PREVENTIVE HEALTH CARE

This is a thoughtful commentary on our general health care system and the specific role ;that preventive medicine can play in enhancing health, cutting costs, and building the model that will provide health care for all. A central theme is this editorial is that third-party payers do not pay for preventive services in general; they reimburse the high technology, high cost therapies, which generally do nothing to treat the underlying condition.

The author notes that reimbursement procedures are also out of balance, since the procedure-oriented physicians, such as cardiologists, radiologists, anesthesiologists, gastroenterologists, surgeons and ophthalmologists, are often reimbursed several times the rate of the general practitioners, internists, and pediatricians who do most of the primary care. Therefore, medical students tend to migrate more to the specialties that to the general types of practitioners, the procedure/crisis oriented health care model continues, while the primary care/preventive model progresses very slowly.

The author takes cardiovascular disease and our approach to it as an example, since it is still the leading cause of death in western industrialized countries. Coronary heart disease killed 497,850 U.S. citizens in 1989. Over 6 million will suffer a heart attack and 500,000 will die.

Sixty percent of these will die before they reach the hospital. The cost of cardiovascular disease, of which coronary artery disease constitutes 60%, is estimated to be $108.9 billion per year. It is noted that over 300,000 coronary artery bypass grafts were done last year, at a cost of $30,000 to $40,000 each, which is an estimated expenditure of $9 billion alone.

Expense of high technology treatments for coronary artery disease, such as coronary angioplasty, coronary bypass, thrombolytic therapy, antiarrhythmic drugs and pacemakers, do not cure but rather only treat symptoms. They do nothing for the underlying cause of atherosclerosis. The author notes that most physicians are totally preoccupied with the use of these palliative therapies, which will do nothing for the next generation of 30, 40 and 50 year olds who will more than likely develop cardiovascular disease.

The author states that "the response of physicians to the epidemic of coronary heart disease is currently inadequate despite the massive efforts to apply costly treatments after disease is clinically manifested."

Between 1978 and 1988, there was a 29.2% reduction in death from heart attacks in the United States. The author states that most of this came from the public assuming more healthy living habits, not from medical treatments. The author also notes that there is increasing evidence that coronary artery disease is preventable, and several studies show that drugs and lifestyle alone can regress the atherosclerotic process in advanced coronary hart disease.

The author notes that cardiac rehabilitation is not reimbursed by Blue Cross/Blue Shield and Medicare, at a normal cost of $1,000 to $2,000 per rehabilitation program, but the same insurance programs will pay $30,000 for a coronary bypass and often more than $100,000 for heart transplant surgery.

Two studies of cardiac rehabilitation programs, over 2 to 3 year periods in several thousand patients, showed between a 20 and 25% reduction in fatal heart attacks, overall mortality, and coronary heart disease. Controlling high blood pressure has reduced the mortality from strokes by over 50% in the last 25 years. Since 60 million Americans have high blood pressure, the author feels that a significant portion could be treated without drugs, using sodium restriction, obesity reduction, and exercise.

The author notes that many of the guidelines for treating heart disease are similar to those recommended for cancer prevention. However, keeping people alive longer has resulted in a proliferation of chronic illnesses, such as arthritis, osteoporosis, hip fracture, dementia, and hearing and visual losses, all of which can be disabling.

The author feels that as our understanding of each of these conditions increases, we will be able to take more appropriate action to prevent these problems. The longer everyone can stay healthy, the less stress there will be on the health care system. The author noes not criticize current medical advances per se, but does "decry" the very large numbers of individuals who come to receive medical care daily for problems that are largely preventable. The author states that we need a balance between the "curative and preventive approaches."

"Preventive Medicine For Our Ailing Health Care System", Leaf Alexander, MD., JAMA, February 3, 1993; 269(5):616- 618. (Reprinted from Clinical Pearls News . . . 3301 Alta Arden, #3, Sacramento, CA 95825, 1(800) 422-9887)

Copyright © 1996. The Light Party.