The aphorism “An ounce of prevention is worth a pound of cure” is as true today as it was in 1735, when Benjamin Franklin used it to make the argument for creating Philadelphia’s first volunteer fire department. But you’d never know it from the way we train physicians and pay for health care.
Government and commercial health plans have always paid physicians and hospitals for cures or for treatments that keep chronic illnesses controlled. Prevention — which, according to Franklin, should be worth 16 times the comparable amount of a cure — has never earned most health care teams a dime, even though our society’s rates of diabetes and obesity, two expensive and arguably preventable conditions, have never been higher.
Patient-centered medical homes have given some physicians a modest per-patient-per-month fee to do routine screenings and help keep their chronically ill patients out of the hospital, and Medicare is starting to pay extra for complex chronic care management, but fee-for-service medicine still predominates and sick people generate more revenue than healthy people.
Health plans have finally started to recognize that this lopsided valuation has to change if they are to avoid being bankrupted by bills for treating chronic disease. Thanks in part to provisions in the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, Medicare is shifting quickly toward “value-based” payment models. These put care teams at financial risk if they fall short at keeping their patients as healthy as possible. Commercial health plans are following suit. Physicians and hospitals will have powerful incentives to become experts at prevention.
To fully execute this shift, our country will have to make some fundamental changes in the way we approach medical education and train our physicians.
Medical education from a public health perspective
The status of prevention has historically been the same in medical education as in professional practice. In the past, the occasional student or resident interested in learning more about preventive medicine and public health may have spent time in state and local public health departments or at the Centers for Disease Control and Prevention, where they would have applied themselves to solving big-picture problems. Or they might have lobbied to limit smoking in public places, or advocated for bike paths or more healthy school lunches. But most medical students never had the chance to have this type of public health experience.
Traditional medical education may include a token course in prevention, but the focus is squarely on how to treat patients. Once in practice, most physicians apply their expertise and time to immediate health problems. They don’t know, and often feel they can’t influence, whether their patients eat a healthy school lunch or have a safe place to ride a bike. At most, they often issue rote reminders to quit smoking or to lose a few pounds.
In order to head off obesity, diabetes, congestive heart failure, obstructive pulmonary disease, and other expensive, debilitating, and potentially preventable conditions, these two paths — public health and clinical practice — must meet.
What should all medical education and resident training programs include to bring together these two strands?
Teamwork. In a preventive framework, a physician isn’t always at the top of the pyramid handing down orders. Preventive medicine requires a care team: physicians, nurses, nurse practitioners, physician assistants, social workers, case managers, community health workers, and more. We must expand medical school faculty to include more non-physicians, and teach future physicians a certain style of humility so they can effectively partner with people who have the skills and knowledge to address conditions in a community that affect patients’ health.
Population health. As physicians increasingly have access to mountains of data, they need to know how to use it. For example, if they know something as basic as a patient’s address, they can use databases to find out or deduce the patient’s likely socioeconomic status, water and air quality, exposure to contaminants or carcinogens, available educational opportunities, access to transportation or social services, or distance to fresh vegetables. It does no good to recommend that a patient eat more salad when the nearest lettuce is five miles away by bus. But the physician might help petition to get a grocery chain to open a new store in the patient’s neighborhood, or modify treatment or lifestyle recommendations to match the patient’s situation.
Physicians don’t need to become experts at mining big data, because population health technology can do most of the heavy lifting. But they do need to understand its potential and how it works with clinical, wellness, and claims data (to name just three sources) to help keep their patients healthy.
An appreciation for complexity. Much of cure-oriented clinical practice moves in a reasonably straight line from diagnosis to treatment to follow-up. There’s nothing linear about a prevention-focused health system, especially during this time of transition for the health care system. Physicians will need to understand and address the multiple factors that contribute to their patients’ health risks at the same time that they juggle the payment arrangements and performance benchmarks set by Medicare, Medicaid, and commercial health plans. More and more physicians will be part of one or more accountable care organizations, and so will need a grasp of organizational dynamics that’s normally associated with business school, not medical school.
Putting it into practice
At the University of Wisconsin, our medical students and residents understand where things are headed. Almost two decades ago, we began to transform medical education by teaching an after-hours elective course on integrating public health and clinical practice. The first class attracted only 20 students out of a class of 175. This fall, the class met in a lecture hall that seats 125, and just about every seat was filled.
By taking an “ounce of prevention” seriously, medical education can and should transition to support the shift to value-based care. A preventive framework — teamwork across a medical school’s faculty; leveraging population health technology; and having an appreciation for the complexities of a prevention-focused health system — includes all critical elements toward achieving a forward-looking approach to medical education.
We have created a longitudinal public health curriculum for medical students and residents. All of our medical students take courses in population medicine and epidemiology, and threads of public health are woven into many of their other classes as well. The “Path of Distinction in Public Health” was created to provide medical students with a formal option to merge medical training with the principles and practice of public health by developing new elective courses and public health service learning experiences. The goal is to shape a new generation of physicians who will incorporate health promotion and disease prevention into their practice.
In addition, in 2014 we created a formal preventive medicine program that trains clinicians to look at patients from a public health perspective. Residents learn that patients may or may not have reasonable economic security, a solid support system of friends and family, a safe neighborhood, access to nutritious food, or public spaces that encourage exercise. We believe that when it comes to prevention, these social determinants of health are just as important as the information in a patient’s medical record.
At a time when 1 in 4 US adults has multiple chronic conditions, accounting for nearly 70 percent of all US health care spending, the need for prevention has never been clearer. Broadening the training that physicians receive, so that prevention and social determinants of health are integral to patient care, is critical to ensuring that our health system and medical practices can confront this national health crisis.
Thomas J. Van Gilder, MD, is chief medical officer and vice president of informatics and analytics for Transcend Insights, a population health company based in Campbell, Calif. He helped create the University of Wisconsin’s Preventive Medicine Residency Program and advises on its ongoing curriculum. Patrick Remington, MD, is professor and associate dean for public health and director of the Preventive Medicine Residency Program at the University of Wisconsin, Madison.
This is the way to go although preventive health is associated with lmic
Corrupt healthcare providers undermine the promise of preventive care. Many high-deductible plans promise to cover “preventive” procedures at 100%. But the reimbursement rates for doctors for those preventive-coded procedures are less than non-preventive ones. So my experience has been that many doctors code procedures that are clearly preventive as something else (typically an “office visit,” which they don’t have to specify in detail). That means it is not free; the cost comes out of your deductible–and therefore your pocket. This is a huge problem that nobody is even acknowledging.
Much of prevention requires nonmedical policy changes that ensure “upstream” health improvement. While public health and clinical practice have a role to play, until other social issues such as food deserts and inadequate childcare are dealt with, we’re swimming against the current. The other problem that exists is the difficulty of “proving” prevention. It may take years of follow-up and extremely intricate experimental protocols to really demonstrate that what is assumed to be preventive actually is worth investing in. I do believe we need to help med students to become better communicators regarding health behaviors, but given the growing volume of data (much of it conflicting) about prevention strategies, how do we proceed?