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Have we Built an Infrastructure that Can Pursue Prevention Effectively

Editor’s note: How do you balance the desire to live longer, more productively (using enormous amounts of health related resources for critical care when it is likely too late) versus utilizing resources for prevention, but the evidence  to pursue this direction requires knowledge, a degree of belief,  and trust in scientific studies that in some case prove out and in others prove to be false?

Said differently, people maintain a degree of skepticism until presented with unassailable facts regarding their demise before being compelled to act. An example of this is smoking behavior.

In the NY Times article the case for engaging prevention behaviors, research and making real sustainable changes in societal structures is something that is impacted by many variables. The debates that must ensue in order to sort this out and develop a uniform direction are complex, emotional and at the very root of the competing beliefs of our society.

Giving people access to health care, enabling comparative effectiveness, funding health information exchanges, funding measurement of quality and effectiveness are puzzle pieces of the architectural structure. Arranging that structure so that it is effective and serves the dual purposes of delivering quality care that is financially responsible is the work that must be done before we build  square pieces for round holes.

So read the article here:

New York Times: http://www.nytimes.com/2009/11/13/health/research/13prevent.html?_r=1&em=&pagewanted=all

A good friend offers this view of human behavior as it relates to these choices.

“When I was a young lawyer, we defended insurance claim of varying kinds.  In particular, we defended products liability cases, many of which involved the effort to establish liability based on failure to warn, or, when there was in fact a warning, the failure to warn adequately.  Every one of these cases would involve an expert testifying about the need for warnings to permit people to identify and manage risk.  The problem was that there was a lot a research that demonstrated that people simply failed to act no mater how clear the warning.  The attached article references that tendency and even talks about focusing cancer research on drugs that treat existing cancers because the population somehow refuses to take low cost drugs proven to prevent cancer.  In perhaps one of the most classic coincidences, I was trying a failure to warn, products liability case and the fire alarm went off in the courthouse.  No one moved for a few seconds, and the Judge called to the deputy to see what was going on and whether there really was anything to worry about.  I think that it was in this case that the jury box had a swinging door that said “pull”, and every time the jury got up to leave, they wound up pushing the door to no effect.  They not only failed to read the plainly labeled door – they couldn’t remember from the morning to the afternoon, or from one day to the other, that one had to pull the swinging door inward.

As I recall the research, it demonstrated that people have a built in risk assessment program – perhaps genetically coded.  It tends to work well in a simple natural surrounding, like the African veldt where much of our evolution occurred.  It fails spectacularly in our modern setting.  The military research on the topic disclosed that certain hard wired training programs were required to reset behavior norms (there were some aircraft accidents as pilots took off from aircraft carriers in WWII that prompted this effort).

The implications for public policy are troublesome.  I hear some say that people cannot be trusted to look out for themselves and that therefore some top down direction is required.  Viewed from a macroscopic societal level, this may even be true.  It might cost less for the society to prevent cancer than it does to treat those cancers that occur.  After reading this article, you would have to say that we can achieve prevention effectively by retraining everyone in the society.  This raises that interesting philosophical question of whether we should have someone who has the authority to say “I know what’s good for you and I’m going to make you do it no matter what!”  In essence, the current health care legislation takes that position with having health care.  It mandates coverage.  It mandates coverages within policies.  In these respects, it presumes to tell individuals what they must do.  Yet, after looking at the article, and all the common health wisdoms that find no statistical support in rigorous studies, can you imagine how many mandates we might face if this philosophy finds traction?  For example, I have looked at the underlying studies on DDT and for trans fats, and those fail to correlate the substances with negative effects.  Indeed, the World Health Organization recently lobbied to reinstate the use of DDT, which provoked a firestorm of criticism.

Our political structure as framed in the Constitution was intended to make such mandates incredibly difficult to impose.  It appears that our political class has overcome the philosophical difficulties with imposing requirements at the point of a gun.  It will remain to see if the Supreme Court goes along.  There is apt to be some serious litigation on these topics in my view.”

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November 15, 2009 - Posted by | Accountability, Affordability, Cost, Economics of Health care, Electronic health records, Federal Government, Health care delivery, healthcare, Prevention and Wellness | , , , , ,

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