Is Managed Care Harming Preventive Medicine? by Nathan Johnson Despite good intentions, health plans designed to save money by preventing disease in the first place are falling short. print article      send to a friend

Remember how your grandmother used to say that an ounce of prevention is worth a pound of cure? Cliché though it may be, it turns out that Grandma knew what she was talking about, especially when it comes to staying healthy.

Preventive medicine, the concept of taking measures to ensure patients don't become sick in the first place and of preventing the spread of existing disease, is just as familiar to physicians as it was to your grandmother. And while it sounds like a great idea in theory, in a health care environment dominated by managed care plans, it doesn't always work out that way.

Physicians' Perspective on Prevention

"We need to prevent as much as possible," says Augusto M. Torres, MD, president-elect of the medical staff at St. Michael's Hospital in Cleveland. "We have to encourage patients to use preventive measures to treat their diseases. This includes having them control their diet to treat obesity because it can cause other problems, like pulmonary complications, blood clots, and slow healing, and advising them to stop habits like smoking, which can lead to lung cancer or other pulmonary problems.

"Preventive medicine should be one of physicians' primary concerns and be part of a routine to give advice, like proper diet and exercise, which will end up saving money," Dr. Torres says.

Some physicians have a different take on what preventive medicine means.

"To me, it's not letting something happen in the first place," says a Minnesota physician who didn't want his name used. "I tell people, you essentially have three choices when it comes to your health--number one, you can sit around and wait until something happens and then detect it and treat it; number two is try and prevent it; and number three, which I think is the best way to go, is to do a combination of both.

"Mammograms and pap smears are not prevention. They're just disease detection, a method to prevent further progress of the illness. Detecting things is not prevention," he says. "What we need to do is take men and women and teach them from day one things that they can do to keep their immune systems healthy and prevent disease in the first place."

While both of these physicians are adamant about preventive care for their patients, recent studies have shown that not all physicians are putting prevention into their practices.

Missed Opportunities

In the past three years, research supported by the US Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) found that low-socioeconomic-status patients were substantially less likely to be up to date on immunizations and screening tests (with the exception of blood pressure readings) than other patients.

Their research has also shown that American physicians are missing many opportunities to help their patients quit smoking. Physicians in one study counseled smokers to quit at only 21 percent of office visits. In another AHRQ-supported study, researchers concluded that if doctors advised each of their patients who smoked to quit, an additional 1.7 million people would quit smoking each year.

In addition, the Centers for Disease Control reported in February 1998 that a high proportion of office visits to obstetricians or gynecologists, internists, family or general practitioners, cardiologists, and other specialists in 1995 did not include counseling for the prevention of cardiovascular disease.

So why aren't physicians doing more to help patients prevent disease?

Who's to Blame?

"There are two issues here," says David Wold, a partner in Professional Business Consultants, Inc., and the CEO of Healthcare Information Services, both in Oak Brook, Illinois. "One, physicians don't really have the incentive or the resources to set up a preventive care program, and two, once a program is set up, how can he or she keep the patient following that protocol? The physician really can't control that.

"Physicians are scrambling, just trying to see more patients because their reimbursement has continued to decline, so their major focus is on how to maintain their income. They have to work harder and they really don't have a lot of time to develop programs that aren't going to generate revenue," Wold says.

"There hasn't been any financial incentive for physicians to develop these programs," Wold continues. "Theoretically, in a managed care plan, the physicians incentive would be to keep the patient healthy and happy through wellness and preventive programs so he's not coming in and running up lab charges and X-ray charges. I've yet to see a physician able to do that. For the most part, the average physicians get killed in a managed care plan because they're unable to control how patients use the program. What we typically see happen is the use go up because in many cases, there's no out-of-pocket expenses for the patients, and they're just going in all the time," says Wold.

"The whole concept of preventive programs in managed care is, 'Why, we'll have the premiums so low that we're going to keep all the patients healthy so they don't get sick.' However, so far we haven't seen that," Wold adds.

Managed Care Plans Could Do More

A recent report from the non-profit Center for the Advancement of Health (CAH) shows that managed care plans could do more to help enrollees change their unhealthy behaviors. While most health plans offer some services to help members better manage chronic conditions or modify health risk behaviors, the majority of the efforts consist of handing out brochures or pamphlets, which has shown to be ineffective in producing sustained change.

According to the 1999 report, health plans said they were reluctant to incorporate behavior change interventions into their systems of care, in part because the cost impact of doing so is unclear. Also, the study found that while most health plans offer programs to help patients manage disease as part of routine care, risk-behavior change programs are usually offered off-site and often result in out-of-pocket costs to patients.

"We found that health care purchasers expect that when they buy a comprehensive health benefit from a managed care plan it will include effective strategies for controlling risky behaviors and managing chronic diseases," says CAH Executive Director Jessie Gruman, Ph.D. "Most employers or purchasers are unwilling to offer behavior intervention services directly to employees or negotiate for them separately with a health plan for fear of paying for these services twice," she adds.

The findings show that managed care decision-makers, health care purchasers, providers and consumers find it difficult to distinguish effective behavior change approaches from ineffective ones. Gruman says this needs to change, particularly since both health plans and health purchasers now recognize that the health of individuals is highly influenced by behavior. "Well designed and widely available behavior change services could--if fully implemented--make a significant contribution to improving health outcomes as well as reduce costs," she says.

What You Can Do

As a patient, what can you do? Not a whole lot, but a few steps could prove helpful. Chances are you're part of a managed care health plan.  Use it wisely. Don't go to the doctor at the slightest sign of a sniffle or such just because you face only a $10 copay. Instead, call the doctor's office. Chances are there are staff members (such as physician assistants, nurse practitioners, and even doctors themselves) ready to help determine over the telephone if an appointment is necessary -- and, if not, what measures you can take to get better.

In addition, use the preventive information your doctor gives. Take the smoking cessation program offered free through your plan. Read the brochures you're sent home with. Join a gym using your employee discount. Take the stairs. Go for a walk after lunch.

If you're not satisfied with the so-called preventive features offered by your plan, make some noise about it. Tell your doctor what you expect. More importantly, tell your employer. If enough of your coworkers complain, your company just might listen.

Finally, remember that you have the power to work outside the managed care  system. Odds are that your doctor offers elective services outside managed care's realm.