For healthcare, put kids and prevention first

Imagine being a deep-pocketed, benevolent czar in charge of doling out money for healthcare. That’s what 253 health professionals from six developing countries did in an international survey published online last week in the journal PLoS Medicine.

Take care of children first, they said, in ranking the 10 top healthcare spending priorities. And put more money into preventing illnesses, so that less is needed to treat disease.

Though U.S. healthcare workers were not part of the survey, those basic priorities would probably ring true here too. Many physicians, particularly those in specialties such as primary care and internal medicine as opposed to the “doing” specialties such as surgery, are voicing frustration in a system that spends more on treating conditions than on preventing them in the first place.

But the desire for more preventive care is at odds with the spending habits of the United States and 29 other developed nations. Those countries spend an average of just 2.8% of their healthcare budgets on prevention, according to a 2004 report on health spending by the Organization for Economic Cooperation and Development, a 30-member group of countries supporting democracy and free markets.

That doesn’t surprise Dr. Anne Peters, a Beverly Hills endocrinologist who specializes in treating patients with diabetes before costly complications, such as heart disease, blindness and limb amputations, set in.

“I get no money to prevent an amputation,” says Peters, who keeps her practice alive through fundraising and donations because insurance payments cover only about 30% of her costs. “I would get a whole bunch of money to perform an amputation.”

The U.S. spends more on healthcare per person than any other industrialized country, and federal forecasters predict that spending will double to $4.1 trillion during the next decade. But when people talk about setting healthcare priorities, the public often fears that what’s meant is rationing and wants no part of it.

In fact, the country already is rationing care, says Kate Wilber, professor at the USC Davis School of Gerontology. “But we don’t ration it rationally,” she says.

People who are unemployed, have preexisting conditions or don’t make enough money to afford insurance but make too much to qualify for Medicaid or Medi-Cal programs are essentially rationed out of the system. The result is 47 million uninsured Americans. “It’s an extremely complex nonsystem that we have in this country,” Wilber says.

This country’s first and only attempt to set priorities in healthcare spending was the Oregon Health Plan, started in 1989, for the state’s Medicaid recipients. With advice from citizens and experts, the legislature came up with a list of about 700 conditions and treatments, ranking them by medical necessity.

But the plan ran into economic hard times during the recession of the late 1990s, and although it still survives as a regularly updated list of priorities, the state was forced to add co-payments and deductibles.

Its woes had nothing to do with prioritization of procedures, says Howard Leichter, chairman of the political science department of Linfield College in McMinnville, Ore.

“It’s limping along because of economic conditions,” Leichter says.

But the state hasn’t given up on the system. Every two years, the legislature comes up with a list of about 700 conditions and treatments, examines the money available in the Medicaid budget, and draws a line where spending must stop.

“Usually the line is at about condition 500,” says Leichter, who has studied the state’s system since it began.

“At the top of the list is preventive care. Below the line are things like diaper rash and warts. Nobody has ever died because they were denied a life-saving treatment.”

Still, a system of setting priorities has never caught on in any other state. Oregon could be the exception because it’s a small state with a relatively homogeneous population, Leichter says.

For about five years in the early 1980s, citizens held town hall meetings to discuss healthcare priorities in a statewide program called Oregon Health Decisions. By 1989, Oregonians were ready for the prioritization experiment in a way citizens of larger, more diverse states are not.

The international survey of six countries, which ranked childhood immunizations first, followed by anti-smoking education for children and general practitioner care for common illnesses, got into some ethically messy territory at the bottom of its 10-item list. Cancer treatment for smokers was given the lowest priority -- most likely because many see that as a self-inflicted disease.

Making such moral judgments is a pretty slippery slope, Wilber says.

“Where do we go with that?” she says. “I think we can’t get into that moralistic thinking -- the deserving and the undeserving of care.”

The PLoS survey was a measure of what providers, in nations much poorer than America, believe is important care. As America’s own healthcare crisis deepens, solutions, including prioritization, are predicted to be topics of hot debate.

susan.brink@latimes.com