EDITORIAL

Prevention and Cost Control

Science  21 Sep 2012:
Vol. 337, Issue 6101, pp. 1433
DOI: 10.1126/science.1229493
CREDIT: CANDACE DICARLO

Prevention is the key to cost control and improving the quality of health care in many nations. Most people think of prevention as vaccines and screening tests. But it is tertiary prevention—keeping people with established diseases from becoming worse—that holds the greatest promise for strengthening the health care system. Why? Health care costs are unevenly distributed across populations. In the United States, 50% of the population uses hardly any health care, whereas 10% consumes nearly two-thirds of all health care spending. The latter are patients with one or more chronic conditions, such as congestive heart failure, diabetes, or cancer. To control costs, we must prevent the conditions of this 10% of patients from worsening.

Primary preventative strategies (treating healthy people to avoid disease), such as vaccination, and secondary strategies (diagnosing and treating people who are at risk of developing disease) remain critical interventions. Tertiary prevention improves the care of patients with serious and often multiple chronic illnesses, and it requires extending responsibility for their health beyond the hospital and physician's office. This approach begins with interventions that transform medical care: entrusting care to multidisciplinary teams that share a common electronic health record with a single care plan; giving the patient access to a health care provider who has the patient's clinical notes, diagnoses, medication list, and care plan; and establishing specialized clinics for recurrent problems. It also requires careful monitoring at home of early physiologic indicators; frequent interactions (in person, by phone, or by e-mail) to enhance patient engagement with their own health through activities such as diet compliance; home services, including house calls for emergencies; education and support for the patient's caregivers and family members; and even transportation services to ferry patients to and from medical appointments.

CREDIT: ISTOCKPHOTO.COM/OLEG PRIKHODKO

This type of intensive outpatient care for the chronically ill can achieve remarkable results. For instance, CareMore, a private health plan for seniors, has documented a 56% reduction in hospitalization of patients with congestive heart failure and a 60% reduction in amputations for diabetics.* Overall, CareMore's Medicare beneficiaries have a readmission rate of 10% as compared to approximately 20% for all Medicare patients (Medicare is the U.S. federal health insurance program for seniors). Hospital lengths of stay are 38% shorter than the national average. The primary care team and specialists work together closely, avoiding many superfluous tests and treatments. This approach has dramatically improved the quality of care, with cost savings focused in three areas: reductions in emergency room use, hospitalization and readmission rates, and use of specialists. Overall, groups such as CareMore reduce costs by 15 to 20%.

The expansion of tertiary prevention presents important challenges. How can proven models be successfully introduced into new settings? Can Medicare, Medicaid, and private payers transform their payment systems to incentivize the appropriate types of services? Groups that have successfully implemented tertiary prevention usually receive global capitation payments that allow them to redirect resources and reward physicians and other providers for improving the health of their patients, rather than rewarding them for treating acute exacerbations. Somehow, health care systems must move away from a fee-for-service payment system that rewards performing more interventions and penalizes a tertiary prevention approach. Any quality health care system must control costs. An effective implementation of tertiary preventative measures is an important step in this direction, while simultaneously improving health.

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