The US will devote 17.5% of GDP to health care this year, around $3 trillion. Yet only 3 percent of that will be spent on prevention, including both primary prevention (preventing illness in the first place) and secondary prevention (preventing sick people getting sicker or having a relapse). Medicine saves lives, doctors are heroes and the best earn Nobel prizes. Prevention, by contrast, is mundane, measurement of effectiveness is difficult, rewards and recognition pale by comparison.
In a recent NEJM paper, Tom Farley, Philadelphia Health Commissioner, bemoaned the underfunding of proven prevention programs while sick people certain to die nevertheless continue to receive expensive treatments. Why does a utilitarian greatest good for the greatest number perspective not prevail? Farley cites two reasons: when a life is at stake, it’s unethical to withhold treatment, regardless of cost effectiveness; second, medical treatments are funded by payers and providers whereas prevention programs are typically funded from public health budgets subject to annual budget cuts by short-sighted politicians.
There is another important reason. Diet, exercise and other lifestyle decisions are viewed by many as matters of personal choice, even though society may later have to pick up the health care costs associated with these decisions. Prevention involves taking personal responsibility for one’s health. The worried well do so, wearing Fitbits or following diets, the chronically ill often do not.
Why do people not respond to good advice regarding diet and exercise? Some, especially the young, feel invincible, want to live for today and imitate their peers. Others, often older, are fatalistic, can’t change their habits, or believe the damage they’ve already done to their bodies is irreparable. A third group is prepared to trade off irresponsible behavior for the inevitably increased probability of getting sick because someone else will pay for it. For the same reason that many people don’t save enough for retirement, they resist sacrificing the pleasures of today for uncertain future health benefits.
The effectiveness of prevention messaging is inadequate. Most public health prevention campaigns rely on public service announcements developed pro bono by ad agencies and aired by television and radio stations in unsold time slots when few are viewing or listening. To be effective, prevention messages must be properly researched, targeted at the correct consumer segments, and placed in relevant and influential media. Not enough preventive health messaging leverages social media. Messages designed by public health officials tend to be over-serious and preachy rather than humorous, attention-getting and memorable.
In addition, preventive health messages that try to persuade people not to do something are at odds with the focus of commercial advertising which is largely aimed at persuading people to do something i.e. buy a product. Some of the most famous and respected brands in the world push processed foods and beverages overloaded with sugar, sodium and the wrong kinds of fat. Attractive pricing, packaging design, extensive shelf facings and intensive distribution add to the marketing appeal of these often addictive products.
Prevention messages are buried under this avalanche of marketing expertise. Access is also a problem. Around 10% of the US population lives in food deserts, where convenience stores in gas stations that sell soda and chips but not fresh fruits and vegetables are the principal source of food. Others live in dense urban areas without easy access to exercise opportunities in parks or other recreational facilities.
Once a person has a diagnosed medical condition, (s)he is more likely to pay attention to one-on-one advice from doctors and nurses – perhaps supported by appeals from friends and family — to avoid a recurrence or further deterioration. For this reason, investments in secondary prevention are often more cost effective than primary prevention.
Ineffective primary prevention messaging has spawned increasing interest in economic incentives that nudge people towards more healthful behaviors. Soda taxes in Hungary, Mexico, the United Kingdom and other countries are one example. Though they are criticized as regressive, substantial government taxes on tobacco products along with relentless messaging have helped to reduce consumption in developed countries.
Beyond messaging and financial (dis)incentives, the third lever available to public health officials is regulation. Marketing can be constrained. Affirmative labeling disclosures can be required. Minimum ages for purchasing a product can be set. Often, affected companies are able to stoke “freedom of choice” opposition to such regulations. Mayor Bloomberg’s effort to cap soda serving sizes in New York was roundly criticized by small restaurants and was struck down by the courts as “arbitrary and capricious.” It’s not clear that the restriction to the 16 ounce size would have reduced soda consumption and obesity anyway; many consumers of “big gulp” serving sizes said they’d just buy two 16 ounce sodas to get what they wanted. Public health officials often fail to consider thoroughly the sometimes perverse attitudes and behavioral reactions of the consumers they are trying to help with their nudges and regulations.
Now for some good news.
First, the Affordable Care Act encourages greater focus on prevention. Providers are motivated to pay more attention to minimizing hospital readmissions and to population health in the communities they serve. Payers are motivated to better understand consumer behavior and improve the lifestyles of their chronically ill clients, benefiting from any savings against government reimbursement rates for specific conditions. Interestingly, the clients never get to share in the cost savings; presumably, they should be grateful to be nudged towards healthier behaviors. In time, however, new business models will emerge that engage consumers as financial partners in improving their health.
Second, the size of the health care sector plus the increased emphasis on prevention are attracting more interest from entrpreneurs. At last month’s Harvard Business School New Venture Competition, two of the three grand prize winners, Astraeus Technologies and UrSure, focused on health care, the first on creating better, faster, tests for lung cancer screening and the second on HIV prevention drug adherence. Three of the four runners-up also focused on health care prevention, testing and telehealth. Like other prevention initiatives, none of these start-ups involve diagnostics or drugs that require lengthy regulatory approvals.
Third, and perhaps most important, use of the word “prevention” is fading. The word “prevention” has a negative, paternalistic and restrictive connotation, implies a delayed benefit and often provokes a defiant response. Better to focus on the promotion of “well-being” and “resilience” which are positive and empowering in tone, expansive in scope and suggest a more immediate benefit.