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The Podium

Health care vs. sick care: Why prevention is essential to payment reform

If people take better care of themselves, countless medical conditions could be prevented. (Josh Reynolds/The Boston GLobe)The Boston Globe/Globe Freelance

The president and Congress recently cut funding for local public health initiatives dramatically as part of a deal to offset the planned cuts to Medicare physician payments. Eliminating critical and promising community prevention funding was a huge disappointment, and a real setback to programs that successfully cut health care costs.

The foundation of our current health care system is the treatment of illness and disease rather than the promotion of good health. If we created the conditions to make it possible for people to take better care of themselves, countless medical conditions such as type II diabetes, certain cancers, heart disease, and obesity could be prevented. And the treatment of these diseases is what leads to skyrocketing health care costs. Local public health interventions – such as reducing air pollution, making healthier food more available, improving sidewalks and bike paths to promote physical activity, and preventing young people from getting hooked on tobacco – can play a significant role in avoiding costly medical care.


Massachusetts spends more than $60 billion on health care costs each year and seems ready to pass significant health care reforms this session. But re-aligning health care payments without addressing the root cause of many illnesses is short-sighted and will not be sufficient to contain costs. According to a 2011 study by the Urban Institute, known for their economic modeling of our landmark health reform law, our state could save billions in health care costs over the next decade by investing in prevention measures that are often cheaper and more effective than medical treatment.

Evidence-based prevention strategies focused on preventable illnesses will complement payment reform, are essential to reducing overall costs and will provide a better quality of life for our residents. For example, type II diabetes afflicts an estimated 380,000 Massachusetts residents, an increase of 75 percent since 1994. People of color and individuals with low educational attainment have significantly higher rates of diabetes than the state average. And the cost of treating diabetes is tremendous: roughly $6,000 per year for every diabetic.


But diabetes can often be prevented by modest changes in daily behavior. Local community interventions such as increased physical exercise and improved healthy food options have shown significant results. In one study, a group that was able to implement lifestyle changes developed diabetes at a 58 percent lower rate than a group with no interventions. Even better, many of these healthy community changes and healthy choices don’t just affect diabetes, they also help prevent or control heart disease, stroke, hypertension, asthma, and some cancers. By targeting these strategies to the communities with the highest burdens of diabetes, we can also make significant progress to reduce our state’s unacceptable health disparities.

The Urban Institute concludes that by reducing the prevalence of diabetes and hypertension in Massachusetts by just 5 percent, we could achieve significant savings right away: $135 million within one to two years and $450 million within five years. According to the Trust for America’s Health, an investment of just $10 per person could reduce the prevalence of type II diabetes and hypertension by 5 percent within one to two years.

Private payers have much to gain from these savings as well. While the state would save $19 million annually in Medicaid costs within one to two years and $55 million within five years, private payers would save even more: $65 million per year in the short term and $147 million per year in. As our leaders grapple with payment reform, we urge them to establish a Prevention and Cost Control Trust, funded with a small assessment to insurers, similar to the mechanism used to successfully underwrite pediatric immunization services.


A payment reform package that doesn’t prioritize public health and embrace prevention strategies will mean that state and local governments, businesses, and families will forgo these savings – undermining the success and sustainability of expanded coverage. A commitment to prevention programs is a commitment to the good health and quality of life of the people of Massachusetts. As Massachusetts prepares the next phase of health care reform, let’s lead the nation and make promoting better health before people are sick a key component.

Thomas M. Menino is the mayor of Boston. Dr. Paula Johnson is executive director of the Connors Center for Women’s Health at Brigham and Women’s Hospital and chair of the board of health of the Boston Public Health Commission.

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