Several years ago I had the privilege of discussing preventive medicine initiatives with the medical director of what, at that time, was one of the state’s leading health maintenance organizations. I suggested that surely they must have an aggressive program to encourage smoking cessation, as the health ramifications of cigarette smoking are so vast and pervasive that the care dollars saved might be enormous. They had such programs, he advised me, because they are the right thing to do, but not because they save any money. The reality, he explained, is that if people keep smoking they die younger of cancer rather than staying alive to develop cardiovascular disease at an older age—financially, the former is cheaper than the latter. Welcome to the real world of health care economics!

 

As we struggle as a nation to face our financial obligations, we are stymied by the rapid rise in medical expenses, without an apparent increase in health value. In fact, even though the United States ranks near 20th amongst the industrialized nations in many parameters of healthcare, we spend more than twice the dollar amount per person of any other nation. Cardiovascular disease is not only the leading killer of men and women in this country; it is also the most expensive. Ironically, as mortality decreases, many of the people who now survive previously lethal cardiac events progress to various stages of congestive heart failure, a chronic debilitating, and expensive disease. Perhaps most incredibly, the vast majority of clinical cardiovascular disease is potentially preventable with careful attention to diet, exercise and control of other risk factors (hypertension, hyperlipidemia, smoking, obesity). It is in this context that the American Heart Association recently released a policy statement (Circulation. 2011;124:00-00.) Value of Primordial and Primary Prevention for Cardiovascular Disease. After a reasonably careful analysis, they conclude that, given the vast expenses necessary to care for a largely preventable disease, the expense of public and personal preventive measures is likely to be highly cost-effective—a reasonable, but somewhat unproven hypothesis.

 

There is an underlying assumption pervasive in the health-care debate that somehow eludes careful scrutiny—that good care is less expensive care. It is certainly true that multiple complications and unnecessary procedures can seriously inflate costs. However, so can good care. A recent study of patients with congestive heart failure in California found that those centers which were the most expensive (which spent the most caring for the patients) also had the lowest mortality rates. The cynic would have to note that in a DRG system of fixed payments to hospitals for a given diagnosis, the most financially expeditious approach for the hospital with a patient with severe coronary artery disease would be to perform heart surgery and have the patient die on the table. Although the perspective is helplessly dark, the point is that in a system of fixed income (i.e. limited available resources) the less care rather than the more care becomes more financially feasible. It is this reality that drives the need for prevention. Healthy lifestyles tend, in general, to be healthy lifestyles. A calorically reasonable diet rich in fruits and vegetables, whole grain, lean protein, healthy (omega) fat, combined with a program of regular and reasonably vigorous exercise is likely not only good for your heart—it may well help prevent certain types of cancer, preserve health to your muscles and joints, discourage diabetes, ameliorate aging, etc. The less care needed, the less dollars spent. It is for this reason that the Florida Heart Research Institute has dedicated itself to an aggressive program of community screening and education, worksite wellness and prevention efforts with the medically underserved. But truth be known, even if the healthcare economists were to advise us somehow that in the long run such an approach saves no money, we would have to reply like my friend the medical director, that that’s okay – it’s the right thing to do, and we will do it anyway.