Putting Prevention into Practice


For Nurse Practitioner World News
March/April 2010
By Carla Mills, ARNP

Who is responsible for putting prevention into practice: individuals or society? If it’s an individual’s responsibility, then what business does society (that is, health professionals, employers, insurance companies, and the government) have interfering in people’s personal lives? If it’s society’s responsibility, is it cheaper to practice preventive care, or should we just wait until people get sick and then treat them?

In fact, health is a shared responsibility between a society and its citizens. Society is responsible for maintaining a healthy environment: clean drinking water, safe and healthy food, nontoxic air and soil. Individuals are responsible for their own personal health habits and for paying the price for the choices they make.

Who Pays?

Current “health care reform” (more aptly called “insurance reform”) seeks a way to provide affordable, universal health insurance that will cover medical expenses for accidents and illness without limitations on preexisting conditions. But to expect insurance companies to cover both preventive care and disease management at a low price and to offer the same benefits to everyone is simply unrealistic. The reality is that the care an individual gets is going to depend on the care an individual is able to afford.

Insurance companies can stay in business only when they have a large pool of premium-paying customers who do not file claims. That’s how they get the money to pay for the people who do file claims. The situation today is that an aging population is moving into the years of highest medical utilization, and a younger population is choosing to opt out of health insurance because it’s too expensive and they are not required to buy it. When the uninsured end up in the emergency room, they receive the most expensive care; but lacking insurance, many have no means to pay for the care. This perfect storm has led to personal financial disasters and a failing health care system. The situation is in desperate need of reform.

Historically, health insurance has paid for the largest portion of total health care expenses. The public has shared little responsibility for the rising costs of care. Now the public wants health care reform to provide both medical and preventive services and to do it at a lower cost. This is an unrealistic attitude, and one that threatens to bankrupt our country and topple our economy.

Does Prevention Save Money?

An article titled “Does Preventive Care Save Money” in the February 2008 New England Journal of Medicine reported, “Some evidence does suggest that there are opportunities to save money and improve health through prevention.”

Yet in August 2009, the Congressional Budget Office sent a letter to the US House of Representatives Subcommittee on Health reporting that “Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.”

As with all complex problems, the devil is in the details. Some interventions save lives and save money; others save lives but cost more; and others save neither lives nor money.

From society’s standpoint, we must continue to identify those interventions that save both lives and money and aim to practice them—providers and patients alike—100% of the time. This is why evidence-based practice is advocated as the gold standard of quality health care.

From an individual’s standpoint, it’s time we recognize that everyone is going to be paying more for health care. We had all best start budgeting for it. Not everyone will be able to afford a new Jaguar; some may be able to afford only a used Volkswagen. We must each tailor our expectations for what we can personally afford.

The cheapest way to save money and reform health care is to decrease utilization, that is, to stay out of the system as much as possible. The best way for each person to do that is to stay healthy, pay for routine screenings (out of pocket, if necessary), and make smart health choices that put prevention into practice in our personal lives.

Does Prevention Save Lives?

Only a few preventive interventions have been analyzed from both a cost and a lives-saved perspective. The same New England Journal of Medicine article reported that the following interventions have been shown to be both life-saving and cost-saving. But they are not practiced nearly enough.

  • Daily aspirin for adults—Fewer than 50% of American adults now take a daily aspirin.
  • Smoking cessation counseling by a health professional, including an offer for medication and other assistance to quit—Only 28% of smokers receive this counseling now.
  • Colon screenings for adults age 50 and older—Only 50% of people in this age group keep up to date with colon screening.
  • Annual flu shots for adults age 50 and older—Only 37% get them now.
  • Breast cancer screening for women age 40 and older at least every 2 years— Currently, 67% of women have recommended breast cancer screenings.
  • Annual chlamydia screening for sexually active young women, which would prevent 30,000 cases of pelvic inflammatory disease—Only 40% of the target population gets screened regularly now.

The New England Journal of Medicine article also listed the following as worthy of further study:

  • Screening for diabetes, hypertension, high cholesterol, depression, stress and anxiety, medication compliance, exercise behaviors, weight status, and dietary habits
  • The cost-effectiveness and clinical outcomes of health risk assessments and counseling of adults and children
  • Effectiveness of smoking cessation programs for youths and adults
  • Role of fast food in chronic disease risk development, and whether health warnings should be placed on these foods as they are on tobacco products

Smart Health Choices

A free society cannot and should not dictate personal health behaviors, even if they prevent disease. It is unreasonable to think a health professional, an employer, an insurance company, or the government can keep people healthy.

Ultimately, health is a personal responsibility, personal expense, and personal effort. Every individual must choose his or her own life habits and path. Knowing how to stay healthy and how to reduce the need for expensive sick care services is the most cost effective way to prevent disease and lower health care costs and utilization. Each of us will personally bear the costs of our own health choices and health outcomes, in terms of both money and quality of life.

Nurse practitioners’ preventive interventions beg further study. My book, A Nurse Practitioner’s Guide to Smart Health Choices, outlines the national treatment guidelines for those health risks the New England Journal of Medicine article deemed worthy of further study. The book details simple measurements that NPs, and patients themselves, can use to determine if preventive interventions work.

Nurse practitioners manage chronic illnesses and teach people how to stay well. NPs promote healthy behaviors, see that screenings are up to date, and educate patients how to make smart health choices. NPs put prevention into practice.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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