Disease Prevention and the Future of Medicine

• Introduction
• Definitions
• Consumer Demand
• Philosophy
• Principles
• Process
• Barriers to Change
• Threads of Hope
• The Future
   

Introduction

Total health care expenditure in New Zealand has increased from $7 million in 1925 to $7.4 billion in 1997, in nominal terms. In real terms this is an annual average rate of increase of 5%. Given the ageing population,current technology, treatment sophistication and increasing public expectations, it does not take Economics I to recognise a major problem – both today and increasingly so into the next century. This is a global challenge.

Although medical opinion leaders in New Zealand increasingly talk about preventive medicine as a solution, implementation has faltered. The public is driving a trend towards low intervention, self-efficacy, lifestyle management and wellness. In the leading OECD economies preventive medicine has now become a significant discipline with its own colleges, journals and subspecialties. More ambitious proponents seek to integrate prevention into all areas of medicine.

New Zealand spent $199.1 million on public health in 1997 ($51 per capita). This is 2.5% of the total health spend (public and private) and includes funding for well child, occupational health promotion and disease prevention, immunisation and vaccination, isolation, heath education, border control, medicine control, pollution control, inspection services and hygiene supervision. This leaves little funding for true preventive medicine.

True preventive medicine is in its infancy in New Zealand. Despite being a small country with a relatively well-educated population, New Zealand is behind most developed nations in developing an integrated policy, structure and discipline for effective disease prevention. While a number of gallant efforts are being made, they are occurring in a fragmented, isolated and financially vulnerable environment. The Heart Foundation, the Hillary Commission and some small corporate health initiatives have achieved some gains.

While many would see preventive medicine as just another opportunity to establish a committee and a funding agency, it is sensible to consider the scope of preventive medicine and to find its place within our health care system. Some healthy dialogue between providers and funders of health services would help to crystallise definitions, philosophy, principles, processes and barriers to change. This paper is an attempt to begin the discussion.

New Zealand appears to be deeply entrenched in a "sickness paradigm" and there are significant structural barriers to changing to a preventive medicine approach. Preventive health care is potentially a radical departure from traditional Western health care practices, funding schemes and outcome measures. New Zealand is comparatively small and, as a late starter, can evaluate the best practices that have been developed elsewhere. This is particularly relevant, as good evidence in preventive medicine has only emerged in the last decade.

On a cautionary note, the journey into preventive medicine is difficult for two key reasons. The goal of preventive medicine is to eliminate health problems and, ideally, to optimise the well-being of individuals and the community. As such it is quite different to problem-focused individual approach (see the WHO definition below). This attitude is seldom prevalent when the typical New Zealand patient consults a typical New Zealand doctor. A preventive intervention may have little meaning for the patient until well into the future. In some cases it will have no relevance but will be an important process within a strategy to monitor and prevent disease at a population level. Immunisation is an example of a successful intervention. Managing obesity has been less successful.

Secondly, preventive philosophy is embedded in many forms of health care – some ancient and some new. In the absence of "scientific evidence’ western medicine has tended to devalue many alternative approaches. The approach is scorned along with the untested activities. In some cases, sanction of alternative approaches is so severe that skilled clinicians abandon traditional practice in order to escape the conflict and work within a more holistic environment.

However, the evidence is expanding and some traditional medical practitioners are beginning to engage with preventive practices. I submit that prevention is, in fact, a central discipline within medicine. Preventive medicine should inform branches of medical practice and all streams of funding. It should be rigorously researched, tested and monitored. The underlying philosophy will place a tension on the current obsession with evidence-based practice.

Definitions

A full definition is beyond the scope of this discussion paper but a quick Internet search, starting with the American College of Preventive Medicine website (http://www.acpm.org), provides a good working model.

Preventive medicine is most visible in the following areas:

• early detection and screening
• health promotion (education, hygiene, vaccination and disease avoidance)
• wellness (lifestyle practices, well-being and optimal health)
• sports medicine (which extends and maintains the limits of human performance)
• occupational medicine (keeping a workforce healthy)
• general practice – to a variable degree.

The simplicity and wisdom of prevention is recognised in the World Health Organisation’s definition of health: "A state of dynamic harmony between the body, mind and spirit of a person and the social and cultural influences which make up his or her environment." Surely this definition must be applied within all medical practice?

Consumer Demand

An Australian futurist recently estimated that 60% of Australian health expenditure is spent on areas other than conventional Western medicine. True or not, the comment is challenging. What are traditional "patients" spending their health dollars on? What exactly are they buying? Is it "evidence-based medicine", philosophy, hope, comfort, someone with time to listen, optimal health or simply entertainment?

