Paying for Prevention
Prevention efforts in the United States are usually measured in terms of dollars spent and lives lost. Currently, we're not spending a lot of dollars on prevention and we're losing a lot of lives. The 3 leading causes of preventable death — tobacco use, poor diet, and limited exercise — account for about 800,000 deaths annually and for nearly 17% of total healthcare expenditures. In a healthcare system that spent about $1.9 trillion in 2004, this represents a huge sum of money.

The real cost, of course, is premature loss of human lives: Tobacco use, diet, and physical activity alone account for more than one third of annual mortality. Including all actual causes of death, about half of annual mortality is preventable. Efforts to control the underlying causes of preventable death, however, are severely underfunded, representing less than 5% of total health spending.

The large burden of preventable deaths is a big target for public health programs. Efforts to improve lives and reduce medical care costs are taking aim, but no direct hit has been registered. Tobacco-related mortality has not yet declined in step with the remarkable progress in tobacco control, and there has actually been a sharp increase in the number of deaths due to poor diet and exercise.

Part of the reason that we have failed to finance prevention efforts comes down to basic economic principles. While the cost of preventable diseases is enormous, there is no immediate return on investments in prevention. Any savings would most likely occur in the relatively distant future, beyond normal budget cycles and political campaigns, and returns from any upfront prevention investments by third-party insurance payers would most likely be reaped by another payer many years from now. Our current system of employer-based third-party insurance has strengths and weaknesses on its own merit, but it is clearly not a good fit for prevention efforts. Barring a radical shift in provider reimbursement, our current approach of squeezing nonmedical costs into the medical reimbursement system is not a sustainable option.

As it stands, there is a stark imbalance between short- and long-term investments in health. Despite the fact that about 50% of the annual burden of deaths is preventable, only 3% to 5% of all medical spending in the United States is directed towards prevention, well care, and population health. An overwhelming proportion — 95% — is directed towards treatment and curative medicine. Historically, this sector of healthcare has had limited impact on overall population health when compared with lifestyle, genetic factors, and environmental exposures.

More recently it seems that the importance of medical care is increasing; it accounts for a bit more than 40% of the gains in life expectancy since 1950, compared with its contribution of less than 20% of the gains in life expectancy over the entire course of the 20th century. Even with this shift, however, dedicating 95% of resources towards medical care can't be supported as a reasonable way to assure a healthy population.

A simple solution would be to change the ratio of expenditures on medical care compared with population-wide health. Even a small shift could make a big difference, and prevention efforts could be considered an investment in Medicare. As the final insurance most Americans will have, Medicare functions as a backstop that catches all the poor health outcomes that result from years of missed prevention opportunities. But there is no mechanism in place for leveraging incentives among the employer-based insurance programs that provide years of care before individuals enroll in Medicare, and in our current political climate of incremental change it is unlikely that Medicare will become a driving force for prevention.

Initial changes in prevention spending patterns may require new financing mechanisms, such as an idea from McGinnis and colleagues to use "small portions of medical care premiums or payments for redeployment for communitywide initiatives." Developing new resources is often a very difficult task, and in this case it is the critical barrier. In the past, the evidence basis for prevention has been cited as an additional barrier, but at this point we already have the evidence we need to guide our prevention efforts. The Institute of Medicine published a report in 2000 that details the case for intervention strategies using multiple levels of influence based on generic social and behavioral determinants of disease.[8]

Recently published, The Guide to Community Preventive Services includes specific recommendations to improve population health on the basis of scientific evidence.[9] The latest addition to the evidence ranks is a new Cochrane Collaboration focus on behavioral medicine.[10] Although prevention research — like medical care research — must address many unanswered questions, we have enough information to start saving lives with prevention interventions today.

Massive diffusion of responsibility is part of the reason that financing for prevention efforts has not yet been developed. This also creates a challenge for implementation of prevention programs. There are few agencies, organizations, or individual health workers who are in a position to be accountable for future health outcomes that depend on a blend of social and medical programs. After all, behavioral choices are the greatest lever we have to shift the health status of populations, but the evidence has shown that attempting change on an individual basis is a losing proposition.[7] Meaningful prevention efforts require interventions that span medical and nonmedical determinants of health at a community-wide level. The essence of effective prevention is an ecological approach that incorporates aspects of biology, behavior, and the social environment.

For example, consider social support interventions for physical activity in community settings. There is strong evidence of effectiveness for these programs, which can include groups or partner systems to encourage and track physical activity.[9] Individual clinicians, however, have not historically played such a role and may not have available resources. Organizations that affect the social environment (such as schools and religious organizations) may not have a health agenda or the central organization needed to deliver a consistent program to the general population. What organization or agency should be charged with accountability for prevention and funded to deliver social support interventions for improved health?

Perhaps the best answer is a combination of several agencies including medicine, public health, and social services. A more feasible approach, however, would be to deliver interventions through our existing public health departments at the local and state levels. In fact, the 10 essential public health services include "inform, educate and empower"; "mobilize community partnerships"; and "develop policies and plans to support community health efforts."[11] These services are well aligned with current prevention needs, but public health agencies are not adequately funded to deliver appropriate programs.

We know that our health spending priorities are out of balance, and we have the research evidence needed to start implementing important prevention efforts. Population-based prevention programs deserve financing, and public health departments are in the best position to develop effective interventions. Right now, prevention efforts aren't costing us in terms of dollars, but we're paying in terms of lives; let's aim to reverse that ratio.