Home Uncategorized Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion.

Uncategorized

Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion.

1) Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion. 2) Describe how this focus(foci) is/are reflected at the individual (patient/provider), organizational (hospital/clinic/company), and societal (norms/policy/laws) levels using examples (your profession-specific related examples.) Demonstrate professional credibility by using citations for your chosen examples. 3) Summarize the problems/barriers that occur for patient care when these foci are in conflict with each other.

Paper 1: The Focus of U.S. Health Care

Course: Health Care Systems and Policies

Spring 2020

Requirements:

1. Title page: title of paper, author, course, date.

2. Word count 1500 words minimum (2000 max).

3. Single-spaced (standard 11pt font) with page numbers.

4. Organization for a formal academic essay includes an intro/thesis, body, and a conclusion.

5. This is formalize writing: DO NOT use first person (“I”) language.

6. Submission: DO upload a separate or file for your assignment.

7. Review the rubric for grading criteria.

8. References required. APA citation style required. (References not included in word count.)

Paper 1

Writing Prompt:

1) Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion

the topic of U.S health care system is seen to be controversial. Controversial meaning, there a various factors that play a huge role in determining the quality of the health care system. Factors such as quality of disease prevention enforcement, efficiency in treatment of disease.

in the sense that The issue of the policy makers of the health care system t

BioMed Central

Philosophy, Ethics, and Humanities
in Medicine

Open AcceBook review
Book review of Introduction to U.S. Health Policy: The Organization,
Financing and Delivery of Health Care in America by Donald A. Barr
Audrey R Chapman

Address: Division of Medical Humanities, Health Law and Ethics, Department of Community Medicine and Health Care, University of
Connecticut School of Medicine, Farmington, CT 06030, USA

Email: Audrey R Chapman – achapman@uchc.edu

Abstract

Donald A. Barr’s Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health
Care in America (second edition, 2007) offers a lucid and informative overview of the U.S. health
system and the dilemmas policy makers currently face. Barr has provided a balanced introduction
to the way health care is organized, financed, and delivered in the United States. The thirteen
chapters of the book are quite comprehensive in the topics they cover. Even those knowledgeable
about the U.S. health care system are likely to find much to stimulate their thinking in the text. The
book can also appropriately serve as a basic text for a health policy course or in the medical or
nursing school curriculum.

Book details

Barr Donald A: Introduction to U.S. Health Policy: The Organi-
zation, Financing and Delivery of Health Care in America 2nd
edition. Baltimore, MD, The Johns Hopkins University Press;
2007. xiv + 303 pages, ISBN – 13:978-0-8018-8574-7 (hard-
cover) and 13:978-0-8018-8574-4 (pbk)

Review

Currently there is widespread dissatisfaction with the
health system in the United States. Health care reform has
once again emerged as a priority domestic policy issues at
the national level, and it is likely to play an important role
in the forthcoming U.S. presidential election. Following
the example of Massachusetts, several states are also con-
sidering health care reform initiatives. Notably, even
organizations like the American Medical Association and
major corporations, which once ardently opposed com-
prehensive health care reform, are advocating for major
structural changes in the U.S. health care system.

Several trends account for much of the current momen-
tum toward health care reform. The first is escalating

health costs. While in 1970 people in the United States
spent an average of $341 per person on all types of health
care, by 2003 this figure had risen to about $5,670 per
person, a figure which is more than 50 percent higher
than any other industrialized country and 140 percent
above the average for OECD (Organization for Economic
Cooperation and Development) countries [1]. Although
other developed countries also face the pressure of rising
health care costs, primarily from covering the cost of new
and more expensive technologies and pharmaceuticals
and meeting the health care needs of aging populations,
the U.S. problem is more severe [2].

A second issue is gaps in coverage and access to care. The
U.S. is the only industrialized democracy that does not
recognize a right to health care and/or provide universal
health insurance for its citizens. Despite escalating health
costs and the highest per capita investment in health care
in the world, one-sixth of the U.S. population lacks health
insurance, and the numbers are rising every year. Disturb-
ingly, the absence of health care insurance falls dispropor-

Published: 3 March 2008

Philosophy, Ethics, and Humanities in Medicine 2008, 3:9 doi:10.1186/1747-5341-3-9

Received: 15 February 2008
Accepted: 3 March 2008

This article is available from: http://www.peh-med.com/content/3/1/9

© 2008 Chapman; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Page 1 of 4
(page number not for citation purposes)

http://www.peh-med.com/content/3/1/9

http://creativecommons.org/licenses/by/2.0

http://www.biomedcentral.com/

http://www.biomedcentral.com/info/about/charter/

Philosophy, Ethics, and Humanities in Medicine 2008, 3:9 http://www.peh-med.com/content/3/1/9

tionately on vulnerable groups, specifically low-income
Americans and ethnic minorities, particularly blacks, His-
panics, and native Americans. As might be anticipated,
lack of health insurance for these groups often translates
into the failure to obtain timely and appropriate health
care.a

Yet another factor accounting for the support for health
care reform is that the system of employer-based insur-
ance on which the U.S. uniquely relies is unraveling.
While the costs of health insurance benefits were once
modest, today health coverage for a family of four is esti-
mated to be more than $10,000 [3]. Given the financial
pressures, many employers are reducing health insurance
benefits, transferring more costs onto employees, or drop-
ping insurance for some or all employees. In 2005, nearly
eight in ten uninsured people, equivalent to more than
one-fifth of the adult work force, came from families with
at least one full time worker [4].

