Important parts of the medical establishment think of the current political climate that favors reforms in health financing as an occasion to develop and sell new medical services. This became clear at a session on illness prevention that was sponsored by the New York Academy of Medicine and took place there on April 7, 2009. It was moderated by Jo Ivey Boufford, who was at one time the head of New York City’s Health and Hospitals Corporation and is now President of the New York Academy of Medicine.

The tone of the common enterprise was set by the first speaker, Dr. Jeffrey Levi, who is the executive director of Trust for America’s Health. He said that talking about cost containment was a way into a conversation with legislators on the federal level, even though it should be clear that some prevention practices should be encouraged even if they do not save money. In other words, it is, in Dr. Levi’s view, alright to adopt Aesopian language when speaking with outsiders: you don’t have to clearly say what your main interest in legislation is. That is a message that presented few problems for an audience made up mostly of medical doctors and MPH’s. Dr. Levi said that people who advocate that an individual has a certain responsibility to manage their own healthy practices can be educated to appreciate that people who do not have sidewalks to run on can’t exercise for free, nor can people who live in unsafe neighborhoods. Dr. Levi neglects the fact that middle class people chose to move to the suburbs in part because they were sick of sidewalks and wanted to settle in places that at least evoked a sense of the outdoors. Moreover, street safety as well as the building of sidewalks is clearly a public policy issue rather than a medical issue in that it is supported by general tax money rather than the money set aside for medical care either through insurance plans or by the public treasury. Does Dr. Levi want money for medical care spent on sidewalks? If not, why not offer an example of what circumstance of social life should be addressed by medical care money?

The actual view of Dr. Levi as well as the other two speakers about the proper domain of medicine was made clear in a chart Dr. Levi presented. The chart was based on a study done by his organization and was also cited by the other two speakers. The chart claimed that ten dollars a person would pay for preventive care. But this is misleading. He is not saying that ten dollars added onto the cost of an individual patient’s care would pay for that person’s preventive care. He is saying that the aggregate cost of the programs for prevention would work out to ten dollars a person. Yet the figure presented is of the single patient cost, as if that were the cost added to the price of an office visit for the extra time spent counseling the patient to stop smoking. By and large, for all the references to structural changes that result in better health, the model of medical intervention used by these doctors is the patient-doctor encounter and how that is managed. Other matters, such as safer highways, are not part of the medical budget.

The main objectives of preventive care money, all three speakers agreed, are to get people to eat better, lower their weight, exercise more, and stop smoking. Those would have the greatest impact on preventing life threatening illnesses, though Farzad Mostashari, who is an MD, MPH, and Assistant Commissioner of New York City’s Department of Health and Mental Hygiene, admitted that obesity does not itself lead to a lower life expectancy, and so is to be treated as a quality of life issue as well as a cost issue because it leads, for example, to otherwise unnecessary knee replacement operations. Prevention, by this analysis, comes down to finding a way to nag people. Doctors can do that about the topics mentioned because the patients are already primed for that advice. What patient doesn’t know that, all other things being equal, it is probably better to be more fit? Not mentioned are the illnesses where doctors do not yet know what to nag about, unless they have become willing to nag oldsters to stave off Alzheimer’s by doing crossword puzzles, and illnesses where nagging is not yet politically correct, such as advising poor people to clean their houses so that their children do not develop asthma as a result of exposure to roach particles.

Dr. Mostashari wants to increase the efficiency with which doctors pursue their nagging. He wants an information technology sophisticated enough to trace the health lives of large numbers of people so as to identify the people that need intervention. His main example was a program that significantly increased the number of people over sixty five who received pneumonia prevention injections because they were reminded to do so by phone. Dr. Mostashari foresees the need to develop a new member of a doctor’s office whose specialty will be to call and remind people to get their injections. Increased compliance with health regimen schedules might be paid for, he said, through the use of a fund created from the savings that would accrue to the health care financing system as a result of such interventions. Yet since savings are always anticipated rather than real, in that the savings are in the long term, calculable for a population only when the people in it have died. That means the fund for preventive care is an additional expense backed by possible future revenues, which is the kind of accounting that has gotten us into a lot of trouble recently. Moreover, the idea behind cost saving is that the money saved by preventive care would be used to lower the overall cost of medical care so that insurance premiums and tax outlays could be reduced and thereby make a national health care plan feasible. Dr. Mostashari’s idea is to plow savings back into the business, as if there is no need to cut the overall costs of the system. No wonder Dr. Levi had said that cost savings was a way to get a conversation with legislators started. It is not where you want the conversation to end up.

The third speaker, Guthrie S. Birkhead, who is Deputy Commissioner, Office of Public Health, in the New York State Department of Health, agreed with what the prior speakers had said. What he added was the idea of creating a five year plan of health goals to replace the ten year plan of health goals that had been established a decade or so ago. What this stipulation of goals was supposed to accomplish he did not say, nor did he comment on why some of the goals of the ten year plan were met and some weren’t. The important point is that he did not, nor could he, allocate what part of the success or failure to achieve goals was the result of the expenditure of health care monies rather than the result of general social trends, such as, perhaps, families less likely to take meals together and so individually going out to or ordering in from McDonald’s, or the result of legislation, such as restrictions placed on smoking in restaurants.

In general, the doctors agreed that something should be done, expenses made, to make sure that patients comply with what they take to be the sources of illness and disability that most catch the fancy of doctors for the moment. They restrict themselves to the kind of problems that are not going to go away any time soon, the chronic public health concerns, that also happen to be subject to individual patient doctor interaction. Never do the doctors consider how to make a system so efficient that it eliminates the doctor patient interaction from the picture. If you eliminate the nagging, and screening procedures are proved through Walgreen’s, then you most of the time don’t need the individual patient-doctor relation at all. Doing that effectively would save medical dollars that could better be spent on covering catastrophic and chronic illnesses for really sick people.