by Michael J. Pramenko, MD
Featured in the March/April 2019 Colorado Medicine.
Ask government officials, the business community, the media or even individual physicians to identify the greatest driver of health care costs and you’ll likely get 10 different answers. And while the issue of cost is certainly complex without a one-size-fits-all solution, there is one large root cause that is often overlooked: patients’ risky or unhealthy behaviors and our society’s incentives to pursue wellness.
If our individual communities, the state of Colorado or the nation want to effectively address health care costs, we simply must align the various elements that guide our behaviors from commercial interests to social norms.
If not, even the world’s best designed health care system will fail under the weight of preventable chronic disease, substance abuse, mental health problems and poverty.
Societies throughout human history have fallen into decline or collapsed altogether. Just like a business, if a society fails to adapt or respond to challenges over time, it will fail.
An advanced society of the future will align its commercial, governmental and civil interests to navigate the incredibly high cost of modern-day health care.
Commercial determinants of health, as defined by Kickbusch et al. in an article in the medical journal “Lancet,” are “strategies and approaches used by the private sector to promote products and choices that are detrimental to health.” Pick your poison, from alcohol to marijuana, from tobacco to firearms, our society spends more energy and resources advocating unhealthy behavior than we do advocating healthy behavior.
It is no wonder we are losing ground. Life expectancy in the United States is falling. Nicotine abuse is making a comeback with vaping. Type 2 diabetes is exploding with the obesity epidemic. Alcohol abuse continues to devastate lives and families. And of course, everyone is aware of the tens of thousands of lives lost each year to firearms.
Ignore the commercial and social determinants of health at your own peril.
We are drowning in them.
Good health begins with the individual and not the health-care system. However, the decisions made by each single individual are heavily influenced by the society in which that person resides. Recent research has shown that your ZIP code is the best indicator of your health status.
While the private sector appropriately demands a control on the high cost of health care, components of that same private sector continue to market products that push us in the opposite direction of affordable population health. The same is true for the general public. We are demanding a more affordable health-care system but do we truly support the alignment of policies that will be essential to reach that goal?
Would you support greater sin taxes on tobacco? Would you support alcohol rehab and payments to the health care system financed by sin taxes on alcohol? Would you support a sugar tax? While some groan at the very idea of such policy, remember that we are all paying an increasingly large “tax” every month with your insurance premiums. Purchase a health insurance premium or pay taxes to cover Medicaid and Medicare and you are increasingly paying a tax to treat preventable chronic disease.
So, in the future, private industries distinctly linked to poor health outcomes must help lower health insurance premiums via sin taxes. At the same time, we should offer discounted health insurance premiums to individuals who commit to healthy living. After all, auto insurance and home insurance companies have marketed these types of policies.
In essence, we would market healthy behavior. Once we market healthy behavior more aggressively than we market unhealthy behavior, we can expect to see real progress.
True innovative disruption of the American health care system will address the commercial and social determinants of health. After all, human behavior makes up the most modifiable component of health care costs.
Michael J. Pramenko, MD, is the executive director of Primary Care Partners in Grand Junction. He is chairman of the board of Monument Health and is a past president of the Colorado Medical Society.