Dive into the archives of any medical journal and you will find study after study demonstrated the benefits of preventive care and early detection in a number of chronic or life-threatening conditions, like diabetes and cancer.
For example, early diagnosed colorectal cancer (stage I) can typically be cured with surgery alone and 93% of patients are alive at 5-years. Stage III disease is more advanced, typically requires surgery and costly chemotherapy, and only 35% to 60% of patients survive 5 years.
As another example, the CDC says nearly 6 million people are living with undiagnosed diabetes. Undiagnosed or untreated diabetes is associated with a myriad of complications, such as kidney failure, heart disease, stroke, blindness, infection, and amputations.
One of President Obama's top priorities in healthcare reform was increasing the emphasis on preventive care. Not only will this save lives, but it reduces the burden of illness on our economy. In the past, lack of insurance or resources led many patients to skip preventive care:
First, we note that individuals appear to be price sensitive towards preventive services. Kenkel finds that women with insurance are five percentage points more likely to have breast exams and cervical screenings. Mullahy finds that those with insurance are three percentage points more likely to get a flu shot.Cherkin et al. finds that $5 co-pay resulted in fewer physical exams. In the Rand Health Insurance experiment women with free care were three to seven percentage points more likely to receive preventive care.
The doctor/patient relationship is an important component of promoting prevention. Patients without an established relationship with a primary care provider are less likely to know about recommended screening tests. Preventive care covers procedures like mammography, colonoscopy screening, cervical cancer screening, and routine laboratory tests for glucose and cholesterol levels.
Not only does extending healthcare coverage to tens of millions more people increase the likelihood that more people will avail themselves of preventive care, the bill itself includes provisions designed to promote this:
*By September, new private policies must cover 100% of preventive services and immunizations, which will not be subject to deductibles. (Preventive services are those recommended by USPSTF with a grade of A or B.) Current plans must be in compliance by 2018.
*In 6 months, women will not be required to get preapproval to see a gynecologist. This may mean more women are likely to visit the gynecologist for annual cervical cancer screening and breast examinations.
*Beginning with 2011, seniors on Medicare will receive one free annual wellness visit--no deductible, no copayment.
*As of 2011, Medicare will no longer charge copayments for preventive services and they will no longer be subject to deductibles. (Preventive services are those recommended by USPSTF with grade A or B.)
*Pregnant women enrolled in Medicaid will receive free services to encourage smoking cessation as of 2011.
In addition to individual measures, the law funds larger, national efforts to prevent disease and promote early detection. In addition to provisions likely to affect patients with cancer directly—namely, no denials for pre-existing conditions, no benefit caps, and provision of subsidies—the law addresses other aspects of cancer care, with an emphasis on prevention and early detection.
It calls for a "national evidence-based campaign" to increase awareness of breast health and breast cancer in younger women. The Centers for Disease Control and Prevention (CDC) will oversee the program, which has been allocated $9 million annually for fiscal years 2010 through 2014. The CDC will give grants to organizations and institutions that provide health information and assistance to young women with breast cancer and pre-neoplastic breast disease. As part of the program, the law charges NIH with conducting studies on the psychosocial effects of breast cancer on young women.
The CDC will also direct a similar 5-year awareness campaign on preventing various oral diseases, including oral cancer. The campaign will emphasize the importance of screening.
Beginning in 2010, facilities such as hospitals, community health centers, comprehensive cancer centers, and nonprofit groups are eligible for grants to conduct screening programs for individuals considered at risk for environmental health conditions. The 10-year program covers screening for diseases such as asbestosis, mesothelioma, and malignancies of the lung, colon, rectum, larynx, stomach, esophagus, pharynx, or ovary.
Small institutions or independent researchers working on promising cancer treatments or tools for the early detection of cancer will be eligible to receive tax-free grants to continue their work.
In addition, HHS will fund a 5-year pilot Wellness Program from 2010 through 2014 that covers public programs to screen people aged 55 to 64 years for cancer, stroke, and diabetes; assists the uninsured in finding coverage; and provides referrals for tobacco cessation and other programs. Starting in 2011, small businesses will also be able to apply for grants for up to 5 years to establish workplace wellness programs.
The law also creates a national program designed to prevent diabetes. It will discourage obesity and increase awareness of the need for screening, particularly in more susceptible populations.
In total, the legislation allocates $7 billion in fiscal years 2010 through 2015 and $2 billion each year thereafter to finance prevention, wellness, and public health programs. While the economic benefits of a few preventive measures are outweighed by their costs, nearly all save lives.
Medication Adherence
Do not underestimate the importance of providing drug coverage in improving health outcomes. A recent study found that seniors on Medicare who fall into the donut hole are 14% more likely to skip drugs during this time. In some cases, this can have serious health consequences. Reducing and ultimately eliminating the donut hole should help remedy this.
Many other people skip medications because they cannot afford them. The caps on out-of-pocket expenses, which are on a sliding scale, will help ensure that people can better afford to take their prescribed medications. This will improve recovery or reduce complications that require further treatment.
Personalized Medicine
Another aspect of the bill that has not received a lot of attention outside of the medical professionals circles is the dedication of resources to pursue personalized medicine research and compare treatments for their effectiveness. In medicine, particularly cancer, there is an increased drive to identify genetic or biological markers that drive the disease or influence a patient's response to treatment.
To understand how important this is, let's go back to colorectal cancer. Less than a decade ago, drugs designed to inhibit endothelial growth factor receptor (EGFR) in colon cancer hit the market. These drugs, known as EGFR inhibitors, were found to improve survival in patients with cancer. They would enroll X number of patients (let's say 100) in a trial and find that 60% survived. Because this was an improvement over the rate associated with existing treatments, the FDA approved the drugs.
A few years later, they discovered that many of the 40% of patients who did not respond had a genetic mutation that made the drug ineffective. These patients no longer get that drug. They recently discovered another mutation that appears to make the drug far less effective, but these patients are not yet excluded from getting the drug, and the maker of one of these drugs continues to push that the data is "inconclusive" to discourage physicians from discontinuing use of the drug.
With comparative effectiveness research and an eye on personalized medicine, the government researchers will look at genetic drivers of response to help determine whether a subset of patients should not get this drug.
Ultimately, pharmaceutical companies will get wise (many already have) and find out reasons for poor response before seeking approval so that the drug is used in the right patients. You see this shift in a recent trial of PLX4032, a drug that treats advanced melanoma. This drug was the subject of a recent New York Times series. The researchers new that PLX4032 would likely not work in patients with a BRAF genetic mutation, so they screened them before allowing them to participate in the trial. If PLX4032 is approved, it will likely only be approved for people without the BRAF mutation.
The law is not perfect. Improvements are needed to make pharmaceuticals more affordable, for example, and promote greater prevention and early intervention for other important near-epidemic conditions in the country, like HIV and autism.
We should continue to work toward and support single-payer healthcare. A government-run national healthcare system affords the greatest opportunity to control costs and guarantee fair, effective coverage.