August 4, 2010
The Big Lie of Preventive CareBy Michael Applebaum, MD
The Patient Protection and Affordable Care Act (PPACA) will change the face of American medicine, based in no small part on a big lie about preventive care. A list of so-called "Preventive Services Covered under the Affordable Care Act" can be found here.
To apprehend the folly, it is necessary to understand what is meant by "preventive."
It is clear that preventive care should "serv[e] to prevent the occurrence of disease."
There is no ambiguity.
Here are a couple of the "preventive services" that "beginning on or after September 23, 2010, ... must be covered without your having to pay a copayment or coinsurance or meet your deductible, when these services are delivered by a network provider."
There is an inherent conflict: "The objective of medical screening is to identify disease[.]"
Unquestionably, for a disease to be "identified," it must be present, and therefore, its "occurrence" was not prevented.
The "heroes" of the quote are Jacobean -- i.e., they are engaging in "the use of merely entertaining dramatic devices at the expense of integrity and meaning."
In a prior life, Sebelius "called for universal health care for Kansans, but declined to detail how she would pay for it."
Michelle Obama "helped create" the University of Chicago's (U of C) Urban Health Initiative (UHI).
The UHI is "a policy which refers underinsured patients to neighborhood health clinics and community hospitals instead of treating them at the UCMC [U of C Medical Center] or its local clinics."
UHI was described by the American College of Emergency Physicians as
Flatly, other "medical professionals ... accuse[d] the university of dumping patients on its neighboring institutions."
UHI prompted a call by U.S. Rep. Bobby Rush for "a congressional hearing" "to investigate the policy" and led to the resignation of UCMC (U of C Medical Center) CEO James Madara.
They are dissemblers on a crusade for which we all get to pay.
An analogy explains.
The sick care industry is a repair and rescue industry. It springs into action after an infraction (bodily damage) has occurred. (Review ICD and CPT codes for proof.)
This is similar in some respects to the police. They ticket after an infraction has occurred -- e.g., someone runs a "STOP" sign. They do not counsel drivers to obey the rules of the road before the fact. They don't screen persons randomly to test them for safe driving knowledge or whether they know the meaning of octagonal red signage.
Preventive care failure is the most probable result of the PPACA lie.
Learning how to drive is up to the individual, and he/she is supposed to learn that someplace other than traffic court or the back of a squad car. Once in custody, an infraction has (likely) occurred.
Preventive care is similar. It is what you are supposed to learn outside of the sick care system. Once you are in the sick care system, a disease has (likely) not been prevented.
Going to a sick care worker to learn preventive care is like going to the body shop to learn how not to get a fender-bender.
There is virtually nothing that the sick care system or anyone can do to teach the means to prevent some illnesses since so few factors are under the control of an individual and there are myriad illnesses unrelated to prevention by known learned behaviors.
The rear-ending while at a stop light; the brain cancer from causes unknown to this day; the exposure to an infectious virus on public transportation -- there are many others. In each case, it is almost certain that there was no way to "teach" someone how to prevent developing it.
And among those behaviors that can be taught to prevent or delay chronic illnesses, according to current knowledge, there are but a few, and they are well-publicized -- e.g., achieving and maintaining nutritional fitness, having protected sex, not abusing intoxicants or drugs.
But the workers in the sick care system are not with persons 24/7 cooking, portioning, serving, and feeding; they are not chaperoning and slipping condoms onto or into sex partners; they don't party with the each person in the nation, enforce Dram Shop Acts, or interrupt the acquiring and taking of drugs/intoxicants.
So the however-many-minutes encounter with the sick care system the one day of 365.25 in a year (if that often) will do almost nothing to help prevent disease absent a patient's willing commitment to a daily regimen of self-imposed practice.
There is absolutely no way to proactively ensure the behavioral compliance that is necessary to prevent preventable illness (a compelling argument against merit pay for physicians based on outcome).
The most costly conditions in terms of dollars and suffering and the most likely to kill are closely related to overweight/obesity.
Organized medicine itself voluntarily admits that it cannot and has not been able to influence the behavior of the public. Yet this important truth remains in disregard by the Jacobeans on the Potomac.
Ditto for workplace wellness programs, quixotic undertakings at best. They are primarily weight loss programs. Like organized medicine, they don't work, either.
Just as ignorantia juris non excusat ("ignorance of the law does not excuse"), so, too, at some point, a person's ignorance of how to care for him- or herself is inexcusable.
That point is past. Using nutritional fitness as the example:
The media are filled with reports of the ill effects being overweight wreaks on the body (and society when the public is made to pay for the bad results). There is no shortage of information. For those who misinform, there are mechanisms to stop them, and they are grossly underutilized.
If one ignores the law and gets caught, one is expected to pay.
If one ignores nutritional fitness and gets sick as a consequence, one should be expected to pay.
Consequences that have an effect make a difference.
The best way to ensure compliance is by effective consequences that make a difference in the direction of the desired outcome. A bad way to ensure compliance is by effective actions that remove consequences.
For example, there is "evidence that being insured increases body mass index and obesity."
This appears to be the result when "the obese do not pay for their higher medical expenditures through differential payments for health care and health insurance" since "body weight decisions are responsive to the incidence of medical care costs associated with obesity."
Even rewarding people in the hope of preventing the most common cause of chronic illnesses (overweight/obesity) by making others pay them does not make a difference in the desired direction -- i.e., achieving a "healthy" weight.
Therefore, the sole preventive care there is, fitness, can be achieved only by persuading the unfit to change in the right direction through a series of actions that remove the rest of us from their rescue and repair.
Allow them to be responsible for their actions, and change may occur.
Continue making others responsible, and certainly there is inadequate motive to change.
The face-saving counter-argument of preventing disease complications by early detection fails since:
a. The primary disease process has already occurred and has not been prevented.
c. When it comes to the most important compliance matter that can have the greatest effects on costs, suffering, and death -- i.e., nutritional fitness -- the data are clear that compliance is lacking.
Prevention occurs only when meaningful consequences are understood/experienced and must happen before entry into the repair and rescue system.
If not, it is not prevention.
Michael Applebaum is a physician and attorney practicing in Chicago, IL. His website is www.surviveobamacare.com.