Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion.

From “Sick Care” to Health Care: Reengineering Prevention into the U.S. System

Farshad Fani Marvasti, MD, MPH1 and Randall S. Stafford, MD, PhD1

1Stanford Prevention Research Center and the Department of Medicine, Stanford University Medical School, Stanford, CA

Although the United States pays more for medical care than any other country, problems

abound in our health care system. Unsustainable costs, poor outcomes, frequent medical

errors, poor patient satisfaction, and worsening health disparities all point to a need for

transformative change.1 Simultaneously, we face widening epidemics of obesity and chronic

disease. Cardiovascular disease, cancer, and diabetes now cause 70% of U.S. deaths and

account for nearly 75% of health care expenditures.2 Unfortunately, many modifiable risk

factors for chronic diseases are not being addressed adequately. A prevention model,

focused on forestalling the development of disease before symptoms or life-threatening

events occur, is the best solution to the current crisis.

Disease prevention encompasses all efforts to anticipate the genesis of disease and forestall

its progression to clinical manifestations. A focus on prevention does not imply that disease

can be eliminated, but rather embraces Fries’ model of “morbidity compression,”3 in which

the disease-free lifespan is extended through the prevention of disease complications and the

symptom burden is compressed into a limited period preceding death. Thus, a prevention

model is ideally suited to addressing chronic conditions that take decades to develop and

then manifest as life-threatening and ultimately fatal exacerbations.

Although the need for a prevention model was highlighted during the recent health care

reform debate, efforts to expand prevention continue to be thwarted by a system better suited

to acute care. A century after the Flexner report, the acute care model and its cultural,

technological, and economic underpinnings remain securely embedded in every aspect of

our health care system.

The organizational structure and function of our medical system is rooted in fundamental

changes made at the beginning of the 20th century that emphasized an acute care approach

and marginalized prevention and public health. Breakthroughs in laboratory sciences led by

Koch and Pasteur provided powerful tools for mechanistically understanding and treating

infectious diseases. Bolstered by philanthropy and the Flexner report, U.S. medicine became

Author responsible for correspondence: Randall S. Stafford, MD, PhD, 251 Campus Drive MC 5411, Stanford, CA 94305-5411, Phone: (650) 724-2400, Fax: (650) 725-6247, [email protected].

Reprint requests will not be available from the author.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

NIH Public Access Author Manuscript N Engl J Med. Author manuscript; available in PMC 2015 February 24.

Published in final edited form as: N Engl J Med. 2012 September 6; 367(10): 889–891. doi:10.1056/NEJMp1206230.

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reliant on laboratory research.4 This strategy made sense 100 years ago, given the

prominence of acute infectious diseases in a young population; it makes little sense now.

With the aging of the population, the shift in the burden of disease toward chronic

conditions has accelerated. The most prevalent preventable causes of death are now obesity

and smoking, which result in delayed but progressive disease.5 Even in the developing

world, increases in the prevalence of chronic disease are outstripping reductions in acute

infectious diseases.1 Such epidemiologic evolution demands a focus on public health and

prevention.

Yet economic and technological factors dating from the early 20th century remain strong

barriers to effective disease prevention. A key feature of U.S. health care is its use of a

piecemeal, task-based system that reimburses for “sick visits” aimed at addressing acute

conditions or acute exacerbations of chronic conditions. Economic incentives encourage

overuse of services by favoring procedural over cognitive tasks (e.g., surgery vs. behavior-

change counseling) and specialty over primary care. The current model largely ignores

subclinical disease unless risk factors are “medicalized” and asymptomatic persons are

redefined as “diseased” to facilitate drug treatment. These mismatched economic incentives

effectively preclude successful prevention through health maintenance.

Moreover, our reliance on ever newer, more advanced technology has perpetuated an

expensive system in which costly new technology is widely adopted in the absence of

comparative advantage. When combined with economic incentives for patenting devices and

drugs, these technological factors become self-reinforcing. Although many preventive

strategies may be cost-effective, they unfortunately have limited potential for wide adoption

because they cannot be patented or made profitable. Therefore, the primacy of patentable

therapies impedes research on prevention and diffusion of prevention approaches that could

cost-effectively address the burden of chronic disease.

