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Underwriting medical failures
EDITORIAL
Underwriting Medical Failures CARMINE
M. VALENTE,
Ph.D., and ALBERT M. ANTLITZ,
n 1984, one billion dollars per day bought 50,000 coronary bypass operations, 188,000 open heart procedures, and 500,000 cardiac catheterizations [ 11. These figures clearly illustrate that as a nation, we are spending our limited resources on treating preventable diseases. In a very real sense, the government and insurance carriers are underwriting medical failures rather than rewarding health care successes. Some years ago, a major oil company aired a commercial that indicated, you can pay us now or pay us more later. The message was that it was far cheaper to maintain your car’s engine with frequent oil and filter changes than to disregard engine maintenance with resultant future costly engine repairs. Why hasn’t the medical care system promoted a preventive maintenance approach to a much stronger degree? Why does the insurance sector continue to reimburse for treatment of disease without providing a clearer and stronger incentive for disease prevention? Medical science has clearly established risk factors for many disease states. Cigarette smoking, high blood pressure, and elevated levels of blood lipids are the greatest modifiable contributory causes of coronary artery disease. The deleterious effects of cigarette smoking are well documented. Thirty percent of all cancer mortality, 85 percent of all lung cancer, 30 percent of all coronary heart disease, and 85 percent of all emphysema and bronchitis are attributed to smoking [2-61. Just as cimetidine has been shown to reduce the need and cost of surgery for gastric ulcers [7], stopping smoking has been shown to be as successful in the prevention of ulcer recurrences as the administration of cimetidine [8], and is cheaper still. The “pay now” approach to the smoking problem suggests providing meaningful support to prevent people from starting smoking and providing resources to help people quit smoking and remain nonsmokers. The “pay more later” scenario implies treating heart disease and lung disease caused by smoking. Screening, diagnosing, and treating high blood pressure and high blood lipid levels are the converse of paying for uncontrolled hypertension and hyperlipidemia and their resultant sequelae of coronary artery disease, stroke, and kidney disease later.
I
M.D.,
F.A.C.C.,
F.A.C.P.
The data are available and are sufficiently clear to accelerate action. Many disease states are preventable and certainly postponable. This knowledge requires that prevention be placed in its proper perspective, paying now to avoid more costly expenses later, and suggests that a re-evaluation be made of what the medical care dollar buys. This encourages an open-mindedness, that acknowledges that procedures such as coronary bypass surgery and renal dialysis, although technical advances, represent at least in part a failure of the medical system to avoid the necessity of performing these procedures. Incentives need to be built into the medical care system to encourage disease prevention and health promotion activities by compensating for medical success in place of underwriting medical failure. It has been clearly stated that, “if we are to make preventive medicine and health promotion more attractive to physicians and patients, we will have to give them more incentives” [9]. The choice is obvious, pay now or pay more later. REFERENCES 1. 2.
3. 4. 5.
6.
7.
8.
9.
The Medical-Economic Digest 1986; 3: 3. American Public Health Association: Smoking: after 20 years still the public health challenge. The Nation’s Health 1984; 14: 1. De Vita VT Jr: Cancer as a preventable disease. MD Med J 1985; 34: 42. Doll R, Peto R: The causes of cancer. JNCI 1981; 66: 1222. The health consequences of smoking: cardiovascular disease. A report of the Surgeon General (publication no. PHS-8450204). Washington: United States Department of Health and Human Services, 1983; 7. The health consequences of smoking: chronic obstructive lung disease. A report of the Surgeon General (publication no. PHS-84-50205). Washington: United States Department of Health and Human Services, 1984; 9. lsenberg JI, Peterson WL, Elashoff JD, et al: Healing Of benign gastric ulcer with low-dose antacid or cimetidine: a double-blind, randomized, placebo-controlled trial. N Engl J Med 1983; 308: 1319. Sontag S, Graham DY, Belsito A, et al: Cimetidine, cigarette smoking, and recurrence of duodenal ulcer. N Engl J Med 1984; 311: 689. Relman AS: Encouraging the practice of preventive medicine and health promotion. Public Health Rep 1982; 97: 217.
From the Center for Health Education, Inc., Baltimore, Maryland. Requests for reprints should be addressed to Dr. Carmine M. Valente, Center for Health Education, Inc., Coggins Building, 1204 Maryland Avenue, Baltimore, Maryland 2120 1. Manuscript submitted September 22, 1986, and accepted Septem ber 29, 1986.
