, pulmonary conditions, diabetes, and stroke), with a population increase of only 19%, the report foresees the potential to reduce this growth substantially.

If the prevalence of obesity can be reduced to 19%, and overweight to 32.2%, smoking to 15%, alcohol abuse reduced, physical activity levels increased, cholesterol levels reverted to 2000 levels, air quality improved, illicit drug use declines, a modest improvement in early detection and intervention, and a 0.5% slower rate of inflation in sick care costs, the optimistic vision could be achieved. The key is simply not to accept “business as usual”, the kind of healthcare system and stakeholder behaviors that have produced the current crisis, but to work together to achieve modest changes.

Essentially, we have mainly stood by while the seven chronic conditions, and the risk behaviors/conditions that have been responsible for them, have been increasing at what amounts to epidemic rates. It seems clear that we are at least approaching a “critical mass” level of willingness to invest the time, effort and resources needed to stop and partially reverse the trends we have been alarmed about but little else. This will require an entire “village” of parties to accomplish, but seems clearly worth pursuing.

The advantages of achieving even these modest changes over the next fifteen years are substantial. First, unless they are made, it seems unlikely, indeed financially impossible, that we will be able to enable the entire population of the country to be covered by even basic sickness care insurance. Unless we are able to achieve the improvements in workforce productivity and performance the changes will enable, we will lose still further share in the global marketplace, since rival countries are already working toward the same kinds of changes.

Perhaps the greatest change required will be in the behavior of sickness care providers, currently devoting most of their energy and resources into increasing their sickness care capabilities and trying to protect their payment for such care. It seems unlikely that even the modest changes envisioned in the report can be achieved without the active cooperation of physicians, nurses, and other clinicians or alternative practitioners, the most trusted source of health information and advice for most consumers. If such provider put all their eggs in the sickness care basket, they may have too much invested to threaten their financial interests by cooperating in reducing sickness care expense, even if it is only 18.8% of the $8.5 trillion in savings anticipated.

Hopefully, the professional and institutional missions of physicians and hospitals will enable them to become partners in such an effort, rather than either ignoring or resisting it. Many are already doing so, even though it results more often in losing than making money in the process. Just recently, U.S. Preventive Medicine®, already working to enable the development of preventive health partnerships with hospitals and physicians, announced the acquisition of Specialty Disease Management Services, Inc. a national provider of disease and health management services, to augment its preventive capabilities. [“U.S. Preventive Medicine Acquires Specialty Disease Management” USPreventiveMedicine.com Oct 2, 2007]

Health insurance plans are also acquiring health/disease management (H/DM) organizations, or have developed in-house capabilities they are offering to employer insurance clients, and even non-clients. Mayo Clinic has been offering H/DM services for years, and has 70 or so national employer clients already. Other hospital and physician systems offer H/DM services to their own employees. It should not make a serious disruption in current operations if hospitals and at least primary physicians became roughly equally focused on health as well as sickness care. There will certainly be enough sickness to go around for the foreseeable future.