AARP: Policy and Research Information for Professionals in Aging

Promoting Better Preventive Care

Good health is a lifelong pursuit; that is, health in later life is often predicated on behaviors and interventions earlier in life. For example, researchers at the National Institute of Child Health and Human Development (NICHHD) now describe osteoporosis as a pediatric disease with geriatric consequences.53 Health conditions (including an absence of healthy behaviors) at early ages that go unchecked can lead to poor health as this population ages. America has an opportunity—indeed, an obligation—to address these problems early in a person’s life, not just to ward off a later reckoning, but to give America’s children the best chance at a fully productive life.

…lifestyle choices and behaviors have a greater influence on how we age than any other factor, including genetics.

Developments in two related areas—diabetes and obesity—demonstrate the potential contribution of better health promotion and disease prevention efforts. The fastest-growing causes of disability among the younger population are diabetes and musculoskeletal problems, conditions that are associated with obesity.54 According to researchers at RAND Health, if historical trends in obesity continue, by 2020, up to 20 percent of health care expenditures would be devoted to treating the consequences of obesity.55 The American Diabetes Association estimates the costs of diabetes at $132 billion annually, with much of that money coming from Medicare and Medicaid.56

Clearly, these trends have negative implications for the nation’s health care system. To the extent that these conditions occur among younger populations, society has an opportunity to address them before they begin to drive up costs in Medicare and Medicaid. But even prevention among older people can result in positive health and economic outcomes. Primary prevention, encouraging healthy behavior to prevent a health problem from occurring, is critical. Based on a ten-year study documented in Successful Aging, Jack Rowe and Robert Kahn find that lifestyle choices and behaviors have a greater influence on how we age than any other factor, including genetics.57 Likewise, Centers for Disease Control and Prevention (CDC) researchers also point out that three important habits—physical activity, good nutrition, and not smoking—can keep people healthy and delay disability by at least ten years.58

Behavioral changes could achieve the same goals as an enlightened health care policy. However, behavioral change is not necessarily easy to effect, and recognizing this challenge is important if the public effort to change behavior is to be serious. Creating behavioral change is not just a matter of individuals being aware of the right thing to do; if it were, there wouldn’t be so many people driving without seatbelts, eating the wrong foods and/or excessive quantities of the right foods, not exercising, smoking in bed, not wearing lifejackets in boats, not securing guns in homes, and not receiving prenatal care. Despite this challenge, there is reason to be hopeful about achieving behavior change. As the result of a concerted national campaign to reduce smoking, over the past 20 years (from 1983 to 2003), the prevalence of smoking among adults in the United States declined significantly from 32.1 percent to 21.6 percent.59

Secondary prevention, seeking clinical services that screen individuals in order to detect health problems sooner, is also critically important. Unfortunately, clinical preventive services are often underutilized. One key factor is insurance coverage: uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services or to receive them on a timely basis.60

With an aging population comes an increase in the incidence and prevalence of chronic conditions. One analysis found that Medicare beneficiaries with three or more conditions (46 percent of beneficiaries) account for almost 90 percent of total spending, while those with no chronic conditions account for less than one percent.61 Conditions such as heart disease, diabetes, and asthma are now the leading cause of illness, disability, and death. Patients with multiple chronic conditions are likely to have higher health care spending. Nonetheless, today’s health care system remains overly devoted to addressing acute, episodic care needs.

These facts argue strongly for more effective mechanisms for providing chronic care. One of the goals of better management of such chronic diseases is tertiary prevention, the slowing of disease progression and other complications of an established disease so as to improve or maintain function. Research points to a chronic care model consisting of patient self-management, practice teams that include non-physician personnel, and decision support that includes evidence-based practice guidelines and clinical information systems.62

Managing chronic care is easier to accomplish in integrated delivery systems where teams can form and information can be shared. Fortunately, in recent years, the Centers for Medicare & Medicaid Services (CMS) has launched a number of chronic care demonstrations, the latest created by the Medicare Modernization Act of 2003.