In addition, there are problems with the quality of health
care. Indicators on health performance show that the U.S.
health system compares unfavorably with other advanced
and even some middle income countries in terms of life
expectancy, infant mortality rates (with the U.S. having
the lowest of 23 industrialized countries), and avoidance
of preventable mortality [5]. A 2000 WHO study ranked
the overall performance of the U.S. health system as 37th

of 191 countries [6].

A variety of approaches to health care reform have been
put forward, but with quite different goals and emphases.
Several, including a Canadian style single-payer approach
and various proposals to impose individual and or/corpo-
rate mandates for health insurance, seek to find ways to
cover some or all of the 47 million U.S. citizens who are
currently without health insurance. In contrast, the
emphasis in other plans, as for example health savings
accounts, is on preserving or increasing choice and reduc-
ing health-related costs. It is difficult, however, to assess
the proposals being put forward to reform the U.S. health
system without understanding the factors leading to the
problems noted above and the reasons that major health
care reform initiatives were unsuccessful in the past.

Donald A. Barr’s Introduction to U.S. Health Policy: The
Organization, Financing, and Delivery of Health Care in
America (second edition, 2007) can serve as such a needed
resource. The book offers a lucid and informative over-
view of the U.S. health system and the dilemmas policy
makers currently face. Barr, who is trained both as a phy-
sician and a sociologist and holds an appointment as an
Associate Professor of Sociology and Human Biology at
Stanford University, has provided a balanced and inclu-
sive introduction to the way health care is organized,

financed, and delivered in the United States. The volume
provides a helpful introduction to the U.S. health care sys-
tem for anyone wishing to understand how the U.S. can
simultaneously have the best and worst of health care sys-
tems among industrialized countries. Even those knowl-
edgeable about the U.S. health care system are likely to
find much to stimulate their thinking in the text. The book
can also appropriately serve as a basic text for a health pol-
icy course or in the medical or nursing school curriculum.

The thirteen chapters of the book are quite comprehensive
in the topics they cover. The first chapter opens with a
brief historical description of the unique history of health
care in the U.S. and the policy decisions that have shaped
the current system. The chapter provides data about the
costs of healthcare, and the burdens that these increases
impose on both the public and the private sectors. It also
briefly compares the U.S. with other developed countries
in terms of the amount we spend on health care and the
overall health status of our population. The introduction
has sections on concerns about the quality of health care
and additionally introduces the problem of the growing
number of the uninsured, another characteristic unique to
the U.S. health care system among industrialized demo-
cratic countries.

The second chapter describes many of the institutional
norms, cultural values, and expectations that have shaped
the unique character of the U.S. health care system. It
highlights American “exceptionalism” by briefly compar-
ing the U.S. and Canadian health systems. One particu-
larly insightful section of this chapter examines how
fundamental cultural and value differences and between
the U.S. and Canada are reflected in their respective health
care systems.

The third chapter addresses the professional structure of
U.S. health care. It covers the history of medical education
and the medical profession as well providing a brief anal-
ysis of the development of the nursing profession. It
examines the structure of hospitals and other types of spe-
cialized referral centers. This chapter documents the unu-
sually dominant role physicians and the American
Medical Association have played in shaping the character
of the medical system. Barr also mentions how the medi-
cal profession organized to block previous efforts to
reform the system.

The next few chapters offer an overview of health care
structures. Chapter 4 focuses on health insurance and the
development of health maintenance organizations. Chap-
ters 5 and 6 describe the history of Medicare and Medicaid
and explore the policy questions confronting these two
major government health care programs. Chapter 7 con-
siders the increasing role of for-profit health care in the

Page 2 of 4
(page number not for citation purposes)

Philosophy, Ethics, and Humanities in Medicine 2008, 3:9 http://www.peh-med.com/content/3/1/9

delivery of health care and some of the consequences for
the health care system.

Chapter 8 focuses on pharmaceutical policy and the rising
cost of prescription drugs examining the way the U.S.
health system organizes, pays for, and delivers pharma-
ceutical products to patients. Some of the topics included
in this discussion of what has become one of the central
issues of U.S. health policy are pharmaceutical research
and the development of “me-too” drugs; the marketing of
new drugs to physicians; the lack of meaningful oversight
of physicians’ relationships with the pharmaceutical
industry; past efforts to control pharmaceutical costs; and
the 2006 Medicare prescription drug benefit.

Long-term care is the subject of chapter 9. The topics dis-
cussed include the growing need for long-term care
among frail elderly people, home health care, hospice
care, and life-care communities as an alternative to long-
term care.

Chapters 10 and 11 return to the problem of access to
health care. Chapter 10 deals with the uninsured, and
chapter 11 addresses factors other than health insurance
that impede access to health care. Barr points out that the
U.S. is alone among developed countries in maintaining
national policies that exclude segments of the population
from health insurance coverage and explains how and
why this has occurred. He analyzes who the uninsured are
and projects what the future numbers are likely to be
unless there are new initiatives to provide coverage. Non-
insurance barriers that Barr identifies include out-of-
pocket expenses, the inadequacy of Medicaid coverage,
disparities in treatments offered to members of different
racial groups, and the organizational complexity of the
health care system.

