Preventive Care vs. Disease Care

Enclosed is an article that I believe would fundamentally change the direction of the United States health care system to a more sustainable model. If adhered to (Preventive Medicine For Our Ailing Health Care System, JAMA, February 3, 1993.269(5);616-618).

With all good intentions, the development of a national health care system or a totally free enterprise medical system will not change a fundamental flaw that is built into our present model. We have a crisis care procedure-oriented health care system that is reimbursed several-fold higher than preventive strategies. No matter what constraints we put on it, if we do not focus on disease prevention, more high technology and capital intensive procedures will be utilized and paid for, eventually bankrupting our health care system.

What needs to transpir æ ƒ a fundamental shift from procedure-oriented reimbursement to reimbursement for either benefit or preventing illness. I can guarantee a dramatic reduction in expenditures and more emphasis on prevention if procedure-oriented specialists were not reimbursed several-fold higher than the people who deliver primary and preventive care such as pediatricians, internists and family practitioners. In the long run, our health care costs would be reduced dramatically.

Take coronary artery disease as a case in point. More that $108 billion was spent in 1992 on cardiovascular disease. Of that, $9 billion was spent on coronary artery bypass alone. Third-party reimbursements and Medicare will pay $30,000 to $40,000 for this technology. This does nothing for the underlying cause of the disease, but, at best, is a symptomatic treatment (JAMA, February 3, 1993;269(5);616-618).

What is truly sad about the cardiovascular disease model is we now know, through the excellent work of Dr. Dean Ornish, professor of preventive medicine at the University of California at San Francisco, atherosclerosis can be reversed by diet, Lifestyle and stress management practices (Lancet, July 21, 1990.336;129-133). It is shameful that we will pay $30,000 to $40,000 to do a coronary bypass surgery, whether through Medicare or private insurance, and yet we will not pay $1,000 to $2,000 for cardiac rehabilitation, which has been shown to reduce the incidence of a recurrent cardiac event by 25% on a program similar to Dr. Ornish’s recommendations.

You can take this one example of cardiovascular disease, extend it to each specialty and find a high technology procedure that receives excellent reimbursement. An example in orthopedics might be hip replacements. At a recent talk, I asked the audience if anyone had the estimated cost of a hip replacement. A gentlemen, who had just had one, said it was between $30,000 and $40,000 for one hip and he was out of the hospital quickly. A related problem is hip fractures. Each year, Americans suffer from 280,000 hip fractures. This number is expected to increase to 650,000 by the year 2050, more than doubling the current number of hip fractures.

This is a very serious problem, resulting in considerable disability and tremendous cost. Preventive strategies to reduce this emerging epidemic include exercise, diet and medication reduction (“As Population Ages, Orthopedists Gird For Increasing Number of Hip Fractures.” Medical Tribune, March 11, 1993;16). Let us look at cataracts. If we could delay cataract surgery by 10 years it has been estimated that we could save millions, if not billions of dollars. Cataract surgery and related doctor visits make up the largest portion of the Medicare budget - $3.2 billion. A 33% reduction in the incidences of cataracts has been shown in people consuming very moderate levels of vitamins C and E (300 to 600 mg and 400 mg per day respectively). “Cataract: Relationships Between Nutrition and Education,” Journal of the American College of Nutrition, 1993.12(2),138-146). And the list goes on and on.

Another point is now young physicians who make decisions about whether to be specialists or generalists. Look at the excellent review by Dr. Alexander Leaf, AMA, February 3, 1993;269(5):616-625). As students go through the medical school system, they see specialists who employ these high technology procedures. They’re being reimbursed at several-fold the amount internists, pediatricians and general practitioners do. Students are more driven to fill those particular specialties, especially when they have an incredible debt to pay after graduating. This motivation shifts our medical system into a preventive model, which could be a cost effective alternative to the current high-technology, procedure-oriented model.

Another topic of great interest to me - once part of my livelihood is made compiling and organizing nutrition and preventive medicine research - is the role of therapeutic nutrition in reducing æ •ital stays and subsequent costs. Take for an example the cost of premature infants in neonatal intensive care units. The average cost per day at the University of California at Los Angeles Medical Center for one room only was more that $1,100. This does not include the doctor or any procedures.

It has been suggested that vitamin A can reduce the incidence of broncho-pulmonary oyspiasia in very-low-birth-weight infants (Journal of Parenteral and Enteral Nutrition , May-June 1993;17(3);220-225). The question of this study was whether supplementing with 2,000 IU of vitamin A intramuscularly three times a week, beginning on the tenth through the fourteenth day of life, would have any effect on the duration or stay in the neonatal intensive care unit, compared to administering this vitamin on the second to the fourth day of life. As you can see, the length of neonatal intensive care unit stay was significantly reduced from 81 days to 60 days when the vitamin A supplementation by intramuscular injection was given on the second to fourth day of life.

