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March 14, 2014
Viewpoints: Rethinking preventive health care

HEALTH_ACCOUNTABLE_CARE_2.JPG(March 14 - By Akhilesh Pathipati, Special to The Bee)

One of the hottest buzzwords in the health care lexicon is "preventive care." It's easy to understand why: Millions of Americans die with preventable illness every year, with smoking alone responsible for 1 in 5 deaths. Economically, an estimated 75 percent of health care spending is on chronic illness, much of which is preventable.

Existing reforms attempt to address the problem with secondary prevention: incentives designed to change physician behaviors after hospital admission. The Affordable Care Act is littered with policies that tie physician payment to efficiency. For instance, hospitals receive decreased reimbursements for preventable readmissions.

But there is no reason that physicians should come into contact with many patients in the first place. The discussion around preventive care consistently starts with patients but morphs into one surrounding practitioners. As a result, remarkably little has been done to promote health through patients themselves.

Preventive policies must recognize that the responsibility for an individual's health ultimately lies with the individual. The best approach may therefore be to financially incentivize healthier behaviors through patient-centered preventive care. Research indicates that patients respond to economic principles. Of particular note, smoking rates show strong responses to increased taxation.

The question then becomes how to structure patient incentives. While program design presents certain challenges, multiple stakeholders can help people make healthy decisions. More specifically, employers, governments (both federal and local), and involved third parties (e.g., insurers) can take steps to empower patients.

Johnson & Johnson provides an example of an employer-based program. The company runs one of the oldest corporate wellness programs, through which participating employees complete an online health assessment. High-risk employees then work with health advisers to come up with solutions. Employees receive up to $500 in insurance premium credits for their participation.

The program has been extraordinarily successful. Between 1995 and 2010, the rates of tobacco use, high blood pressure, high cholesterol and being "sedentary" all dropped between 46 and 68 percent. The resulting rates fall well below U.S. averages for those health metrics and more, and independent evaluations of the company's program confirmed that its focus on healthy employees led to annual savings of $565 per employee.

The ACA does have a little-discussed provision to promote employer wellness programs by allowing organizations to offer larger incentives for participation. Yet, corporate offerings are not the only option. A broader national policy could incentivize health behaviors by offering tax rebates to those who meet health benchmarks or encourage the expansion of patient incentives to insurers. The result would be improved population health and lower long-term health care costs, while easing the burden of the physician shortage.

Despite their promise, the use of financial tools in health reform has generated considerable opposition. Opponents of wellness programs note that some programs have not demonstrated savings. Even so, there are two reasons to pursue them. First, even if an incentives-based program is cost-neutral, the health benefits for enrollees would make the endeavor worthwhile.

Second, these programs are designed to bring down long-term health care costs. If they have not yet shown savings, it may be because they have not been in use long enough to do so. A young adult who engages in unhealthy behaviors would be at high risk for many diseases, but those diseases would not manifest for years or decades.

Policies designed to change behavior have also run into political roadblocks in the past. Critics argue that behavioral interventions discriminate against the poor because activities like smoking tend to be disproportionately prevalent in low-income groups. However, people in all populations often disregard their long-term health; unhealthy behaviors do not necessarily demonstrate an income-based stratification.

Granted, there are many nuances that a program would need to account for, including other income-based factors and genetic predispositions. Opponents also worry that poor populations will have fewer resources to improve their health, which is why it is important to couple health targets with the tools to achieve them. Regardless, it is not difficult to believe that people want to be healthy. Providing them with an incentive and the resources to do so is perhaps the most sustainable policy.

Policymakers will continue to develop innovative ways to keep patients out of hospitals. But health care reform has come up with solutions that have not worked because they rely too heavily on medical intervention. We should instead use financial tools to prioritize the prevention of illness.

Akhilesh Pathipati is a Stanford medical student and Harvard graduate who has worked on health initiatives in Massachusetts and California. He is a Sacramento native.