The final two chapters explore topics related to health care
reform. Chapter 12 focuses on key policy issues for decid-
ing on the direction. According to Barr, to be successful in
restructuring the U.S. system of health care, we will need
to deal simultaneously with the three problems that lie at
the center of U.S. health policy: constraining the cost of
care, maintaining and improvement the quality of care,
and increasing access to care. He also considers whether
rationing health care is inevitable and under what kinds of
conditions it might be acceptable. Chapter 13 concludes
with a brief consideration of some of the options for
health care reform.

One of the strengths of this book is that Barr consistently
places the health care system in a broad social and cultural
context. He draws on theories from fields as diverse as
economics, sociology, and organizational behavior to
assess the broad social forces that coalesce to create the

structure of U.S. health care and the problems inherent in
it. His discussion of the cultural expectations and institu-
tions that drive the U.S. health care system is particularly
insightful.

Barr contrasts the primacy accorded to the rights of the
individual in the U.S. with the greater emphasis on the
common good in other countries, like Canada, that pro-
vide universal health care. He points out that this differ-
ence in disposition has resulted in very different
organizing principles for the Canadian and U.S. health
care systems. In Canada health care is a basic right; the
power of the medical profession is limited by its social
obligation; health care is organized through a single-payer
system; and there is one standard of health care for all
Canadians. In addition, Canadian political culture recog-
nizes the need for limits in health care expenditures and
accepts the appropriateness of the system allocating scarce
health care resources to those in greatest need, measured
in terms of the risk to their life or health.

In contrast, Barr shows that the principles around which
the U.S. health care system has come to be organized are
quite different and contribute to current problems. In the
U.S., health care is considered to be a market commodity
to be distributed according to the ability to pay rather
than a basic right; power over the organization and deliv-
ery of health care has historically been concentrated in the
medical profession without a strong countervailing tradi-
tion of social obligation; even as its contribution to
financing the health system has grown, government has
historically had relatively little role in guiding the system
of health care; and there is no uniform standard of care as
in Canada, but instead, the quality of care received often
reflects the ability to pay. In addition, Barr points out that
the U.S. culture lacks a sense of the need for limits in
expenditures on health care. Thus there is an always rising
public demand for access to new pharmaceuticals and
technologies, even when there is no evidence that they are
necessarily more effective.

Given the importance of health care reform, it is disap-
pointing that Barr does not give this issue more attention.
His analysis clearly underscores that the current U.S. sys-
tem of health care is not sustainable. Barr shows that there
are simply too many areas of potential crisis and financial
instability for the system to survive without substantial
reform. Nevertheless, he offers a superficial discussion of
the options. A short final chapter of only 13 pages pro-
vides a very brief description of four alternative
approaches and with a few phrases highlights their poten-
tial strengths and weaknesses. It does not assess the pros-
pects for adoption of any of these models or alternative
plans. This is an important issue, especially in light of the
multiple past attempts to reform the U.S. health care sys-

Page 3 of 4
(page number not for citation purposes)

Philosophy, Ethics, and Humanities in Medicine 2008, 3:9 http://www.peh-med.com/content/3/1/9

Publish with BioMed Central and every
scientist can read your work free of charge

“BioMed Central will be the most significant development for
disseminating the results of biomedical research in our lifetime.”

Sir Paul Nurse, Cancer Research UK

Your research papers will be:

available free of charge to the entire biomedical community

peer reviewed and published immediately upon acceptance

cited in PubMed and archived on PubMed Central

yours — you keep the copyright

Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp

BioMedcentral

tem. Perhaps the third edition of the book will cover this
issue in greater depth or, even better, be able to provide an
analysis of successful future health care reforms.

Endnote

a. See the Kaiser Family Foundation website particularly
“Key Facts: Race, Ethnicity and Medical Care 2007
Update,” “The Uninsured: A Primer,” and “How Trends in
the Health Care System Affect Low-Income Adults: Identi-
fying Access Problems and Financial Burdens” [7].

About the author

Dr. Chapman is the Joseph M Healey, Jr. Professor of
Medical Humanities and Ethics at the University of Con-
necticut Medical School. She is the author, coauthor, or
editor of sixteen books and numerous articles and reports
dealing with ethical, human rights, theological, and intel-
lectual property issues related to health, genetic develop-
ments, and pharmaceuticals. She also has published
works on economic, social and cultural rights; health care
reform; transitional justice; reconciliation; and develop-
ment issues.

Competing interests

The authors declare that they have no competing interests.

References

1. Anderson GF, Hussey PS, Frogner BK, Waters HR: Health Spend-

ing in the United States and the Rest of the Industrialized
World. Health Affairs 2005, 24:905.

2. Anderson GF, Hussey PS, Frogner BK, Waters HR: Health Spend-
ing in the United States and the Rest of the Industrialized
World. Health Affairs 2005, 24:903-914.

