Preventive Care vs. Disease Care
Enclosed is an article that I believe would fundamentally change the direction of
the United States health care system to a more sustainable model. If adhered to (Preventive
Medicine For Our Ailing Health Care System, JAMA, February 3, 1993.269(5);616-618).
With all good intentions, the development of a national health care system or a totally
free enterprise medical system will not change a fundamental flaw that is built into
our present model. We have a crisis care procedure-oriented health care system that
is reimbursed several-fold higher than preventive strategies. No matter what constraints
we put on it, if we do not focus on disease prevention, more high technology and
capital intensive procedures will be utilized and paid for, eventually bankrupting
our health care system.
What needs to transpir æ ƒ a fundamental shift from procedure-oriented reimbursement
to reimbursement for either benefit or preventing illness. I can guarantee a dramatic
reduction in expenditures and more emphasis on prevention if procedure-oriented specialists
were not reimbursed several-fold higher than the people who deliver primary and preventive
care such as pediatricians, internists and family practitioners. In the long run,
our health care costs would be reduced dramatically.
Take coronary artery disease as a case in point. More that $108 billion was spent
in 1992 on cardiovascular disease. Of that, $9 billion was spent on coronary artery
bypass alone. Third-party reimbursements and Medicare will pay $30,000 to $40,000
for this technology. This does nothing for the underlying cause of the disease, but,
at best, is a symptomatic treatment (JAMA, February 3, 1993;269(5);616-618).
What is truly sad about the cardiovascular disease model is we now know, through
the excellent work of Dr. Dean Ornish, professor of preventive medicine at the University
of California at San Francisco, atherosclerosis can be reversed by diet, Lifestyle
and stress management practices (Lancet, July 21, 1990.336;129-133). It is shameful
that we will pay $30,000 to $40,000 to do a coronary bypass surgery, whether through
Medicare or private insurance, and yet we will not pay $1,000 to $2,000 for cardiac
rehabilitation, which has been shown to reduce the incidence of a recurrent cardiac
event by 25% on a program similar to Dr. Ornish’s recommendations.
You can take this one example of cardiovascular disease, extend it to each specialty
and find a high technology procedure that receives excellent reimbursement. An example
in orthopedics might be hip replacements. At a recent talk, I asked the audience
if anyone had the estimated cost of a hip replacement. A gentlemen, who had just
had one, said it was between $30,000 and $40,000 for one hip and he was out of the
hospital quickly. A related problem is hip fractures. Each year, Americans suffer
from 280,000 hip fractures. This number is expected to increase to 650,000 by the
year 2050, more than doubling the current number of hip fractures.
This is a very serious problem, resulting in considerable disability and tremendous
cost. Preventive strategies to reduce this emerging epidemic include exercise, diet
and medication reduction (“As Population Ages, Orthopedists Gird For Increasing Number
of Hip Fractures.” Medical Tribune, March 11, 1993;16). Let us look at cataracts.
If we could delay cataract surgery by 10 years it has been estimated that we could
save millions, if not billions of dollars. Cataract surgery and related doctor visits
make up the largest portion of the Medicare budget - $3.2 billion. A 33% reduction
in the incidences of cataracts has been shown in people consuming very moderate levels
of vitamins C and E (300 to 600 mg and 400 mg per day respectively). “Cataract: Relationships
Between Nutrition and Education,” Journal of the American College of Nutrition, 1993.12(2),138-146).
And the list goes on and on.
Another point is now young physicians who make decisions about whether to be specialists
or generalists. Look at the excellent review by Dr. Alexander Leaf, AMA, February
3, 1993;269(5):616-625). As students go through the medical school system, they see
specialists who employ these high technology procedures. They’re being reimbursed
at several-fold the amount internists, pediatricians and general practitioners do.
Students are more driven to fill those particular specialties, especially when they
have an incredible debt to pay after graduating. This motivation shifts our medical
system into a preventive model, which could be a cost effective alternative to the
current high-technology, procedure-oriented model.
Another topic of great interest to me - once part of my livelihood is made compiling
and organizing nutrition and preventive medicine research - is the role of therapeutic
nutrition in reducing æ •ital stays and subsequent costs. Take for an example
the cost of premature infants in neonatal intensive care units. The average cost
per day at the University of California at Los Angeles Medical Center for one room
only was more that $1,100. This does not include the doctor or any procedures.
It has been suggested that vitamin A can reduce the incidence of broncho-pulmonary
oyspiasia in very-low-birth-weight infants (Journal of Parenteral and Enteral Nutrition
, May-June 1993;17(3);220-225). The question of this study was whether supplementing
with 2,000 IU of vitamin A intramuscularly three times a week, beginning on the tenth
through the fourteenth day of life, would have any effect on the duration or stay
in the neonatal intensive care unit, compared to administering this vitamin on the
second to the fourth day of life. As you can see, the length of neonatal intensive
care unit stay was significantly reduced from 81 days to 60 days when the vitamin
A supplementation by intramuscular injection was given on the second to fourth day
At the bare minimum of cost, giving vitamin A early on would potentially save $26,400
for just the room charge fee per child. The early vitamin A treatment given to the
24 children in this study equates to a $554,400 savings. I would dare to bet the
total cost including Physicians fees and all the procedures occurring in a neonatal
intensive care unit would probably be close to double. Now we’re talking approximately
$1 million of savings for 24 infants who were given vitamin A eight to ten days earlier.
