Doctors realize that an ounce of prevention is worth a pound of cure, but getting patients that ounce can be tons of trouble. Standing in the way are structural problems, payment problems and sometimes even the patients themselves. However, the fact remains that diseases such as cancer, diabetes and hypertension are partly preventable, and California's healthcare reformers have high hopes they can help.

"The kids are who we should be focusing on-that's where prevention matters the most," says Nabil Razzouk, PhD, president of the Inland Wellness Information Network, a nonprofit project of the San Bernardino County Medical Society.

Since there is no overarching approach to prevention and wellness in the schools of San Bernardino and Imperial Counties, IWIN stepped in 13 years ago to give kids an early start in prevention education with its Healthy Lifestyles program. "We go to schools and encourage teachers to take a little time to work with students on internalizing the concept of wellness and coming up with concepts themselves," Dr. Razzouk explains.

In a creative, competitive format, the project teaches kids about important elements of healthful living, such as exercise and the food pyramid. "They've been really receptive to it," says Victor Ching, MD, IWIN vice president and a urologist based in Upland. "Healthy Lifestyles is run by teachers, and it's freeform. Students can decide whatever type of project they want to do, with any type of health [focus]," Dr. Ching says. Past projects have included videos, posters and board games, with whole classes working on a project together or compiling individual projects into a book, he says.

For motivation, Healthy Lifestyles awards a $300 honorarium to the winning classes. "We would like more schools to step up to the plate during their health-week emphasis, to get each classroom to participate in a project that would represent their [grade level], and submit it for our review," says Clifford Walters, MD, a Loma Linda-based gynecologist and president of SBCMS. IWIN will be promoting Healthy Lifestyles again this fall, in hopes of increasing participation, Dr. Walters adds.

But even among young kids, wellness and prevention can be an uphill climb. "We go to schools pushing for healthy products, and when the kids have a break, what do they get? They get a Coke or a Pepsi," Dr. Razzouk complains. "We have the best quality healthcare service you can get anywhere, [but] we're behind in the area of preventive medicine."  And the problem is not limited to education and attitudes. "We don't have the infrastructure for preventive health. For instance, I cannot just walk into a clinic to get diagnostic tests," Dr. Razzouk says. "Until we get to that point, what we have is management of sickness rather than a preventive health culture."

But things may be slowly changing at the state level. Spurred on by California's healthcare crisis, legislators are taking halting steps toward encouraging overall patient wellness, pointing to examples of successful preventive health efforts by large employers and health maintenance organizations.

While vaccine programs and antismoking campaigns have been quite successful in the past, there appears to be a new emphasis on preventing or managing chronic diseases through exercise, nutrition and screening. "All the ducks are lining up now, because the baby boomers are getting to an age where they're afraid of not being healthy," speculates Dr. Razzouk. At the same time, employers are realizing that good employee health means higher productivity, while consumer pressure is pushing insurance companies in a similar direction, he says. "It is going to take some time, but I think it's really going to take off."

Elements For and Against Prevention
Preventive medicine's major barrier is that the healthcare system is organized to cater to acute illness, says Randall Stafford, MD, PhD, an associate professor of medicine at Stanford University in Palo Alto, and director of its Program on Prevention Outcomes and Practices. "By 'organization,' I mean a whole range of things, including reimbursement, but also the ways in which physicians interact with patients, the locations where patients seek care, and so forth," he says.

"From the physician's [and the patient's] points of view, the main reason for a visit is to deal with a particular problem, and those problems more often than not tend to be framed as, 'This is a problem that can be taken care of now,'" explains Dr. Stafford. Typical examples include an asthma attack, a sprained ankle or sudden back pain.

Current reimbursement practices reinforce healthcare's episodic nature, Dr. Stafford says. "Reimbursement varies depending on factors such as a problem's complexity, the amount of information a doctor can gather about a problem, the complexity of a doctor's decisions, and the problem's potential for lasting complications," he says. "We almost take that [system] for granted, but it's not that difficult to imagine other ways in which you might set up care." For example, it might make more sense to have patients see their doctors more regularly and to communicate more frequently by telephone or through e-mail and Web sites, he suggests.

"I pride myself on the fact that my patients, from the report cards that I get, live longer and healthier," says Samuel Gendler, MD, a Garden Grove preventive medicine specialist and a member of the Orange County Medical Association. Part of his secret is encouraging patients to visit often, especially the sicker ones, while being tough on those with cholesterol problems or diabetes. "Today I told a [patient] that if his son--weighing 300 pounds at 12 years old--doesn't comply with the nutritionist, I'm going to talk to Child Protection Services," he says. Beyond systemic problems affecting preventive health, the field's biggest problem is poor patient compliance, especially among high-risk groups, such as the obese, Dr. Gendler adds.