3. Krugman P, Wells R: The Health Care Crisis and What to Do
About It. The New York Review of Books 53:39. March 23, 2006

4. National Coalition on Health Care: Health Insurance Coverage.
[http://www.nchc.org/facts/coverage.shtml].

5. Commission on a High Performance Health System: A High Per-
formance Health System for the United States: An Ambi-
tious Agenda for the Next President. The Commonwealth Fund
75: [http://www.commonwealthfund.org/publications/
publications_show.htm?doc_id=584834]. November 15, 2007

6. World Health Organization: The World Health Report 2000 – Health
Systems: Improving Performance Geneva: WHO; 2000.

7. Kaiser Family Foundation [http://www.kff.org]

Page 4 of 4
(page number not for citation purposes)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=16136632

http://www.nchc.org/facts/coverage.shtml

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=584834

Home Page

http://www.biomedcentral.com/

http://www.biomedcentral.com/info/publishing_adv.asp

http://www.biomedcentral.com/

2/5/2020 Health Care Industry Insights: Why the Use of Preventive Services Is Still Low

https://www.cdc.gov/pcd/issues/2019/18_0625.htm 1/5

Preventing Chronic Disease

Top

Health Care Industry Insights: Why the Use of
Preventive Services Is Still Low

Susan Levine, DVM, PhD ; Erin Malone, MPH ; Akaki Lekiachvili, MD, MBA ; Peter
Briss, MD, MPH (View author a�liations)
Suggested citation for this article: Levine S, Malone E, Lekiachvili A, Briss P. Health Care Industry Insights: Why the Use of Preventive Services Is Still Low. Prev Chronic Dis
2019;16:180625. DOI: http://dx.doi.org/10.5888/pcd16.180625 .

Chronic diseases are a tremendous burden to both patients and the health care system. In 2014, 60% of adult Americans had
at least one chronic disease or condition, and 42% had multiple diseases (1). Chronic diseases, including heart disease, cancer,
chronic lung disease, stroke, Alzheimer’s disease, diabetes, osteoarthritis, and chronic kidney disease, are the leading causes
of poor health, long-term disability, and death in the United States (2,3). One-third of all deaths in this country are attributable
to heart disease or stroke, and every year, more than 1.7 million people receive a diagnosis of cancer (2). During the past
several decades, the prevalence of diabetes increased dramatically; in 2015 more than 29 million Americans had diabetes and
another 86 million adults had prediabetes, increasing their chance of developing type 2 diabetes (3). Diabetes increases the
risk of developing other chronic diseases, including heart disease, stroke, and hypertension, and is the leading cause of end-
stage renal failure (4).

Chronic diseases can profoundly reduce quality of life for patients and for their families, a�ecting enjoyment of life, family
relationships, and �nances (5). Working can be di�cult for people with chronic diseases: rates of absenteeism are higher and
income is often lower among people who have a chronic disease compared with people who do not have one. Functional
limitations can be distressing, and depression, which can reduce a patient’s ability to cope with pain and worsen the clinical
course of disease, is a common complication (6).

Chronic diseases are also the leading drivers of health care costs in the United States (2). In 2016, total direct costs for health
care treatment of chronic diseases were more than $1 trillion, with diabetes, Alzheimer’s, and osteoarthritis being the most
expensive (2,7). If lost economic productivity is also considered, the total cost of chronic diseases increases to $3.7 trillion,
which is close to one-�fth of the entire US economy (7,8). These costs are expected to increase as the population ages —
projections indicate that by 2030, more than 80 million people in the United States will have at least 3 chronic diseases (7).

Clinical preventive strategies are available for many chronic diseases; these strategies include intervening before disease
occurs (primary prevention), detecting and treating disease at an early stage (secondary prevention), and managing disease to
slow or stop its progression (tertiary prevention). These interventions, combined with lifestyle changes, can substantially
reduce the incidence of chronic disease and the disability and death associated with chronic disease (9). However, clinical
preventive services are substantially underutilized despite the human and economic burden of chronic diseases, the
availability of evidence-based tools to prevent or ameliorate them, and the e�ectiveness of prevention strategies (9–11). For
example, in 2015, only 8% of US adults aged 35 or older received all recommended, high-priority, appropriate clinical
preventive services, and nearly 5% received none (12).

Interview Study
It is far better to prevent disease than to treat people after they get sick (13). This is particularly true for chronic diseases,
which are associated with su�ering, large numbers of deaths, and high health care costs (2,7). Given the gap between the
burden of chronic diseases and the utilization of preventive services, we set out to obtain from health care industry experts
their perspectives on the levers and in�uencers that have the potential to increase utilization of clinical preventive care. The

ESSAY — Volume 16 — March 14, 2019

This article is part of the Health Care Systems, Public Health, and Communities: Population Health
Improvements collection.

1 1



https://www.cdc.gov/

https://www.cdc.gov/pcd/index.htm

http://dx.doi.org/10.5888/pcd16.180625

https://www.altmetric.com/details.php?domain=www.cdc.gov&citation_id=57022296

https://www.cdc.gov/pcd/collections/Healthcare_Systems_2019.htm

2/5/2020 Health Care Industry Insights: Why the Use of Preventive Services Is Still Low

https://www.cdc.gov/pcd/issues/2019/18_0625.htm 2/5

Top

p p p p

objective of our study was to gather experience-based insights that would be valuable to policy makers in developing
strategies, programs, and partnerships across the health care industry to increase utilization of preventive services. We
selected a qualitative interview study design for this investigation, which was conducted from December 2017 to June 2018.
This project involved domain experts rather than human subjects as de�ned by 45 CFR part 46, and therefore institutional
review board approval was not required.

