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Healthy Utah means improving access to care

A central aim of the health law was to improve access to routine care, the theory being that it’s better to pay up front to keep the uninsured healthy than to pay to treat them in the emergency room.
A central aim of the health law was to improve access to routine care, the theory being that it’s better to pay up front to keep the uninsured healthy than to pay to treat them in the emergency room.
Carolyn Kaster, Associated Press

“Cancer screening costs money and can lead to more tests and treatments, which cost even more money. And since a high priority in health care today is to control costs, we should stop cancer screening.”

If you find that logic confusing, or disturbing, you’re not alone. Yet this is the latest argument being leveled against the Affordable Care Act — and more specifically, against Healthy Utah, Gov. Gary Herbert’s private-market alternative to expanding Medicaid. Give people access to health care and they’ll use it, critics say, pointing to a rise in Medicaid spending in states that have chosen to stretch their health safety nets to cover more of the uninsured.

This rejection of the old saying, “an ounce of prevention is worth a pound of cure” is not wholly without merit. A central aim of the health law was to improve access to routine care, the theory being that it’s better to pay up front to keep the uninsured healthy than to pay to treat them in the emergency room.

Indeed, it’s cheaper to prevent an illness than to treat it. No one disputes that. But the cumulative cost of millions of preventive screenings adds up, which is why studies show preventive care in aggregate does not save money and can lead to more downstream spending, not all of it necessary.

Recently, for example, data have surfaced calling into question the value of the standard annual physical — at least, for generally healthy individuals.

But that doesn’t mean we should abandon annual exams. It just means we should deploy them differently. Let’s not confuse the blunt use of annual exams with the precise deployment, and known value, of specific preventive screening and early diagnosis strategies. Some of our political leaders will remember the devastating consequences of polio in the U.S., now prevented with a simple, low-cost vaccine. Do you remember the last time you were scratched by a barbed wire fence or had a splinter from a piece of wood? We take it for granted that we will not suffer the potentially life-threatening consequences of tetanus from such inconsequential injuries, but this depends on adequate treatment and booster vaccinations every 10 years.

As a surgeon in training, I saw patients with advanced breast cancer, large tumors invading the chest wall, muscles and skin. These tumors were the result of delayed diagnosis and required invasive radical mastectomies. Today, efforts at education, screening and early diagnosis have made this disfiguring treatment a thing of the past in most women. Similarly, the Pap smear, HPV vaccination, smoking cessation programs, colonoscopy and many other interventions result in either prevention or earlier diagnosis at a curable stage for one of our most vexing diseases — cancer.

Our challenge as health providers is to identify individuals at risk and target care to the right patients at the right time. This requires access of patients to care — not when symptoms and diseases are advanced, but when intervention is effective and less costly. As a continuously improving and learning health system, we do that and celebrate successes every day at University of Utah Health Care.

Our emergency room diversion program has saved taxpayers $3.7 million a year by proactively assigning Medicaid patients to a primary care physician who can serve as their health ally. Similarly, our U Baby Program saves $2 million annually by providing prenatal interventions to at-risk women. As I write this, one of our physical therapy professors is working on a strategy for identifying Medicaid patients with back pain and intervening early to avoid emergency room visits and unnecessary surgeries or prescriptions for dangerous and addictive pain medicines.

This movement toward focused prevention is happening across the country, enabled by new technologies and improved knowledge gained through research of what works and what does not.

Yes, health care costs money. So does education. As a nation we’ve chosen to invest in these things because we believe them to be indispensable to a free and productive society. These investments pay off in creating healthy, talented citizens whose work benefits all of us.

It’s unconscionable to write off tens of thousands of low-income Utahns as casualties of the system. Not on my watch. Not when there’s something we can do about it. That’s why I support the governor’s Healthy Utah plan. It is not perfect, but it is the right thing to do to show that we revere life — everyone’s lives, and not just those who fall in a certain income bracket and who can afford health insurance.

Sean J. Mulvihill, M.D., is chief executive officer of University of Utah Medical Group and associate vice president for clinical affairs at the University of Utah.