When Benjamin Franklin wrote anonymously in 1735 that “an ounce of prevention is worth a pound of cure,” most people probably don’t realize that he was actually referring to fire safety. Franklin was campaigning that his adopted city of Philadelphia should organize something akin to a fire department, just as had been done to good effect in his native city of Boston.
The wisdom of prevention
This quote typically surfaces in discussions about the wisdom and value of prevention in healthcare. There has been considerable debate about whether and to what extent prevention is actually less costly than treating the problem when it arises. In this debate, over- generalizations and over-simplifications can lead to bad conclusions – the details of what approaches to prevention are being used, in what settings, with what specific diseases or conditions matter a great deal (as this article from the New England Journal of Medicine points out). In formal cost-effectiveness evaluations, it also matters whether we are blurring related-but-different ideas such as health promotion versus disease prevention.
Without sorting through all those arguments here, I favor the position Ron Goetzel articulated in Health Affairs: ”Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to improve population health.” As pay-for-value or pay-for-performance reform initiatives take root in our healthcare system, provider organizations and others at financial risk for outcomes will need to thoughtfully and formally incorporate specific prevention protocols into their service portfolio. One can also argue, financial self-interest and payer requirements aside, that there is a moral imperative to do so.
Types of prevention
Let’s start with a basic language framework to talk about this issue. Traditionally, prevention is divided into three types:
- Primary prevention aims to prevent disease or injury before it ever occurs. Examples of primary prevention include altering unhealthy behavior such as smoking that can lead to disease, or immunization against infectious disease.
- Secondary prevention aims to reduce the impact of a disease or injury that has already occurred, such as regular exams and screening tests to detect disease in its earliest stages (for example, mammograms to detect breast cancer).
- Tertiary prevention aims to soften the impact of a chronic illness or disabling injury that has long term effects. Examples include chronic disease management programs, or vocational rehabilitation programs to retrain workers.
High-cost, high-need groups
Assuming that most would want to steer clear of trying to boil the ocean and attempt to implement all (or many) possible prevention programs relevant to the groups they serve, are there any data that might help us narrow the prevention focus? A number of papers and reports convincingly support the observation that a small percent of people account for a disproportionality large share of healthcare costs. Some examples among many:
- Kuluski et al point out that a growing number of people are living longer with multiple chronic illnesses, accompanied by a high degree of treatment burden and heavy use of health care resources. They refer to the concept of “multi-morbidities” that increase with age. By way of example they observe that in Ontario, Canada, 5% of the population accounts for 66% of health care costs, and these people are characterized by multi-morbidities.
- A report from the US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) found that “half of the population spends little or nothing on healthcare, while 5% of the population spends almost half of the total amount.” The report also indicates that the five most expensive health conditions were heart disease, cancer, trauma, mental disorders, and pulmonary conditions.
Investing prevention resources
One preliminary conclusion might be that a smart “prevention population target” is this high-utilizer group with multi-morbidities, and perhaps with a specific focus on older adults where such multi-morbidities occur at the highest rate. If that’s the direction you chose to go, you’d likely be working largely in the world of tertiary prevention described above that focuses on lessening the impact of chronic illness or disability.
As you think about where to invest your prevention resources, you might also consider the financial contingencies that are now being built into pay-for-value/performance reform initiatives such as Delivery System Reform Incentive Payment (DSRIP) in New York State. By design, some of the measures and projects in the DSRIP initiative align perfectly with the high utilizer population prevention focus described above (for example, “high-risk cardiovascular disease management”). Other DSRIP projects reflect more primary or secondary prevention aims, such as “reduce premature births.” Still others are not really prevention-focused, but emphasize best practice treatments to achieve the best outcomes.
Moving prevention programs from theory to practice
Where to focus is just part of the journey. Another part of the journey is answering the question about what specific prevention models to adopt locally. For those that make this strategic decision, the pathways to implementation require careful thought, deliberation and planning. Some pilot studies can serve as a guide. For example, if your focus is on preventing avoidable re-hospitalizations, Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions is a useful reference. Some of these 15 programs have documented peer-reviewed evidence of success in reducing rehospitalizations.
Though the literature is too vast to summarize here, an internet search for “replicable prevention models” or “replicable disease management models” can be a useful starting point to move from theory to more specific how-to guidance.
I believe that, several centuries later, Ben Franklin’s sage guidance is still worth carefully considering. Deciding whether and how to implement impactful prevention programs ought to be a strategic and moral imperative for provider organizations.
What’s your point of view? In the comments, please let us know if you’ve already begun this journey, and what that experience has been like.