Recruitment of experts
We �rst identi�ed experts with a background in working with decision makers in health care. We then narrowed our selection
to 12 experts, each of whom had at least 10 years of experience in working with one or more types of organizations, including
health systems, hospitals or physician groups, commercial payers, or state Medicaid agencies. We then conducted a short
screening interview to con�rm appropriate expertise and willingness to participate. After this initial selection process, we
scheduled a 1-hour semistructured interview with each of 9 participants. Before beginning the interviews, the participants
con�rmed that they had no con�icts of interest that might bias their comments and that they would not disclose any
con�dential or proprietary information about the organizations for which they currently or previously worked. We tabulated
details of their expertise (Table 1).

Interview questions
Increasing uptake of preventive services requires multifaceted strategies, including but not limited to organizational
leadership, education, measurement, and reimbursement. With this in mind, we developed an interview guide (Table 2),
which included a series of questions focused on how payers, health systems, and physicians determine their clinical and
business priorities for resource allocation and quality improvement e�orts. We asked about opportunities to include
incentives for the use of preventive services under current and emerging designs of models for payment and delivery. We
included questions about examples of successful implementation of preventive services strategies or models and about
clinical–community linkages that focus on chronic disease prevention.

Although primary prevention was not excluded, much of the discussion focused on secondary and tertiary prevention related
to health care system interventions and community interventions linked to clinical services. Throughout the interviews, the
participants were encouraged to draw from their experiences with organizations of various capacities and not to focus only
on high-level performers or models that would be di�cult for average organizations to adopt and replicate. Each interview
was conducted via teleconference and facilitated by the �rst author (S.L.), a senior scientist with expertise in qualitative
research methods.

Interview Findings
Across all interviews, 4 �ndings emerged as major levers or in�uencers of preventive care. These �ndings cut across all health
care industry sectors and organization types.

Financial and economic considerations. The most prominent theme was �nances. All interviewees highlighted the importance
of �nancial and economic considerations when organizations determine priorities and make decisions. These decisions
include where to invest resources, what health bene�ts to cover, or how to bill for clinical services. In the words of one
interviewee, “With no margin, there is no mission.”

Use of metrics to drive change in the health care system. The second �nding was related to metrics and the importance of
using metrics to drive change in the health care system. Interviewees stressed that measures continue to play a crucial role in
the delivery of care, but the “right” metrics — outcome-focused, aligned across payers, and with su�cient �nancial incentives
or risk — are needed to drive uptake of chronic disease preventive services. One participant, emphasizing that reporting and
monitoring can drive change, noted, “Once external reporting is in place, measured outcomes are prioritized.” However,
interviewees cautioned about the “metrics fatigue” that is plaguing health care providers, the misalignment of measures for
reporting and quality ratings, and the current lack of �nancial risk for outcome measures associated with preventive care; in
other words, payments to providers are not based on improvements in their patients’ health status.

Role of health care payers. The third �nding focused on the role of health care payers (commercial payers/health plans,
Medicaid, and particularly Medicare) in in�uencing uptake of preventive care services. Findings coalesced around the
opportunities for payers to drive change in practice. As risk-bearing entities, they provide the payment models and the

2/5/2020 Health Care Industry Insights: Why the Use of Preventive Services Is Still Low

https://www.cdc.gov/pcd/issues/2019/18_0625.htm 3/5

Top
Top
Top
Top

in�uence and incentives that can a�ect uptake of chronic disease preventive services. Several interviewees highlighted the
importance of data for payers. As one expert explained, “Payers have the data that can often drive adoption or uptake of
programs and interventions.”

Rapid changes in health care reimbursement models. The fourth �nding focused on the pace of change in health care
reimbursement models. The shift from volume-based reimbursement has been at the forefront of debate and discussion for
years, but for typical health care delivery organizations, the transition to value-based reimbursement is still in early stages
and is uneven across payers. As a result, the transition has not reached the “tipping point” for providers to change their
practice patterns. As one interviewee observed, “There is some emphasis on value-based care, including focus on outcomes
and reduced spending, but the view is generally short-term.” The health care industry will continue to move in the direction of
value-based care, but changes in provider practice vary across systems and markets. There is also considerable room for
continuing experimentation and evaluation to determine what reimbursement models work best and for whom.

Discussion
Industry experts participating in this stakeholder interview process made it clear that most players in the health care system
are aware of recommended preventive care services and understand the bene�t of preventing disease for the patient and the
larger health care system. Underutilization of preventive services is largely the result of an implementation gap rather than an
information gap; in other words, providers do not prioritize preventive care services although they know that preventive
services can reduce the incidence and burden of chronic diseases. A major reason the implementation gap exists is that
�nancial incentives do not align with a focus on preventing chronic diseases. Currently, most providers, including hospitals
and physicians, are paid to treat rather than to prevent disease. Payers have the potential to increase utilization of preventive
services with value-based payment models and contractual requirements that include reporting on preventive health quality
measures.

