Earnestine Cole won’t forget Sept. 15, 2004. “That was the day I woke up and couldn’t move anything but my eyeballs,” she said.
She was an emotional binge eater, weighing in at 325 pounds. She had high cholesterol and her heart arteries were 70 percent blocked.
Doctors gave her six months to live if she didn’t have surgery. But Cole decided to change her lifestyle instead.
Now, seven years later at the age of 60, Cole teaches two fitness classes at Bally Total Fitness in Dallas, and she has a radio program on KHVN—970AM, which is all about prevention.
“Prevention is the way to go,” Cole said.
Guy Culpepper, a primary care physician, insists people just aren’t interested in prevention. Most only seek medical attention after they get sick, said Culpepper, who works at Bent Tree Family Physicians in Frisco. Ask him why, and the square-jawed doctor turns pensive: That’s the Holy Grail of medical questions.
“It’s the same thing as, ‘why can’t we get people to stop smoking when it so clearly is a major factor in killing us?’” he said. “It’s the same thing as, ‘why can’t we get people to walk a few days a week?’ Maybe health care isn’t entertaining enough.”
But a portion of the Patient Protection and Affordable Care Act requires private insurers to cover a buffet of preventive services without requiring patients to meet a deductible or cover a co-pay. Those services include testing for diabetes, high cholesterol, sexually transmitted infections and certain cancers. The plan is to save money by identifying health problems before they spiral into costly illnesses as well as encourage Americans to improve their habits and maintain their health.
“Our health care system is reactive instead of proactive,” said Tom Ciccotti, senior vice president of CHC Wellness, which sets up health and wellness programs for businesses. The idea behind the reform is that it will be more cost-effective to prevent a condition from developing as opposed to trying to treat and manage it once it develops, he said.
But the nation’s primary care physicians face a major hurdle: encouraging their patients to participate and getting enough funding to make preventive care possible.
Making the grade
The health care reform law will cover preventive services that have “strong scientific evidence of their health benefits,” according to the government-run site Healthcare.gov. The U.S. Preventive Task Force, an independent panel of clinicians and scientists, will make recommendations based on studies they’ve performed over the last decade.
Each medical test gets a letter grade. If a service scores an “A” or a “B,” the task force will recommend it to patients. But if a service scores lower, the task force will suggest that patients skip it because there is a higher certainty that the service has no benefit, or the risks outweigh the benefits.
This past fall, the Prostate Specific Antigen test, a blood screening that checks for prostate cancer, was demoted to a “D.” Instead of recommending an annual PSA test, the task force now recommends patients forgo it.
Blood pressure screening for adults, which is covered by the act, was given an A. The task force recommends screening for high blood pressure in people 18 and older.
“The mission of preventive care is at the heart of all medicine,” Culpepper said. “It’s emphasized at every level of medical training. And there’s study after study that proves massive reduction in costs when emphasis is put on prevention.”
One such study was conducted by the College of Pharmacy at the University of Iowa. The study calculated that the lifetime cost of a stroke, averaged across subtypes, costs more than $103,000 for hospitalization, treatment, recovery and therapy. A hypertension screening is free under the new act’s guidelines.
Cole knows how costly it can be to have a chronic disease. But she wasn’t offered preventive care for the 19 1/2 years she was going to her doctor before 2004. The doctor never told Cole to lose weight, and he must have noticed she was gaining, she said.
“He never offered me any kind of preventive care,” Cole said.
But she said patients are becoming more aware of prevention.
“You have to be your own advocate for your health,” she said.
Participating in prevention
The problem is, people don’t go to the doctor until symptoms begin to develop, instead waiting until they have a sore throat or pain. But the key is to catch conditions such as diabetes and high blood pressure early, said John Flores, an internal medicine doctor at the Little Elm Medical Clinic.
Pre-diabetes and diabetes are conditions Flores and his colleagues catch in patients all the time.
Joseph Valenti, an OB/GYN in Denton, uses this analogy with his patients: People never miss an oil change, but when it comes to their doctor visits, they go two or three years in between.
“You can put a new engine in your car, but you can’t get new parts in your body,” said Valenti, co-owner of Caring for Women.
