The pandemic spreading across our nation has brought many challenges and devastation to our country. Even though much is still unknown about COVID-19, it is known that many of those more severely affected by the disease have had pre-existing conditions including overweight/obesity, hypertension, diabetes, and other lifestyle-related chronic diseases. The data also suggests that those who are most likely to succumb to the virus are those faced with health inequities who have higher rates of poverty, tobacco use, poor nutrition, and chronic stress. A recent Centers for Disease Control and Prevention report found that after adjusting for differences in age, Black people are hospitalized with COVID-19 at a devastating rate that is five-times that of White people in the United States.
Even prior to COVID-19, the majority of primary care office visits in the United States were related to stress and unhealthy lifestyles, more often seen in populations that are most vulnerable. The relationship between an unhealthy lifestyle, stress, and chronic disease has been well demonstrated by decades of research. Despite this, our healthcare system seems to focus on disease management for those with sufficient resources rather than public health and disease prevention for all.
When I was young, I dreamt of being a primary care physician. I thought that much of my day would be spent educating my patients on good nutrition, physical activity, sleep, and prevention of stress. Instead, much of my day was spent diagnosing disease, teaching people how to cope with stress, refilling medications, seeking prior authorizations, and documenting visits in an electronic health record. Little of my time was spent doing what I felt was most important as a physician, which was teaching my patients how to prevent disease.
It is ironic that while the United States is more technologically advanced than ever, our rates of chronic disease continue to skyrocket. According to the U.S. Centers for Disease Control and Prevention, chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. They are also the leading drivers of the nation’s $3.5 trillion in annual health care costs. The truth is that many chronic diseases could be prevented, delayed, or alleviated, through simple lifestyle changes. The CDC estimates that eliminating three risk factors – poor diet, inactivity, and smoking – would prevent 80% of heart disease and stroke; 80% of type 2 diabetes; and 40% of cancer. A refocus on public health and prevention of disease is critical to the sustainability of our healthcare system and for the health of our communities.
We also must focus delivery of healthcare on those most marginalized and find ways to reach them. The answer is not to build more clinics that are inaccessible because of lack of transportation, work hours, or financial constraints. Healthcare systems have not traditionally reached much beyond clinic walls to engage patients. Much of what has been done in the past has been done by community health clinics in the way of public health campaigns or health screenings. Even then, a medical office visit was typically what was expected. What might happen if physicians were trained to engage more robustly with patients in their own setting and health insurers covered the costs of telehealth or home visits for prevention and education, as well as, they covered costs for disease management?
With the spread of COVID-19, healthcare delivery has had to be reimagined. Both physicians and patients have now discovered that virtual office visits can be used successfully and are often more convenient and accessible for many patients. While not able to perform the traditional “routine annual exam” virtually, healthcare providers can offer much of the education and counseling they may not have had time for during traditional office visits. Many providers have grown to feel that the “routine annual exam” was more of a requirement that lacked supporting evidence of benefit anyway, and its usefulness has been called into question. As physicians, we need to take the focus off of services that offer little known benefit and refocus on delivering evidence-based, disease prevention education and counseling that has been shown to effectively prevent and reverse chronic lifestyle-related diseases.
It is clear that a large-scale shift to a focus on universal disease prevention is long overdue and possibly a positive outcome from the pandemic crippling our nation. Keeping people healthy and out of the medical office and hospital is the best and most economical way to improve people’s health. This just may be the opportunity we need to redesign healthcare and improve the health of our nation.