As the participants in our study o�ered their perspectives on the barriers and in�uences surrounding the coverage and
delivery of preventive care services, much of the conversation focused on the in�uence of �nancial considerations on uptake
of preventive care. However, participants generally agreed that �nancial incentives alone are unlikely to result in positive
changes in the absence of a multipronged approach to increasing preventive services among people at risk of or living with
chronic diseases. A multipronged approach would include strong organizational leadership, shifts in institutional culture,
team-based care, systems of care that accommodate preventive services, and willingness of patients to seek out and engage
in preventive care.

Acknowledgments
No �nancial support was received for this essay. The �ndings and conclusions are solely the responsibility of the authors and
do not represent the o�cial views of Deloitte Consulting, LLP, or the Centers for Disease Control and Prevention.

Author Information
Corresponding Author: Akaki Lekiachvili, MD, MBA, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS F-80,
Chamblee Campus, Bldg 107, Atlanta, GA 30341. Telephone: 770-488-5317. Email: anl5@cdc.gov.

Author A�liations: Deloitte Consulting, LLP, Atlanta, Georgia. O�ce of the Medical Director, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

References
1. Buttor� C, Ruder T, Bauman M. Multiple chronic conditions in the United States. Santa Monica (CA): Rand Corp; 2017.

https://www.rand.org/pubs/tools/TL221.html. Accessed October 18, 2018.

2. National Center for Chronic Disease Prevention and Health Promotion. Health and economic costs of chronic diseases.
Atlanta (GA): Centers for Disease Control and Prevention, US Department of Health and Human Services; 2018.
https://www.cdc.gov/chronicdisease/about/costs/index.htm. Accessed October 18, 2018.

3. Centers for Disease Control and Prevention. National diabetes statistics report, 2017. Atlanta (GA): Centers for Disease
Control and Prevention, US Department of Health and Human Services; 2017.
https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report . Accessed October 18, 2018.

1 2

mailto:anl5@cdc.gov

2/5/2020 Health Care Industry Insights: Why the Use of Preventive Services Is Still Low

https://www.cdc.gov/pcd/issues/2019/18_0625.htm 4/5

Top

4. National Institute of Diabetes and Digestive and Kidney Diseases. Current burden of diabetes in the US
https://www.niddk.nih.gov/health-information/communication-programs/ndep/health-professionals/practice-
transformation-physicians-health-care-teams/why-transform/current-burden-diabetes-us. Accessed October 18, 2018.

5. Golics CJ, Basra MK, Salek MS, Finlay AY. The impact of patients’ chronic disease on family quality of life: an experience
from 26 specialties. Int J Gen Med 2013;6(6):787–98. CrossRef PubMed

6. Turner J, Kelly B. Emotional dimensions of chronic disease. West J Med 2000;172(2):124–8. CrossRef PubMed

7. Waters H, Graf M. The costs of chronic diseases in the US. Santa Monica (CA): Milken Institute; 2018.
http://www.milkeninstitute.org/publications/view/938. Accessed October 18, 2018.

8. Asay GRB, Roy K, Lang JE, Payne RL, Howard DH. Absenteeism and employer costs associated with chronic diseases and
health risk factors in the US workforce. Prev Chronic Dis 2016;13:E141. CrossRef PubMed

9. National Center for Chronic Disease Prevention and Health Promotion. The power of prevention. Chronic disease . . . the
public health challenge of the 21st century. Atlanta (GA): Centers for Disease Control and Prevention, US Department of
Health and Human Services; 2009. https://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention . Accessed
November 3, 2018.

10. Healthy People.gov. Clinical preventive services. Washington (DC): O�ce of Disease Prevention and Health Promotion,
US Department of Health and Human Services. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-
topics/Clinical-Preventive-Services. Accessed November 3, 2018.

11. Adepoju OE, Preston MA, Gonzales G. Health care disparities in the post–A�ordable Care Act era. Am J Public Health
2015;105(Suppl 5):S665–7. CrossRef PubMed

12. Borsky A, Zhan C, Miller T, Ngo-Metzger Q, Bierman AS, Meyers D. Few Americans receive all high-priority, appropriate
clinical preventive services. Health A� (Millwood) 2018;37(6):925–8. CrossRef PubMed

13. National Prevention Council. National prevention strategy. Washington (DC): U.S. Department of Health and Human
Services, O�ce of the Surgeon General; 2011.

Tables

Table 1. Areas of Focus of Subject Matter Experts (N = 9) Participating in a Qualitative Interview Study
Designed to Gather Information for Developing Strategies, Programs, and Partnerships Across the Health Care
Industry to Increase Utilization of Preventive Services, 2018

Industry
Sector Role Areas of Focus

Payers Set payment models for
preventive services or
programs

Health plan collaborations with focus on value-based care transformation, population health, and consumerism

Policies, processes, strategies, and information technology systems associated with successful Medicaid and Children’s
Health Insurance Program programs, and other human services programs

Health
systems

Develop and manage delivery
of preventive services

Quality management for large health systems, including implementing health information technology and electronic
health record transformations

Strategy and operations effectiveness of health systems, including care management, vendor management, system
design and implementation, post-merger integration, enterprise cost reduction

Clinical transformation among health systems with focus on pay for performance and patient safety

Providers
and
physicians

Deliver or prescribe preventive
services

Customer/patient experience strategies and digital transformation for health care providers

Physician services design and implementation, including clinical integration, patient retention and physician loyalty,
physician alignment, productivity and compensation, regulatory compliance, and ambulatory operations