In reality the savings wouldn’t be this much since the children would go to less
costly pediatric wards before being discharged, but there still would be substantial
savings as compared to staying the neonatal intensive care unit.
I want to emphasize that this is just one nutrient, one type of disease, in one particular
hospital scenario. If we truly evaluated functional nutritional adequacy in hospitalized
patients and treated them accordingly with therapeutic nutrients, and if we could
just reduce the duration of hospital stay by 50%, billions of dollars would be saved
each year since nutrient costs are very low. But if nutrients become prescription
drugs, they would have a pharmaceutical price tag attached to them.
Another example of the power of nutritional therapy is the editorial entitled “Folic
Acid-Preventable Spina Bifida and Anencephaly” in the JAMA , March 10, 1993;269(10);1292-93.
Folic acid supplementation of 0.4 mg to 4 mgs has been shown to significantly reduce
the incidence of neural tube defects.
The editorial states, “One of the most exciting medical findings of the last part
of the 20th Century is that folic acid, a simple, widely available water-soluble
vitamin, can prevent spina bifida and anencephaly. Not since the rubella vaccine
became available 30 years ago have we had a comparable opportunity for primary prevention
of such common and serious birth defects. The many epidemiologic studies that resulted
in the identification of the preventive effect and folic acid is a model for the
kind of research that needs to be done to identify the cause of and primary prevention
strategies for other birth defects, the leading cause of infant mortality in the
The last example I would like to leave with you, Mrs. Clinton, is related to the
potential power of nutrient intervention in cardiovascular disease. Cholesterol is
one of the known risk factors for heart disease. Recently experts in the field have
reported that protection of the oxidation of LDL cholesterol by antioxidant nutrients
such as vitamins C, E and beta-carotene can be achieved, theoretically reducing the
initiation of the atherosclerotic process. These nutrients are promising therapies.
Yet with all the emphasis on cholesterols relationship to heart disease, more than
50% of all cardiac events have no known classic risk factors associated with them.
The Physicians Health Study found that elevated levels of homocysteine, an amino
acid associated with early atherosclerosis and death, was higher in physicians who
later developed a myocardial infarction (heart attack) compared to those who did
The authors note in the conclusion that there are nutrients specifically from the
vitamin B family that can easily reduce homocysteine levels, an independent risk
factor for heart disease. These nutrients include vitamins B6, B12, choline, betain
and folic acid. Again, these are very cheap and safe supplements. If you read the
article from the American Journal of Clinical Nutrition 1993.57;47-53, entitled “Vitamin
B12, Vitamin B6, and Folate Nutritional Status in Men with Hyperhomocysteinemia,
“you will find that individuals with elevated levels of homocysteine had sub-optimal
vitamin status of vitamins B6, B12 and folic acid.
When these individuals were supplemented with small dosages of vitamin B6 (10 mg),
folic acid (1 mg) and vitamin B12 (0.4 mg), their elevated homocysteine levels were
normalized within six weeks. The authors concluded “Because Hyperhomocysteinemia
is implicated as a risk factor for premature occlusive vascular disease, appropriate
vitamin therapy may be both efficient and cost-effective to control elevated plasma
Again, we suggest that these simple low cost, low toxicity nutrients may help reduce
a significant risk factor for cardiovascular disease, which is still the number one
killer and a great expense to our health care system. The question is this, why are
we not aggressively investigating nutritional assessment and intervention strategies
in chronic degenerative diseases that can be intervened earlier on, before the actual
disease manifests in its most severe form?
As I see it, this research should be given the highest priority if we are to create
a sustainable system of health care in the United States. In closing Mrs. Clinton,
I encourage you to seriously consider the economic incentives that encourage this
unsustainable procedure-oriented, high technology, capital intensive medicine model.
Secondly, I suggest researching just one area of nutritional medicine. It would be
a very fruitful investment to fund I.T. Services to do an in-depth investigation
showing how nutritional assessment and intervention could reduce hospital stay and,
therefore, save millions, if not billions, of dollars. Thirdly, I hope you will encourage
more specific research into functional nutritional assessment with subsequent therapeutic
trials of nutritional supplements that will help prevent these chronic diseases,
costing our health care system phenomenal amounts of money and resulting in incredible
suffering. Lastly, I hope you will not support any attempt to make nutritional supplements
pharmaceuticals, since this will increase their prices dramatically.
Kirk Hamilton, PA-C, IT Services
3301 Alta Arden, #3, Sacramento, California 95825