The
rising costs of health care have alarmed the nation. Measures to control excessive costs are warranted.
That prevention is worth a pound of cure is a hackneyed phrase but does contain
some truth and might define a path to cost containment. However, solutions will not be easy since the
problems are entangled with a variety of unanticipated costs.
Preventive measures may lead to added costs attendant
to testing procedures and for treating newly uncovered conditions, which in and
of themselves may not require treatment.
Such eventualities might stymie preventive measures. Alternatively, the
success of a preventive strategy may depend more on the astute handling of
political forces, since it is these forces, which may present obstacles to
health care reform. The role of
government in disentangling these issues is discussed in detail in The Perspective
Section of the New England Journal of Medicine, 2016: 375: 1710-1712. In this
article, the evolution of ideas leading to health care reform, with a strong
component of prevention is discussed.
The issue of preventive medicine has been a
contentious issue for many years. The fact that it is has been difficult to
document the success of disease prevention has inhibited physicians from a full-fledged
endorsement of preventive strategies. In
an effort to prove beyond doubt the efficacy of disease prevention, the government
established the US Preventive Services Taskforce in 1984. The agency was tasked
with analyzing the data in a scientific fashion, free of cost concerns and
political influence. This panel was proposed to serve as a consultant to practicing
clinicians. In 2000, the Institute of Medicine suggested that congress should
delegate Medicare preventive Services to the USPST, thus establishing a governmental
agency, targeted with determining value of prevented medicine. Wary that the
USPSTF’s credibility as an impartial determinant of efficacy might be
undermined by political and cost considerations, a former task chief suggested
that Medicare be allowed to govern insurance particulars. In 2008, it was
suggested that the Secretary of Health and Human Services be empowered to add
preventive measures if it was felt by the USPSTF that the benefit was
substantial. In 2009, a draft of the Affordable
Care Act contained provisions that the USPSTF stipulate which preventive
measures be covered. However, this
effort was felt to saddle the USPSTF with political and cost befit considerations,
which was contrary to the original intention that this agency be free of such
restrictions. It called to attention the
uproar in Congress when the USPTF suggested that mammography not be recommended
for women under age 40, and later denigrated the value of PSA testing. At
present, there is considerable controversy as to the role of the USPSTF in stipulating
which services are to be covered.
The effective implementation of preventive
medicine measures holds promise for better patient outcomes with reduced cost.
However, the solutions are not easy since the problems are entangled in cost
issues, reimbursement for physician work, and political issues related to stakeholder
expectations. Medicare officials and
those implementing the ACA subserve all these considerations under the
sobriquet of public policy. The goals of the new administration muddy the
waters a bit and an effective outcome is not yet evident.
Posted by Arthur Banner
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