Table 2. Interview Questions Used in a Qualitative Interview Study Designed to Gather Information for
Developing Strategies, Programs, and Partnerships Across the Health Care Industry to Increase Utilization of
Preventive Services, 2018

Theme Questions

 

 
 
 
 

http://dx.doi.org/10.2147/IJGM.S45156

http://www.ncbi.nlm.nih.gov/pubmed/24092994

http://dx.doi.org/10.1136/ewjm.172.2.124

http://www.ncbi.nlm.nih.gov/pubmed/10693376

http://dx.doi.org/10.5888/pcd13.150503

http://www.ncbi.nlm.nih.gov/pubmed/27710764

http://dx.doi.org/10.2105/AJPH.2015.302611

http://www.ncbi.nlm.nih.gov/pubmed/25879149

http://dx.doi.org/10.1377/hlthaff.2017.1248

http://www.ncbi.nlm.nih.gov/pubmed/29863918

2/5/2020 Health Care Industry Insights: Why the Use of Preventive Services Is Still Low

https://www.cdc.gov/pcd/issues/2019/18_0625.htm 5/5

Top
Theme Questions

Organizational leadership and
decision making

How do health systems, payers, or providers determine their priorities (eg, deciding which strategies to focus on and what metrics to
pay attention to, holding their physicians accountable for certain strategies, prioritizing certain interventions over others)?

What are the primary drivers in the current health care delivery system – including both payment and delivery model designs – that
shape guidelines, standards of care, or financial incentives?

Facilitators and barriers
(measurement and
reimbursement)

Could you describe facilitators and barriers that a typical health system faces when considering or implementing chronic disease
prevention services?

What additional opportunities (eg, performance measures, reimbursement structures) can be leveraged to drive uptake of prevention
services among health system stakeholders?

Under the current and emerging designs for models of payment and delivery, what are opportunities to better incentivize preventive
services?

Successful models of prevention Among the health systems you have worked with, are you familiar with successful implementation of preventive services, strategies, or
models?

Are you aware of any health systems that have implemented innovative community prevention programs or models that focus on
chronic disease prevention?

Page last reviewed: March 14, 2019

Surgeon General’s Perspectives

774 

Public Health Reports / November–December 2011 / Volume 126

THE NATIONAL PREVENTION
STRATEGY: SHIFTING THE NATION’S
HEALTH-CARE SYSTEM

I know the pain and hardship that can strain a family
when they experience the loss of a loved one. I lost my
mother to smoking-related lung cancer, my father to a
stroke, and my brother to human immunodeficiency
virus (HIV)/acquired immunodeficiency syndrome
(AIDS), all of which are preventable diseases. It is
my mission to keep other Americans from having to
experience such preventable losses. For this reason, it
is my hope to pioneer our nation’s first-ever prevention
movement. The National Prevention Strategy,1 called
for in the Patient Protection and Affordable Care Act,2
will shift our nation’s health-care system from one based
on sickness and disease to one focused on prevention
and wellness. We need to stop diseases before they start
and allow all Americans to be healthy and fit.

The health and vitality of Americans are critical
to the productivity and innovation essential for our
nation’s future. Students who are healthy and fit come
to school ready to learn; employees who are free from
mental and physical conditions take fewer sick days, are
more productive, and help strengthen the economy;
and older adults who remain physically and mentally
active are more likely to live independently.1 Therefore,
we need to weave disease prevention into the every-
day fabric of our lives, including where we live, work,
learn, and play.

Although the U.S. spends more on health care than
any other country, our nation ranks lower than several
other nations in life expectancy, infant mortality, and
other healthy life indicators.3 Our government is striv-
ing to change our health-care system for the better,
and prevention is essential. A 2006 study by Maciosek
et al. determined that increasing the use of preventive
services—including tobacco cessation screening, alco-
hol abuse screening, and aspirin use—to 90% of the
recommended levels could save $3.7 billion annually
in medical costs.4 Shifting our nation’s focus toward
preventive health will not only result in cost savings
but, more importantly, will save and improve lives.

STRATEGIC DIRECTIONS AND PRIORITIES

The National Prevention Strategy is a guide for our
nation to provide the most useful and attainable means

for leading a healthy lifestyle. This comprehensive plan
encompasses four strategic directions that serve as the
foundation for all prevention efforts.

Healthy and safe community environments
Our nation must build healthy and safe community
environments. Health should be omnipresent and
universal—in our homes, schools, and workplaces. By
enhancing the quality of our nation’s air, land, and
water, we can lessen people’s exposure to environmen-
tal hazards and the associated risks of these exposures
on health. By designing and promoting affordable,
accessible, and safe housing that is free from toxins,
hazards, and pollutants, we can give all people an equal
opportunity at healthy living.

Clinical and community preventive services
We must maintain and enhance our clinical and com-
munity preventive services. We know that when people
receive preventive care, such as immunizations and
cancer screenings, they have better health and lower
health-care costs. For example, by focusing on improv-
ing our nation’s cardiovascular health, we can save
tens of thousands of lives each year. While preventive
services are traditionally delivered in clinical settings,
some can be delivered within communities, worksites,
schools, residential treatment centers, or homes.