Although health care can be expensive, Valenti said, not finding a problem early can be more expensive later. He performs a full physical when women come to his office for their yearly exam. For women between the ages of 15 and 40, the majority of problems are going to be obstetric or gynecological in nature, Valenti said.
Diabetes can often be picked up first during pregnancy, and with the growing obese population, doctors — especially OB/GYNs — are going to be having those discussions with patients about weight, he said.
“We don’t just do pap smears,” Valenti said. “We like to take time with patients to do that, to make sure we are covering all our bases.”
Culpepper does the same thing. He said practicing preventive care when a patient is already in the clinic with a different complaint is the best shot for a physician to reach those least likely to proactively schedule an appointment. If someone comes in with tonsillitis, Culpepper will also check the patient’s lymph nodes, listen for a heart murmur and chat with the patient about alcohol use.
Flores said men are especially difficult to get into the office for their regular checkups.
“You’ve got to counsel them and let them know,” he said.
Healthcare.gov was set up to educate Americans about the myriad of new programs available under the act. It points out that chronic diseases, including heart disease, cancer, stroke and diabetes, are responsible for seven out of 10 American deaths each year. Treatment for these diseases accounts for about 75 percent of the nation’s total health care spending.
The economic benefits of preventive care, which are measured by the cost of preventive services against the cost of treatment, vary widely across the country. It might seem like simple math, but the cost could go either way, according to a September 2011 report from the Kaiser Family Foundation.
Prevention is hard to measure. If someone is overweight, it’s easier to measure how he or she lost weight, said Ciccotti with CHC Wellness. If it is prevented before the person gains weight, there is no way to measure that he or she didn’t gain weight because of prevention, he said.
But, according to the federal health care website, if Americans can shake their bad habits — smoking, fatty diets, physical inactivity and alcohol abuse — scores of costly and fatal illnesses could be prevented, prolonging lives and saving billions.
The U.S. Department of Health and Human Services plans to spend money to make money through an unprecedented commitment to public health. The health care bill created a $15 billion Prevention and Public Health Care Fund, which will be dispersed to states and communities over a period of 10 years to fund preventive programs.
In fiscal year 2010, $500 million was dedicated to implementing preventive services, obesity prevention and fitness, primary and behavioral health integration, and tobacco cessation. In February 2011, the health and human services department made another $750 million investment across the country to support state and community prevention programs.
Since 2010, Texas’ slice of the fund amounts to $38 million for community and clinical prevention, public health infrastructure and primary care training, as well as research and data collection.
The transformation will wither away without funding, said Sen. Barbara Mikulski, D-Md., at a Senate hearing in November.
Culpepper is skeptical. Regardless of how much money is pumped into the programs, he doesn’t expect to see an influx of new patients asking for cholesterol screenings or immunizations. His healthiest patients are the ones who schedule regular physicals and monitor their diet and exercise. For them, reducing cost-sharing will just be a bonus, not an incentive.
The health and human services department estimates obesity prevention could decrease premiums by as much as 0.1 percent, according to the Kaiser report.
But the report also said that if too many people take advantage of free preventive services, the money spent providing care could eclipse the money saved on treatments, resulting in premiums increasing up to 1.5 percent.
Between 2000 and 2009, the 10 major health insurance companies increased their revenues by 250 percent, Valenti said. On the other hand, doctors’ salaries have gone down 30 percent.
“To be honest, insurance companies never lose,” he said.
While profits are going up for insurance companies, Valenti said, utilization is going down.
“But the one thing they [patients] can get is the preventive care, and they should get that,” he said.
The question is: How much is a patient really saving?
Under the guidelines, which went into effect in September 2010, a standard physical without a co-pay might not identify the costly illnesses that are supposed to save money. Under the new guidelines defined by the task force, most lab work is not covered and will be added to a deductible. So instead of paying $35 for an annual physical, a patient will pay nothing to see the doctor, but will receive a bill if the patient has an EKG or chest X-ray.
Ciccotti with CHC Wellness is seeing increased business because of health care reform. The Chicago-based company, which was started in 2003, provides wellness programs to companies across the nation. Currently, 600 companies use CHC Wellness.
