Looking beyond just getting every sick person to a doctor

Salon has a doctor writing about how even "socialized" health care is way too expensive because the emphasis is on "get sick, go to the doctor" instead of on prevention. Like pretty much all decent people outside of the U.S., he takes first world nations' responsibility to see to the health care of all citizens as a moral given, much the way Americans see "socialized" education, roads, and fire departments as a given. So really, this is just an argument about the hows, not the whethers. It's worth noting that Dr. Parikh uses Canada as his main point of comparison, and theirs considered one of the most inefficient universal health systems.

That said, I agree with him that an ounce of prevention really is worth a pound of cure in health care. Which is why I lose my shit watching wingnuts in D.C. redirect HIV aid from prevention to treatment, because I believe they think AIDS is a good disincentive/punishment for having sex and they don't want to interfere with catching it. No matter if you can get AIDS drugs to every man, woman, and child who needs them around the world, you'll save more lives if you blunt the spread of the disease through condoms and education. Few diseases, once acquired, have a magic bullet cure. To use a more mundane example, think about dentistry. They can do amazing things in that field, fix teeth that a century before would have fallen right out your head with a lot of pain attending. If you do lose your teeth, they can make new ones for you. But there's no crown, no filling, no dentures that can equal the tooth you grew by yourself, and any dentist will tell you that. The disease of tooth decay wasn't cured, really, but its worst symptoms were managed. Same story with heart disease, diabetes, and other illnesses that plague our health care system.

The problem is imagining a way to really get prevention at the forefront of a health care system. Dr. Parikh has ideas.

Incentives can be directed at doctors. A new game-changing concept is called "pay for performance," whereby doctors are rewarded based on whether they meet quality goals that push prevention, such as making sure a patient's asthma or diabetes is well controlled.

It sounds ideal, and doctors can work to counsel against, screen for and prevent disease. But it neglects patients' role in making healthcare better. Most health decisions are made at home in the little things we do, and most of those choices aren't very good ones. Economists refer to this as a lack of moral hazard, and healthcare is riddled with it. Only about half of Americans regularly exercise, and less than a third of us eat the recommended servings of fruits and vegetables each day.

We also seem too casual in our acceptance that medical breakthroughs will help us live longer, and too quick to forget that there are things we can do to prevent us from needing those breakthroughs (and their expensive price tags) in the first place. It would be better if our health insurers reimbursed us for buying healthier groceries or taking laps in the swimming pool at the local Y instead of paying for heart bypass surgery or the Lipitor we take just before we go out to eat a double cheeseburger and fries.

I recently attended a healthcare conference, where a representative from IBM told the audience how it provided a $150 break on insurance premiums to employees who joined a gym and worked out regularly for eight weeks. The IBM rep claimed the gym policy has made its healthcare costs rise more slowly than other companies'.

All these things are extra complex because even if we get universal health care, it's not going to be nationalized, but a series of private insurance companies, at least for the time being. I personally see the advantages of yes, doctors getting paid directly by the government, even though people have nightmares of doctors getting soft and lazy without the incentive of an annual Mercedes purchase.* (Which "Sicko" addressed brilliantly, by lavishing attention on the cars and homes of national health service-paid doctors.) You can easily track results and pay prevention bonuses to doctors.

What Dr. Parikh has more in mind, though, is creating patient incentives to look after your own health, which is a trickier game to play. Again, I think if health care was nationalized, it would be easier to pull it off. Because one reason people don't exercise is an infrastructural issue---they don't have time to do it and our transportation system rewards laziness. Changing the country so that most people find it a lot easier to walk and bicycle more (with all attendant services for disabled folks) will cost a lot of money, but the cost will be easier to justify if you see it as an investment in reducing the cost of health care, which comes out of the same pool of money. As it is, the price tag on changing our infrastructure is intimidating, and the direct savings seem hard to calculate.

Direct incentives to people strikes me as too hard to do. After all, it doesn't make sense if you're not monitoring whether or not they actually go to the gym or eat their vegetables, and really even bringing up that kind of surveillance makes me squirm. It's just like what I suggest with environmental changes, and a lot of the changes would be the same---make it frustrating not to exercise and easy to exercise. On the fruits and vegetables front, things are just going to get worse as the price tags in the produce section continue to climb upwards. How can we reverse that trend?

I can see why Dr. Parikh wants to focus more energy on patient incentives over doctor incentives. There's only so much a doctor can do by scolding or trying to get people on good nutrition plans. Almost any system that works requires more work than most people are currently doing in the eating department, like keeping a food diary so that you know exactly what you calorie consumption and nutritional standing is. One thing that might work is requiring that restaurants put their calorie and fat counts on their menus, at least any corporate restaurant, especially fast food, that competes in markets that rewards attracting customers by upping the amount of fat and calories and sugar in food. A lot of those enticements work subconsciously. How many people are congratulating themselves for picking the "healthier" Chipotle's burrito over a Big Mac, unaware that the burrito has almost 1300 calories? And of course, part of what makes Americans so unhealthy is the abundance of corn syrup, which is amendable to policy pressures. One thing that would help a lot is convincing people to cook more often, but how would we do that? Cooking is just more time-consuming than eating out nowadays, and the one thing people don't have is time. What can we do to change that?

One thing we definitely need to do is stop conflating "catching it early" with genuine prevention. A lot of people think "prevention" means regular screening. But if they catch your cancer or or hearth disease or diabetes early, while that's better than letting it fester, it still means that the disease was not technically prevented. That bit of clarity in the debate will improve discussion tremendously.

*Considering that more than half of med school grads are now women, though, maybe people will be more inclined to start paying doctors more like we pay school teachers. Sexism---make it work for you!