Few would argue that there has been some shift toward a more holistic, self-responsible and preventive approach to health care purchasing. Lifestyle, natural cure, peak performance, supplements, mind-body medicine and homeopathic approaches support thriving industries. Conventional medicine is losing this income. Most traditional doctors cling rather doggedly to reactive and pharmaceutically based treatment of symptoms.

Several decades of "evidence-based" business research suggest that a fundamental determinant of a business’s success or failure is the ability to understand and meet its customers’ requirements. So in presenting some early thoughts on prevention and wellness, it is helpful to begin with the "customer" in mind. The health industry has two distinct customers: the individual and the population it serves.

Individuals expect good curative care to be available when they need it. Many are also demanding well-being and optimal health. Population groups expect expert care for the critically ill and, increasingly, communities and their health purchasers are looking for ways to maintain health and productivity while minimising the cost of health care.

Philosophy

The philosophy of prevention is naturally attractive and we all pay it lip service. However, implementation within the current health care structure is brutally difficult.

The goal of preventive medicine is the elimination of disease and distress. Effective prevention will secure optimal health within existing anatomical, physiological and psychological constraints. It is thus appropriate for everyone – fit, sick, old and young.

A good analogy is Total Quality Management (TQM) where businesses have secured unexpected cost savings and customer loyalty by reducing defects towards zero. In the past, whole industries thrived on inspections and repairs much as medicine thrives on the diagnosis and relief of sickness. In industry, as the processes behind products and services have improved, defects have become rare (1:1,000,000 at 6 sigma quality). However, TQM has taken 50 years to develop and faced enormous resistance in the West. Lead by post-war Japan, it took 20 years before quality gained acceptance in the West.

Applying similar thinking to health care, we would need to see our customers as potentially well individuals throughout their full lifespan rather than as episodes of disease. A maintenance and wellness focus should be applied to every contact. Prevention is a long-term strategy. An enormous mental shift is required to establish a relationship between practitioner and patient that optimises a "patient’s" well-being.

Population-based medicine is essential to secure this shift. Practitioners must view themselves not only as treatment providers but also as custodians of the well-being and productivity of a population. This works well at a family, small community or business level but is very hard in our mobile city populations. A capitated funding model can assist provided it is very carefully designed and not based on component costs. In the latter case there are perverse incentives to shift costs across components of the care chain.

Prevention can apply in three situations during a person’s life: in wellness, in health maintenance and in disease management. Wellness aims to secure optimal health and well-being; health maintenance seeks to secure general health and avoidance of illness; and disease management can apply prevention to minimise the impact of a disease process.

To develop preventive medicine it will be necessary to shift resources. Currently clinical skills, technology, facilities and funding are heavily concentrated on acute and chronic illness. Frequently, the highest concentration of resources is applied at the end of life. To make prevention effective, some of these resources must be moved into preventive activities.

To effect change, New Zealanders must view the population at all levels of health status on the Bell curve. While we currently expend a disproportionate amount of resources on those in the far left-hand tail, prevention requires that resources be applied to the population as a whole. This is exactly the methodology of quality management. By so doing, we effectively move the entire curve to the right, significantly shifting the left-hand tail away from unnecessary health care episodes. In addition, we liberate more healthy and productive people into the community.

Principles

Prevention is based on the regular collection of relevant health status measures. This data must be viewed over the long-term and variations from ideal ranges should be addressed immediately. This is equally true for a 2kg weight gain in a fit businessman and in an older patient with heart failure. The later the intervention the more complex and costly the intervention required to correct it.

PHARMAC’s current funding criteria for statins is a good example of failure to apply this principle. Evidence clearly demonstrates that cardiovascular risk increases as cholesterol rises above 4.5mmol/l. PHARMAC only funds statins once the level rises to 9mmol/l. In the case of most risk factors, early identification and management can reduce the need for pharmaceutical and surgical intervention.

Responsibility, knowledge and ability must shift from practitioner to health care consumer. Education, motivation and follow-up become critical competencies for practitioners. These shifts are taking place amongst educated people albeit seldom through traditional health care channels. For those who are older, sicker and poorer, it is more challenging to achieve this level of empowerment. We must find ways to make our patients more effective partners in their own health management.

Prevention must go beyond avoidance of health hazards and early detection. The care interface must promote appropriate physical activity, psychological coping skills and excellent nutrition. These lifestyle management principles are as important for those who are well as for those who are chronically ill. This is a key success factor for disease management in diabetes, heart failure, cancer, coronary disease and depression.