106
January
1967
The American
Journal
of Medicine
Volume
62
Underwriting Medical Failures CARMINE
M. VALENTE,
Ph.D., and ALBERT M. ANTLITZ,
n 1984, one billion dollars per day bought 50,000 coronary bypass operations, 188,000 open heart procedures, and 500,000 cardiac catheterizations [ 11. These figures clearly illustrate that as a nation, we are spending our limited resources on treating preventable diseases. In a very real sense, the government and insurance carriers are underwriting medical failures rather than rewarding health care successes. Some years ago, a major oil company aired a commercial that indicated, you can pay us now or pay us more later. The message was that it was far cheaper to maintain your car’s engine with frequent oil and filter changes than to disregard engine maintenance with resultant future costly engine repairs. Why hasn’t the medical care system promoted a preventive maintenance approach to a much stronger degree? Why does the insurance sector continue to reimburse for treatment of disease without providing a clearer and stronger incentive for disease prevention? Medical science has clearly established risk factors for many disease states. Cigarette smoking, high blood pressure, and elevated levels of blood lipids are the greatest modifiable contributory causes of coronary artery disease. The deleterious effects of cigarette smoking are well documented. Thirty percent of all cancer mortality, 85 percent of all lung cancer, 30 percent of all coronary heart disease, and 85 percent of all emphysema and bronchitis are attributed to smoking [2-61. Just as cimetidine has been shown to reduce the need and cost of surgery for gastric ulcers [7], stopping smoking has been shown to be as successful in the prevention of ulcer recurrences as the administration of cimetidine [8], and is cheaper still. The “pay now” approach to the smoking problem suggests providing meaningful support to prevent people from starting smoking and providing resources to help people quit smoking and remain nonsmokers. The “pay more later” scenario implies treating heart disease and lung disease caused by smoking. Screening, diagnosing, and treating high blood pressure and high blood lipid levels are the converse of paying for uncontrolled hypertension and hyperlipidemia and their resultant sequelae of coronary artery disease, stroke, and kidney disease later.
I
M.D.,
F.A.C.C.,
F.A.C.P.
The data are available and are sufficiently clear to accelerate action. Many disease states are preventable and certainly postponable. This knowledge requires that prevention be placed in its proper perspective, paying now to avoid more costly expenses later, and suggests that a re-evaluation be made of what the medical care dollar buys. This encourages an open-mindedness, that acknowledges that procedures such as coronary bypass surgery and renal dialysis, although technical advances, represent at least in part a failure of the medical system to avoid the necessity of performing these procedures. Incentives need to be built into the medical care system to encourage disease prevention and health promotion activities by compensating for medical success in place of underwriting medical failure. It has been clearly stated that, “if we are to make preventive medicine and health promotion more attractive to physicians and patients, we will have to give them more incentives” [9]. The choice is obvious, pay now or pay more later. REFERENCES 1. 2.
3. 4. 5.
6.
7.
8.
9.
The Medical-Economic Digest 1986; 3: 3. American Public Health Association: Smoking: after 20 years still the public health challenge. The Nation’s Health 1984; 14: 1. De Vita VT Jr: Cancer as a preventable disease. MD Med J 1985; 34: 42. Doll R, Peto R: The causes of cancer. JNCI 1981; 66: 1222. The health consequences of smoking: cardiovascular disease. A report of the Surgeon General (publication no. PHS-8450204). Washington: United States Department of Health and Human Services, 1983; 7. The health consequences of smoking: chronic obstructive lung disease. A report of the Surgeon General (publication no. PHS-84-50205). Washington: United States Department of Health and Human Services, 1984; 9. lsenberg JI, Peterson WL, Elashoff JD, et al: Healing Of benign gastric ulcer with low-dose antacid or cimetidine: a double-blind, randomized, placebo-controlled trial. N Engl J Med 1983; 308: 1319. Sontag S, Graham DY, Belsito A, et al: Cimetidine, cigarette smoking, and recurrence of duodenal ulcer. N Engl J Med 1984; 311: 689. Relman AS: Encouraging the practice of preventive medicine and health promotion. Public Health Rep 1982; 97: 217.
From the Center for Health Education, Inc., Baltimore, Maryland. Requests for reprints should be addressed to Dr. Carmine M. Valente, Center for Health Education, Inc., Coggins Building, 1204 Maryland Avenue, Baltimore, Maryland 2120 1. Manuscript submitted September 22, 1986, and accepted Septem ber 29, 1986.
106
January
1967
The American
Journal
of Medicine
Volume
62