Hepatology as a model for health care # (2009)

As the new United States Presidential administration takes office, concerns regarding health and the health care system are higher on the agenda than any time in the last 15 years, and for good reason. When compared to some health care outcome measures of other countries, the United States struggles to find a place among the top 20, despite the fact that Americans pay thousands of dollars more per capita on health care than nearly every other country in the world.1 These numbers don't seem to add up without acknowledging that medical care is often one of the least important contributors to the overall health of a population. Rather, lifestyle choices, preventive measures, and environmental exposures are thought to determine roughly 90% of our health, with medical care coming into play only for the final 10%. With this in mind, how might our field serve as a model for moving the American health care system toward providing for a healthier population? Like most specialties, hepatology deals with a broad spectrum of diseases, ranging from those that are best handled by lifestyle changes or vaccination to those that respond to treatment with only the most advanced technology available. However, if we step back to consider where most of our time, energy, and research dollars are spent, we would see that they are disproportionately allotted to the technology end of this spectrum. We as a specialty have certainly reaped the benefits of our investments. We are now enjoying the efficacy of antiviral therapies for hepatitis B and C, new methods for imaging, the widespread use of percutaneous tumor ablation, and, of course, liver transplantation, to name just a few of our recent advances. Despite remarkable successes on the technology end of the disease spectrum, we've done little to stem the tide of patients who come to us with preventable forms of liver disease or before these dramatic forms of therapy are needed. In a system of unlimited resources, this combination of expanding technology and a mushrooming patient demand for services would not pose a problem. However, as we are all too often reminded, our system's resources are limited. Despite our growing arsenal of vaccines, medications, and interventions, we can no longer offer the most effective treatments to every patient, but too often are left choosing among those who are certain to reimburse us for our efforts. Admittedly, this problem is not for hepatologists alone to tackle, but its omnipresence in medicine does not absolve us of our obligation to address our own role in this growing dilemma. So again the question begs: what can we, as hepatologists, do to serve as a model for American physicians in general? A complete answer to this question is not simple and will require real thought on the part of a broad group of practitioners, but there are at least a few steps that would seem to be necessary before our specialty can claim to have acted responsibly in the face of our country's burgeoning health care costs. Not surprisingly, these require stepping back from our narrow focus on those 10% of the determinants of health—the costly interventions we've worked so hard to develop—and to redirect our sights on the other 90%. This may entail our professional groups advocating more for money to enforce hepatitis immunizations and less for money to improve tumor ablation techniques; it may mean that we take the time to emphasize the importance of health maintenance to our patients and their primary care providers rather than the time to manage the complications of viral hepatitis; or it may be as simple as remembering to reinforce the importance of avoiding alcohol abuse and overuse with patients concerned about liver disease. Of course, one could argue that these efforts at lifestyle modification and disease prevention may be fruitless by the time patients are being evaluated by hepatologists for liver disease, but if all practitioners took the same responsibility for the overall well-being of their patients, the effect would be to greatly increase the number of patients who are cognizant of the exposures and behaviors that put them at risk for various disease. Only by addressing the factors contributing to preventable diseases will our more technologically advanced therapies be available to those who need them. As a means of trying to put into perspective the issues that the country faces and the need for broadening our scope of influence as physicians, imagine how overloaded our system would be without the preventive measures we currently employ. Consider, for example, the thousands of cases of hepatitis B that are averted each year by our vaccination programs, and compare the cost of preventing the disease, estimated at $900 per case, to the cost of treating the same disease, estimated to be $12,000–$24,000 per case in 1995.2 Or consider the low cost of diet modification and exercise compared to the cost of managing end-stage steatohepatitis. Although similar numbers for efforts on exposure and lifestyle counseling are less dramatic, it remains clear that prevention yields the most benefit per dollar. If we wish to continue to offer patients more sophisticated technology and treatment regimens, we must do a better job of thinking about our part to keep people from needing medical attention in the first place. Only if we, as a field, are willing to recognize our role in addressing those often-forgotten 90% of health determinants will we have the resources to maintain our focus on improving therapies for the remaining 10%. Though it will take a concerted effort on the part of generalists and multiple specialties to see widespread results from these efforts, hepatology's intimate connection to both the preventive and advanced therapeutic ends of the clinical spectrum provides us with both the potential and incentive to serve as models for the rest of the system.