One strategy for exerting healthy pressure on such patients is putting physician extenders in charge of maintenance visits, saving physicians' expertise for when it is really necessary. "There are certainly lots of studies that suggest that involving nurses in the process of providing care ensures a little bit more continuity and more longitudinal care around chronic disease issues, which are often at the heart of prevention," Dr. Stafford says. "For example, those people with diabetes who have good control of their blood sugars over time are much less likely to develop kidney disease or problems with their eyesight."

Unfortunately, care provided by other personnel cannot be easily reimbursed, or it is reimbursed poorly. "So the places where you see this model being adopted are those settings where essentially there's a global budget, and the system needs to figure out how to use the money they have to provide the best care," Dr. Stafford says. Examples of this can be found at Group Health Cooperative Health Care System and Kaiser Permanente, he adds.

Kaiser puts a lot of emphasis on screening for breast, cervical and colorectal cancer, as well as screening for cholesterol, smoking and hypertension, writes Michael Kanter, MD, medical director of quality and clinical analysis for Southern California Permanente Medical Group, in e-mail correspondence. "Kaiser's integrated approach to preventive care ... includes postcard reminders, newsletters, no-charge health education classes and, yes, even personal phone calls to remind them to come in for their health screenings and exams," he writes. To identify and treat members in danger of a cardiovascular event, Kaiser's Integrated Cholesterol Management clinics perform risk assessments, cholesterol and lipid screenings, dietary education, treatment and follow-up.

Another sign of change for the better is the "Welcome to Medicare" physical exam, which the Centers for Medicare and Medicaid Services began offering in 2005, Dr. Stafford says. "It's an opportunity to have the physician focus on some of these preventive issues. I think that's definitely a move in the right direction," he says. "However, in looking at what's required for physicians to get reimbursed for that visit, it's pretty onerous."

Prevention in State Healthcare Reform
If any healthcare reform law passes during this legislative session, observers say it will likely result from a compromise between two parties: Gov. Arnold Schwarzenegger, whose healthcare reform proposal is heavy with preventive medicine ideas, and the Democratic team of Assembly Speaker Fabian Nunez and Senate President Pro Tem Don Perata, whose AB 8 clearly leads the reform pack, but says surprisingly little about prevention.

Unlike Nunez and Perata, Gov. Schwarzenegger has no healthcare reform bill. However, the Democratic team will have to come up with something that the governor wants to sign, since its bill will probably pass the Legislature without a veto-proof majority. Also, Gov. Schwarzenegger fully intends to get his healthcare ideas into law, according to his staff. "It's a little too early to determine [the form]," says Sabrina Lockhart, a spokeswoman for the governor. "But the governor has stated many times that he's confident that reforms will be done this year." So, it makes sense to see what a compromise bill might have in it.

The Nunez-Perata bill discusses preventive medicine and wellness early in its text, but its current wording contains only a few mentions of how such care should be encouraged. "On preventive care, we don't want the Legislature deciding what the best practices are--we leave that up to the experts," writes Perata spokeswoman Alicia Trost in e-mail correspondence. "The bill keeps it generic."

In contrast, Gov. Schwarzenegger's January healthcare reform styles him as a major advocate for preventive healthcare. In fact, the proposal states that "prevention, health promotion and wellness" is one of its three main features, along with universal coverage and "affordability and cost containment." The proposed Healthy Actions Incentives/Rewards programs aim to promote exercise, good nutritional choices and other beneficial habits, while other parts of the plan target diabetes, obesity, tobacco use, medical errors and hospital-acquired infections.

Under the Democrats' AB 8, employers can either make "healthcare expenditures" of 7.5 percent of wages or they can pay the same amount to the California Health Trust Fund, which will provide employee health coverage through the California Cooperative Health Insurance Purchasing Program--otherwise known simply as the purchasing pool. There are a number of ways employers can satisfy the expenditure requirement, but most important for preventive medicine, they can support health measures for employees, including wellness programs, health fairs and health screenings.

A separate part of the Democrats' healthcare reform bill would direct the California Health and Human Services Agency to "encourage fitness, wellness, and health-promotion programs that promote safe workplaces, healthy employer practices, and individual efforts to improve health."

Gov. Schwarzenegger's plan to attack obesity contains ideas that resemble the parts of AB 8 explained above, especially a proposal to encourage employee wellness policies. The governor's other anti-obesity measures include a media campaign and promotion of healthy eating and physical activity. Examples are grants for farmers' markets, grants to make neighborhoods more walkable, healthier school meals and more physical education, Lockhart says.

But fitting together the two proposals' requirements for health plans and insurers is a bit more difficult. Both parties want preventive care available to all Californians, but as the proposals are currently written, AB 8 calls for all insurers to use preventive medicine to control costs, while the governor's plan calls for all insurers to offer at least one benefits package with preventive medicine measures.