The benefits of good nutrition, physical activity and stress management are well established but scarcely impinge on the consciousness of conventional medical practitioners. This raises the final principle: health care providers should walk the talk. How can we ever promote and secure lifestyle changes in our customers if we cannot do so for ourselves?

Process

Every health care process must have prevention built into it. The current consultation and admission processes allow almost no resources for prevention. Preventive processes require the appropriate staff, facilities, technology and time to be scheduled in to every contact. Education, motivational counselling, rigorous follow-up and data management are key skills, which need developing.

The electronic health record is the only reasonable way to secure compliance to prevention goals by both consumer and provider. Future health records will need to track periodic health status data alongside care episodes. Ideally, these records will identify compliance risk so those high-risk individuals can be targeted for case management.

The disease management model (identify, diagnose, manage and maintain) has driven an improved health care process. Early studies of effectiveness have been encouraging. Interestingly, the most successful examples have occurred outside traditional medical practice. Disease management companies have sprung up to take on difficult patients, managing them in parallel to or separately to traditional care givers.

These early examples of disease management show that the care delivery chain may need to be significantly restructured and re-engineered. Isolated general practitioners and specialists will find it difficult to compete with multispecialty groups specialised in certain disease states. If the potential cost savings prove to be sustainable, there is no doubt that secondary providers and funders will seek to engage disease management specialists.

Barriers to Change

Public health care removes individual responsibility if people view health care as a right. As the management of pain and distress improves, health care can become a form of entertainment, an opportunity for financial gain or an excuse not to work. Funding mechanisms have to respect the need to share responsibility and accountability for health. Appropriate incentives for individuals to take better care of themselves could greatly assist preventive medicine goals.

Funding streams recognise and reward acute care. Clinical skills, technology and facilities will gravitate to activities and procedures that are funded. If only coded diagnoses and procedures are funded, big hospitals, wealthy specialists and gadget-infested health care with thrive. New Zealand health care has yet to grasp this fundamental economic reality. Hopefully, insurers may begin to realise the inevitability of funding preventive services as they take on more health risk.

When the traditional health care system fails to deliver preventive care, those consumers who recognise its value move on to alternative providers, magical thinking and various concoctions of doubtful value. This further undermines the credibility of preventive medicine.

Threads of Hope

The growth of research and high quality evidence for prevention is booming. Long-term research that correlates risks with disease and lifestyle practices with well-being has only recently become possible. What has been learned about the genesis of cardiovascular disease, cancer and immune deficiency will eventually reach most rational practitioners. This evidence is most certainly reaching the educated public and is being applied in a variety of innovative ways.

Businesses will be leading players in the emergence of preventive medicine. Business has no option but to lower the direct and indirect costs of health care. Accident insurance legislation is leading the way albeit in its very early stages. Businesses also face ever-increasing pressures to attract, retain and motivate highly productive people. Good health and wellness are fundamental attributes of sustainable productivity. Although private business only invested $2 million in prevention in 1996, this is growing rapidly with risk management, accident prevention, early rehabilitation, screening and health promotion programmes being provided for an increasing number of employees.

The shift to commercially structured hospitals also offers hope. Funding is currently perverse. As it is based on discharge diagnosis and procedures, hospitals are encouraged to increase admissions and procedures. Eventually hospitals, too, will have to serve communities or populations. Early evidence is seen in the efforts to build relationships with primary care providers. Their financial viability will depend on being able to reduce unnecessary admissions, complications and procedures. They will need preventive medicine.

The Future

In essence, preventive medicine challenges us to shift from a traditionally reactive stance to one that is far more proactive. Consumer demand, funding constraints and evidence-based medicine will eventually force this shift. Early adopters will find it hard in the absence of defined markets, funding streams and peer support. The smart players are likely to be innovative and entrepreneurial ventures applying "disease management-type" processes.

hose most likely to succeed will find ways to integrate business acumen, clinical skill and management disciplines. With regard to the latter, marketing, finance, quality management and information technology will be critical. It is probable that some structural or policy reform will be required at the governmental level. The Accident Insurance Act 1998 is a first step in this direction. Government and insurers should seek to align and focus funding mechanisms to enable the development of effective preventive efforts. They need not meddle further.

The medical profession will struggle to adapt. Older practitioners may never change but younger practitioners must respond to changing training programmes, consumer demand and the emerging opportunities. I strongly believe that with the right financial incentives the transition will greatly accelerated. Whether funders have the confidence to make the long-term investments required for payback is unclear.

New Zealand must widely debate the preventive medicine issue. Small, carefully studied pilot programmes are the best way to start the move. Properly engaged preventive medicine holds much promise for better health outcomes. The process of development, research and implementation will be exciting and different.