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Don't Call Me Shirley


When some 900,000 Americans die from easily preventable causes, are we really practicing "health" care? Let's drop the euphemism and call it what it really is.

Let's briefly drop the euphemism "healthcare" and call it what it really is at this place and time: illness and injury care.

If we do so, it might make it easier to understand the fix that our country is in and show us a better way. We also have the related elective cosmetic care - the lifts, the collagens, the lasiks, and so on - but we'll leave those for now as they are an elective consumer activity, not covered by private or public mechanisms.

Calling medically related activities "health" care begs the question. But we as a profession, culture, and nation really ought to turn our attention to actually emphasizing prevention and health instead of after-the-fact clean-up as an important, if partial, solution to the disorganization and runaway costs of our current situation.

It's injury-and-illness to you, buddy.

For the sake of discussion, if you look at the top 10 causes of morbidity and mortality, let's say that about 1/2 of what makes us sick and kills us is, at least in part, our own doing. It would be nice if we could actually stop eating badly, start exercising, avoid alcohol, drugs and tobacco, drive better, and the like.

I know, being a "free" country gives us license to act foolishly and self-destructively; 20% still smoke (!), about 1/2 of us are fat and/or deconditioned, 8% abuse alcohol and drugs, and on it goes. The problem is that those engaging in those behaviors are also "free" to have the excessive cost generated. And for us all to pay it.

Insurance? No. My friend here is picking up the tab.

Yes, there are programs to raise awareness and hopefully prevent such ills, but they are mightily dwarfed by what we do and spend on closing the barn door after the horses are out. And it's tough to legislate against being foolish; look at the disastrous unintended consequences of Prohibition.

Thanks a lot, Volstead.

What is needed is a long-term, relentless national campaign to refocus our attention on keeping us out of the top (bottom?) 10 when it comes to preventable illness and death in the first place. We could then redirect resources to better get a handle on the 50% of afflictions that do not appear, so far, to be the direct result of our personal and collective folly. This must be a cultural change, as well as an informational and organizational realignment for this to fully succeed.

We know that personal efforts by docs to get our patients to change do work, if slowly and unpredictably. But what about the majority of people who do not either go to a suitable physician at all or when it is often too late for change to be significant? Docs themselves are often poor role models, are not trained to be in prevention mode and, most importantly, receive almost no incentives, either stated or financial, to do more than we do, collectively and individually.

Have you seen what an ICD-9 code for preventive, counseling activity will get you? It will not pay the utility bill, let alone anything else. Society/insurance companies/Medicare have all decided to primarily pay the big bucks and give recognition to the late-in-the game, save-a-life procedure, instead of taking the more logical, if difficult, preventive approach.

Dramatic and emotionally compelling, but not economical

What's wrong with us? Why is this so hard? It seems to me that the whole recent debate about medical payments was completely wrong-headed to not prominently address realigning incentives, especially to prevention. Rescue medicine is dramatic and emotionally compelling. But prudent and economical? Alas, not so much.

To kick off a new debate, here are my two bits to get us started:

  1. On the medical side, we need to make common cause among our myriad, self-interested little groups and "Speak Up!"
  2. We need curricula overhaul to get docs in the next generation equipped with the knowledge-based business and organizational tools to effectively assume the leadership mantle to which they are heirs in medical matters.

Physicians and the organizations that purport to speak for us have a bully pulpit that we use inadequately and inefficiently. Physicians occupy a position in America that could be a marketer's dream because we have the moral and intellectual high ground...and at least people will listen.

We have enough studies, enough best practices, enough Cochrane analyses to make a mighty convincing case, right now, for a cultural, economic, and organizational course change. Sure, turning an aircraft carrier is slow and hard, but there is a point to it.

And there is a point to shifting public attention from just illness care to preventitive care. We'll be healthier, happier, live longer, save a king's ransom, and feel pretty good about it all in the bargain. That's a tough win-win-win to beat, and certainly more attractive than the ill-managed mess we're in now.

And re-directing our level of emphasis to prevention will make the other end, the cost spiral tail that is wagging the dog, logically easier to reorganize and sustain. The seemingly inexorable pressure of constantly rising costs for a late-in-the-game fix for preventable illness will be eased, if not actually reversed.

Keep this in mind - the best available estimate is that about 45,000 Americans die every year because of the lack of health insurance. Yet a recent study found that at least 900,000 are dying every year because of the bad habits I cited earlier. That's a 20 to 1 ratio, folks.

The more you think about it, the more of a "Duh!" moment it seems to be, and "Duh!" moments always mean we've long since dropped the ball.

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