Preventive Medicine
What’s a Pound of Prevention
Really Worth?
By DAVID LEONHARDT -
New
York Times Health
Arthur Agatston, the South
Beach diet doctor, came to town last week and, in between bites of filleted
fish, he was trying to persuade me that his patients rarely have heart attacks
anymore.
As he is quick to tell almost
anyone — as he told me before we had even sat down for our Greek lunch
— he is an accidental diet doctor. By training, he’s a cardiologist.
He spent 20 years doing research and seeing patients in Miami before his little
nutrition manifesto was published in 2003. It and its various spinoffs have
since sold close to 20 million copies.
But Dr. Agatston still spends
much of his time as a working cardiologist. After the first book came out, he
opened a private practice where he treats everyone from locals who knew him
when he was just another doctor to wealthy South Americans who fly in to see
the famous South Beach doctor.
The practice has 2,800
patients, and, as best as Dr. Agatston can recall, only three of them had a
heart attack last year. “Heart attacks are essentially disappearing from
my practice,” he says in his Long Island-tinged accent.
It is a fairly stunning claim,
the sort of claim that you might expect to hear from someone who knows how to
sell a product. If Dr. Agatston were to do a thorough review of his files, I
wonder if he might come across a few more heart attacks, perhaps among patients
he doesn’t see regularly.
But his larger point is a
perfectly good one: we now know an enormous amount about how to prevent heart
attacks, with powerful drugs like statins, smoking cessation, exercise and
diet. With the right preventive care, people can cut their risk of a heart
attack by up to 80 percent, cardiologists estimate.
“We have made major
improvements in prevention,” Dr. Gregg W. Stone, the director of
cardiovascular research at Columbia University, says. “But it’s
difficult. It takes frequent visits, a close relationship between a physician
and a patient and a very committed patient.”
Which is exactly the atmosphere
Dr. Agatston’s practice tries to create. Nurses there give patients
specific cholesterol goals to meet and help them deal with the side effects of
the drugs they are taking. A nutritionist, Marie Almon, meets with patients
frequently enough to discuss real-life issues like how to stick to a high-fiber
Mediterranean diet even on a cruise or a business trip.
There is only one problem with
this shining example of a medical practice: it is losing money.
See, preventive medicine just
doesn’t pay in the current American medical system. “The time we
spend with patients — we get rewarded almost zilch,” Dr. Agatston
says. Or as Dr. Valentin Fuster, a former president of the American Heart
Association, puts it: “There is no incentive at all. It’s a
disaster.”
This is obviously an exciting
time for health care reform. In California and Massachusetts, state officials
have announced plans to provide universal health insurance. Last week, the head
of the Business Roundtable, a major corporate lobbying group, and Andy Stern, a
union leader, held a news conference together to
call for universal coverage. President Bush devoted a big part of last nights
State of the Union address to his own health insurance ideas. The push to
reduce the number of uninsured, now approaching 50 million, is long
overdue.
But a lack of insurance is only
one of the two huge problems with health care. The other is the perverse system
of incentives that nudges doctors and patients toward expensive tests and
procedures when cheaper preventive measures might actually produce better
results. Partly as a result, costs are rising rapidly for the 250 million
people who do have insurance.
In cardiac care, nuclear scans
and invasive procedures like bypass surgery bring in the money. Medicare alone
paid almost $15 billion, or about 5 percent of its total budget, for bypasses,
stents and other invasive cardiology in 2005, according to Jonathan Skinner of
Dartmouth. Yet for many patients, there is no scientific evidence that stents
or surgery prolong life.
Dr. Agatston doesn’t need
Medicare reimbursements to make a living. His books, the latest being “The
South Beach Heart Program,” have given him “an outside income,”
as he delicately puts it. “I can afford to be holier than thou,” he
says.
Absent a wealthy patron, many
other clinics that focus on preventing heart disease are struggling to survive,
Dr. Richard Pasternak, a Harvard Medical School cardiologist and Merck &
Company executive, says. Family doctors, doctors who treat back pain and
doctors who treat diabetes all face similar challenges.
It’s important to note
that the economic gains from preventive care are sometimes exaggerated. Sadly,
the cheapest patients are often the ones who receive no care whatsoever,
because many die before they reach their medically expensive golden years.
But the political case —
the moral case — for prevention is unassailable. And to the extent that
drugs and lifestyle changes replace surgery, rather than merely supplement it,
preventive care can help pay for itself.
Given the way the universal
insurance movement has taken off, the most likely path to reform probably runs
through local governments or other pilot programs, and some of this is
beginning to happen.
Humana, the insurer, and Dr.
Fuster will soon begin studying 6,000 high-risk patients, in part to get a
better understanding of how they can be persuaded to take the preventive steps
they should be taking. Medicare, meanwhile, is experimenting with some
pay-for-performance stipends for doctors.
“We still pay more when
patients have more complications and get more services than when they get
better results,” Dr. Mark McClellan, Medicare’s former director, told
me recently.
The prevention push is still
waiting for its Massachusetts moment — a signature event to make it a
topic of national conversation, as Massachusetts’s health insurance plan
did for universal coverage last year. Dr. Agatston, who does have a track
record of getting people’s attention, has one idea.
“My dream has been to go
to a corporation and say, ‘Have all your executives and all your high-risk
employees come to our practice, and if they hit our goals and still have a
heart attack, we’ll give you a million dollars,’ ” Dr. Agatston
said. “My wife and our lawyers say, ‘You can’t do that!’
But that’s frankly my dream.”
Any takers?
leonhardt@nytimes.com |