The cultural and social underpinnings of our system also inhibit optimal disease prevention.

Faith in reductionism, which was infused into medicine in the 20th century, has empowered

medical research to pursue only isolated problems and to yield targeted, immediately

deployable solutions. Consequently, the model for treating acute infectious disease is being

misapplied to the treatment of chronic disease. For example, cancer chemotherapy is

modeled after antibiotic therapy; coronary revascularization is modeled after abscess

incision and debridement. Societal expectations of a “magic bullet” and a focus on symptom

relief also reflect and reinforce the reductionist approach. These scientific and societal

values emphasize discovering a “cure” for the major causes of death. With the advent of

direct-to-consumer advertising for pharmaceuticals and surgical procedures, these cultural

expectations of immediate, simplistic solutions have been bolstered by consumerism and

fully exploited to generate demand for therapies that are marginally indicated and potentially

unsafe. Our very culture thus devalues disease prevention.

Changing the system requires recognition of these cultural, technological, and economic

obstacles and identification of specific means for overcoming them through alterations in

medical education, medical research, health policy, and reimbursement. For example, to

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combat the primacy of technical knowledge and the profit-based system for medical

technology, medical schools must teach prevention strategies alongside treatment

approaches, and emphasize motivational interviewing with a focus on lifestyle modification.

Payers and the federal government must fully reward use of appropriate non-patentable

therapies and support research on the development and dissemination of prevention

strategies.

To change our reductionist way of thinking, we must teach aspiring physicians about

systems science that addresses psychological, social and economic determinants of disease.

Taking a patient-centered, whole-person approach focused on long-term functional status

will also help to address the current fragmentation of care and allow for standardization of

prevention strategies.

Medical school curricula should emphasize homeostasis and health, rather than only disease

and diagnosis, and provide training in the science and practice of cost-effective health

promotion. In turn, payers will need to reimburse for health maintenance and prevention

activities, primary care physicians will have to act as health coaches; and all health care

professionals will need to embrace a coordinated multidisciplinary team approach.

Systematic steps must also be taken to change the culture of medicine so that primary care is

valued. Renewing primary care will require increasing ambulatory care training in

community settings and reallocating funding for residency training away from hospitals to

reimburse appropriately for innovative models such as medical homes. Furthermore, we

must compensate primary care physicians for their work as care coordinators by establishing

reimbursement parity for cognitive and procedural care and accounting for long-term costs

and benefits.

The new approach to medicine endorsed by the Flexner report succeeded because it was

based on sound science and a radical restructuring of the way medicine was taught,

organized, and practiced. Today, we face a similar challenge that requires another

fundamental reordering of our health care system. Although the need for acute care will

remain, centering our efforts on prevention is the only way to thwart the emerging pandemic

of chronic disease.

Current health care reform efforts will bring incremental improvement, but reengineering

prevention into health care will require deeper changes, including reconnecting medicine to

public health services and integrating prevention into the management and delivery of care.

Though change is painful, the successful transformation of medicine at the turn of the last

century demonstrates that it is possible. Ultimately, embedding prevention in the teaching,

organization, and practice of medicine can stem the unabated, economically unsustainable

burden of chronic disease.

Acknowledgments

Grant Support

This project was supported by a grant from the National Heart, Lung, and Blood Institute (K24-HL086703).

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References

1. Fuster, V.; Kelly, BB., editors. Promoting Cardiovascular Health in the Developing World: a critical challenge to achieve global health. Washington, D.C.: The National Academies Press, Institute of Medicine; 2010.

2. Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services; 2010. (Accessed June 14, 2012 at http://www.healthypeople.gov/2020/default.aspx)

3. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980; 303:130– 135. [PubMed: 7383070]

4. Fleming, D.; William, H. Welch and the rise of modern medicine. Boston, Massachusetts: Little, Brown; 1954.

5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291:1238–45. [PubMed: 15010446]

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