At the bare minimum of cost, giving vitamin A early on would potentially save $26,400 for just the room charge fee per child. The early vitamin A treatment given to the 24 children in this study equates to a $554,400 savings. I would dare to bet the total cost including Physicians fees and all the procedures occurring in a neonatal intensive care unit would probably be close to double. Now we’re talking approximately $1 million of savings for 24 infants who were given vitamin A eight to ten days earlier. In reality the savings wouldn’t be this much since the children would go to less costly pediatric wards before being discharged, but there still would be substantial savings as compared to staying the neonatal intensive care unit.

I want to emphasize that this is just one nutrient, one type of disease, in one particular hospital scenario. If we truly evaluated functional nutritional adequacy in hospitalized patients and treated them accordingly with therapeutic nutrients, and if we could just reduce the duration of hospital stay by 50%, billions of dollars would be saved each year since nutrient costs are very low. But if nutrients become prescription drugs, they would have a pharmaceutical price tag attached to them.

Another example of the power of nutritional therapy is the editorial entitled “Folic Acid-Preventable Spina Bifida and Anencephaly” in the JAMA , March 10, 1993;269(10);1292-93. Folic acid supplementation of 0.4 mg to 4 mgs has been shown to significantly reduce the incidence of neural tube defects.

The editorial states, “One of the most exciting medical findings of the last part of the 20th Century is that folic acid, a simple, widely available water-soluble vitamin, can prevent spina bifida and anencephaly. Not since the rubella vaccine became available 30 years ago have we had a comparable opportunity for primary prevention of such common and serious birth defects. The many epidemiologic studies that resulted in the identification of the preventive effect and folic acid is a model for the kind of research that needs to be done to identify the cause of and primary prevention strategies for other birth defects, the leading cause of infant mortality in the United States.

The last example I would like to leave with you, Mrs. Clinton, is related to the potential power of nutrient intervention in cardiovascular disease. Cholesterol is one of the known risk factors for heart disease. Recently experts in the field have reported that protection of the oxidation of LDL cholesterol by antioxidant nutrients such as vitamins C, E and beta-carotene can be achieved, theoretically reducing the initiation of the atherosclerotic process. These nutrients are promising therapies.

Yet with all the emphasis on cholesterols relationship to heart disease, more than 50% of all cardiac events have no known classic risk factors associated with them. The Physicians Health Study found that elevated levels of homocysteine, an amino acid associated with early atherosclerosis and death, was higher in physicians who later developed a myocardial infarction (heart attack) compared to those who did not.

The authors note in the conclusion that there are nutrients specifically from the vitamin B family that can easily reduce homocysteine levels, an independent risk factor for heart disease. These nutrients include vitamins B6, B12, choline, betain and folic acid. Again, these are very cheap and safe supplements. If you read the article from the American Journal of Clinical Nutrition 1993.57;47-53, entitled “Vitamin B12, Vitamin B6, and Folate Nutritional Status in Men with Hyperhomocysteinemia, “you will find that individuals with elevated levels of homocysteine had sub-optimal vitamin status of vitamins B6, B12 and folic acid.

When these individuals were supplemented with small dosages of vitamin B6 (10 mg), folic acid (1 mg) and vitamin B12 (0.4 mg), their elevated homocysteine levels were normalized within six weeks. The authors concluded “Because Hyperhomocysteinemia is implicated as a risk factor for premature occlusive vascular disease, appropriate vitamin therapy may be both efficient and cost-effective to control elevated plasma homocysteine concentrations.”

Again, we suggest that these simple low cost, low toxicity nutrients may help reduce a significant risk factor for cardiovascular disease, which is still the number one killer and a great expense to our health care system. The question is this, why are we not aggressively investigating nutritional assessment and intervention strategies in chronic degenerative diseases that can be intervened earlier on, before the actual disease manifests in its most severe form?

As I see it, this research should be given the highest priority if we are to create a sustainable system of health care in the United States. In closing Mrs. Clinton, I encourage you to seriously consider the economic incentives that encourage this unsustainable procedure-oriented, high technology, capital intensive medicine model. Secondly, I suggest researching just one area of nutritional medicine. It would be a very fruitful investment to fund I.T. Services to do an in-depth investigation showing how nutritional assessment and intervention could reduce hospital stay and, therefore, save millions, if not billions, of dollars. Thirdly, I hope you will encourage more specific research into functional nutritional assessment with subsequent therapeutic trials of nutritional supplements that will help prevent these chronic diseases, costing our health care system phenomenal amounts of money and resulting in incredible suffering. Lastly, I hope you will not support any attempt to make nutritional supplements pharmaceuticals, since this will increase their prices dramatically.

Kirk Hamilton, PA-C, IT Services
3301 Alta Arden, #3, Sacramento, California 95825
916-489-4400/Fax 916-489-1710