Under AB 8, health plans and insurers that have a contract with the purchasing pool would be required to offer "preventive care," "care management for chronic diseases," "incentives for healthy lifestyles" and "patient cost-sharing to encourage the use of preventive and appropriate care," among other cost-control measures. Presumably, cost-sharing is intended to reduce single-event driven healthcare. The bill gives purchasing pool oversight to the Managed Risk Medical Insurance Board, a state board made up of five members appointed by the governor and the Legislature.

The governor's Healthy Actions Incentives/Rewards plan would require all insurers and health plans to offer a benefits package with rewards or financial incentives for healthy "evidence-based" and "cost-effective" patient behavior. Public plans would reward patients for healthy behavior with perks, such as memberships to gyms or weight loss clinics, while commercial plans would also have to offer financial incentives, such as premium reductions. Examples of good behavior are "quitting smoking, managing diabetes, taking steps to lose weight or getting breast cancer screenings," Lockhart explains.

The details above in both plans appeal to physicians like Dr. Walters, whose ideal preventive medicine initiative involves involves mass screenings for cancer, and cardiovascular and metabolic diseases. "Sure, we can do all the exercise and all the diets, but that only goes to a certain point," he says. "We really do need to pick up disease in an earlier stage, and prevent it from getting to where we have to put out millions in expenditures."

FEATURE ARTICLE SIDEBARS

Four Prevention Bills to Watch

While prevention and wellness measures may piggyback into law on healthcare reform proposals, several are going it alone. Here is a list of four active, California Medical Association-approved prevention and wellness bills currently making their way through the legislative process:

AB 1472 (Leno) California Healthy Places Act of 2008
Should this bill become law, the director of the California Department of Public Health would be required to set up an inter-agency working group to study environmental health factors and recommend ways to improve them. AB 1472 would also found the DPH Health Impact Assessment Program, which would provide guidance for land use, housing and transportation planning. HIAP grants for assessments would be available to community organizations, cities and counties, especially underserved groups and areas with poor environmental conditions.

SB 20 (Torlakson) Pupil Nutrition: Free and Reduced-Price Meals
Beginning in fiscal year 2007-08, Torlakson's bill would require schools that are reimbursed for food to follow nutritional guidelines and to stop serving deep-, pan- or flash-fried food and food containing trans fats. It also requires that schools serve food following USDA nutritional guidelines and prohibits food prepared with oil containing more than 20 percent saturated fat.

SB 48 (Alquist) Community Development: Healthy Food Choices
This bill aims to encourage farmers' markets and small grocery stores, and to make healthy food easier to get for people in low-income and underserved communities. The California Department of Public Health would be required to offer competitive, one-time grants and loans from a new Healthy Food Retail Innovations Fund for land acquisition in these communities. Money would also be available for other development costs, such as construction, workforce, refrigeration units and feasibility studies. SB 48 sunsets at the end of 2014.

SB 490 (Alquist) Pupil Nutrition: Trans Fats
Beginning July 1, 2009, this bill would prohibit schools from selling or serving food containing trans fats during and immediately before and after school hours, even through vending machines.


CMA Foundation Supports Obesity Prevention Project

Looking for the best ways to assess and treat obesity, a panel of California Medical Association physicians convened in 2004 created the CMA Foundation Obesity Prevention Project. The project trained its first crop of doctors this past year through its Physicians for Healthy Communities Initiative.

"The physicians we brought together [to study the issue] said that things are not going to reverse themselves if doctors only stay in their offices treating patients," says Christine Maulhardt, the project's director.

Focusing on children and adults, the program teaches practical ways to prevent obesity before it starts, Maulhardt says. "Studies have shown a 5 percent success rate in taking someone who's overweight or obese and having them lose weight and keep it off," she says.

In the fall, the foundation plans for its Web site to provide CMA members with clinical tools that address overweight and obese children and adults, and the weight management of pre- and post-bariatric surgery patients, she adds.

Physician participants in the project learn about communication techniques, treatment options, education materials, and community resources. They also address risk factors, such as poor access to healthy foods in low-income neighborhoods and a lack of safe walking space, Maulhardt says. Doctors are then ready to deliver messages about healthy lifestyles to the community.

"We are trying to form connections between the physicians that we have access to through the CMA with groups that are already active in their community [through Network for a Healthy California], and really bring the physician's credibility and expertise as a medical practitioner to everything happening on the local level," Maulhardt explains. "They do cooking classes, teach how to shop for healthy foods, they run farmers' markets, they do jogging clubs for kids ... all sorts of things related to promoting health," she says.

For additional information, go to www.calmedfoundation.org/projects/obesityproject.aspx.