The idea behind wellness programs — which measure cholesterol levels, blood pressure and weight — is to uncover preventable medical conditions, Ciccotti said.
And the best way to get employees involved in the programs and increase the likelihood of uncovering preventable conditions is by offering incentives, he said. One of the biggest incentives a company can offer is a lower premium.
An employer can artificially increase the premium by 20 percent under the current law, Ciccotti said. By 2014, that could be increased to 30 percent.
The level of engagement is dependent on the strength of the incentive, he said. Other incentives range from gas cards to paid time off.But the incentive is designed to lower premiums because it is a budget-neutral incentive and provides a strong financial value to the participant, Ciccotti said.
“The initial incentive is kind of a catalyst to get [employees] in the program,” he said. Positive improvement related to their health keeps them engaged long-term, Ciccotti said.
One concern employees have in joining wellness programs is that their employer is going to get their personal information, but under HIPAA laws, the employees’ personal information is kept private. What employers get is general statistics on their employees, he said.
As far as the cost of wellness programs, some wellness providers are able to bill claims to insurance companies in network, while others contract with the employer to provide services at a negotiated price, Ciccotti said.
A goal of the wellness programs is to eliminate duplication by providing the employee’s primary care physician with the information collected during screenings. That way, the employee doesn’t have to go through the test when visiting his or her doctor, Ciccotti said. This is only done with the employee’s consent.
The road ahead
Although there remains a lot of uncertainty surrounding health care reform and whether the government will be able to maintain the costs of providing preventive care, doctors agree that patients need to be active about living healthy.
“We as a society need to be in the mode of prevention,” Valenti said.
People would be surprised by how many conditions doctors can pick up on using preventive care, the Denton physician said, adding he thinks some of these new rules under the act might make it better for patients.
Earnestine Cole has become a proponent for wellness and prevention. The keys, Cole said, are to eat right, exercise and manage stress.
“If I can do it, because I was the worst, anyone can do it,” she said.
Cole loves life now because she has energy to do the things she couldn’t before, like run.
“All because I took charge of the body in a preventive way,” she said.
RACHEL MEHLHAFF can be reached at 940-566-6889. Her e-mail address is firstname.lastname@example.org .
COVERING PREVENTIVE CARE
The Patient Protection and Affordable Care Act seeks to lower barriers to preventive care, which can save money on health care costs in the long run. Below is a list of services that could be covered under the new law:
• Cancer screenings, including breast, cervical and colorectal
• Contraception and screenings for sexually transmitted diseases along with counseling for sexually active women, teens and adults at high-risk
• Immunizations, both childhood and adult
• Screening for chronic conditions, including hypertension, lipids, obesity, Type 2 diabetes, depression and osteoporosis
• Health promotion, including newborn and infant screenings, well child and developmental screenings, well woman and domestic violence screening, physicals, vision and hearing assessments, screenings for alcohol abuse, diet and tobacco counseling services
• Prenatal visits including folic acid supplements; screenings for transferable diseases, iron deficiency Rh incompatibility, gestational diabetes, alcohol and tobacco use; breastfeeding support
Source: Kaiser Family Foundation
IF YOU GO
• What: “Healthcare 101,” a nonpartisan, apolitical seminar on the new health care law
• Who: A panel of speakers will explain the health care reform law in a free event sponsored by the Denton Black and Hispanic chambers of commerce.
• When: 6 to 8 p.m. today, with a mixer preceding the seminar from 5 to 6 p.m.
• Where: Emily Fowler Central Library, 502 Oakland St., Denton
SERIES AT A GLANCE
• SUNDAY: An overview of health care as it stands today. A look back shows reform isn’t a new concept. Results of Massachusetts reforms show unexpected results.
• MONDAY: Small businesses react to new law. Reform spotlights need for faster results from research.
• TODAY: Prevention is key to curing cost concerns. Workers with no insurance take health into their own hands.
• WEDNESDAY: Physicians struggle to maintain their business model. Patients try “accountable care.”
• THURSDAY: Texas lags behind other states in setting up insurance exchange, while reform banks on student loans.
• FRIDAY: Mental health treatment remains fragmented, affecting physical health care. Texas county jails are primary provider of mental health services.