VADM Regina M. Benjamin,
Surgeon General

Surgeon General’s Perspectives  775

Public Health Reports / November–December 2011 / Volume 126

Clinical preventive services can be supported and rein-
forced by community-based prevention, policies, and
programs. Community programs can also play a role in
promoting the use of clinical preventive services and
assisting patients in overcoming barriers to preventive
services (e.g., transportation, child care, and patient
navigation issues).

Empowered people
We must empower people to make responsible,
informed, and healthy choices. By providing people
with the tools and information to make healthy deci-
sions, we can lead our country to become an indepen-
dent and reliable manager of its own health. People
want to be healthy; we need to provide them with
easy and affordable options to maintain their health.
These options include access to healthy food, places
to exercise, appropriate nutrition information, and
positive social interactions.

Elimination of health disparities
Finally, we must eliminate the health disparities that
exist in our nation. No population should shoulder
a disproportionate burden of illness and disease.
Unfortunately, many health concerns, including
heart disease, asthma, obesity, and HIV/AIDS, dis-
proportionately affect certain populations of people.
Without education and employment, people are often
ill-equipped to make healthy choices. Education can
increase health knowledge and allow people to make
better-informed choices for themselves and their
families. Employment can provide access to health
coverage and prevention care, allow people to live
in healthy and safe neighborhoods and housing, and
enable families to afford healthy food and other basic
goods. Programs and policies to reduce high school
dropout rates make advanced education more attain-
able, promote job growth, and, ultimately, have a large
impact on people’s ability to make healthy choices.1

With a strategic focus on the communities at greatest
risk, and those that require the greatest support, we
can work toward providing all Americans with a chance
to live a healthy and fi t life.

Priority areas
In addition to these strategic directions, the National
Prevention Strategy has identifi ed seven priority areas
that require immediate focus to improve the health
of the American people, particularly those who are
disproportionately affected by disease and injury:1

• Tobacco-free living

• Preventing drug abuse and excessive alcohol use

• Healthy eating

• Active living

• Injury- and violence-free living

• Reproductive and sexual health

• Mental and emotional well-being

In focusing on these priorities, the National Prevention
Strategy seeks to address the underlying causes—e.g.,
tobacco use, misuse of alcohol and other substances,
obesity, and community stressors such as discrimination
and violence—of chronic conditions (e.g., heart disease
and diabetes) and unintentional injuries.

A NATION’S EFFORT

While the core of this prevention movement will come
from a trained and knowledgeable prevention work-
force that is attuned to community and population
conditions and disparities, and equipped to serve the
needs of an aging nation, many other stakeholders
will need to help ensure the success of this National
Prevention Strategy.

Public and private sectors alike can improve the
coordination and collaboration of prevention-driven
services and programs that address key health needs.
For instance, businesses can support workplace well-
ness, health providers can enhance health-care quality
and delivery, and educators can incorporate prevention
competencies into relevant curricula.

On the individual level, we can all make changes
to incorporate prevention activities into our day-to-day
lifestyle. Using alternative transportation such as bik-
ing or walking, purchasing energy-effi cient household
products and recycling, and better managing personal
health through technology such as text reminders
and phone applications are all simple ways to make
informed, responsible, and healthy choices.

This strategy for disease prevention must become
America’s plan. All of us, together, must take ownership
of our health, and we must collaborate and cooperate
to achieve a healthy and fi t America.

Regina M. Benjamin, MD, MBA
VADM, U.S. Public Health Service

Surgeon General

The author thanks Arndreya D. Price, Neha A. Deshpande, and
Jo Ellen Russ for their contributions to this article.

776  Surgeon General’s Perspectives

Public Health Reports / November–December 2011 / Volume 126

REFERENCES
1. National Prevention Council (US). National Prevention Strategy:

America’s plan for better health and wellness. Washington: Depart-
ment of Health and Human Services, Office of the Surgeon General
(US); 2011. Also available from: URL: http://www.healthcare.gov/
center/councils/nphpphc/strategy/report [cited 2011 Jul 14].

2. Patient Protection and Affordable Care Act. Pub. L. No. 111-148
(2010).

3. Centers for Medicare and Medicaid Services (US), Office of the
Actuary, National Health Statistics Group. National health expen-
ditures 2009 highlights [cited 2011 Aug 22]. Available from: URL:
http://www.cms.gov/NationalHealthExpendData/downloads/
highlights

4. Maciosek MV, Coffield AB, Flottemesch TJ, Edwards NM, Solberg
LI. Greater use of preventive services in U.S. health care could save
lives at little or no cost. Health Aff (Millwood) 2010;29:1656-60.

/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK2

4/?report=printable

/16

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Institute of Medicine (US); Stoto MA, Behrens R, Rosemont C, editors. Healthy People 2000: Citizens Chart the Course.
Washington (DC): National Academies Press (US); 1990.

8. Health Promotion and Disease Prevention in the Health Care System

Because of the important role it plays in detecting, treating, and preventing diseases and injuries, the health care
system is critical to implementation of the Year 2000 Health Objectives. However, according to the nearly 100 people
who addressed this in their testimony, there are severe problems with ace, s to preventive services and an unfulfilled
potential role for health professionals in preventing disease and promoting the health of the U.S. population. Some
witnesses digressed from the narrow focus of the objectives to the broader problems of access to health and medical
care in general.

Milton Roemer of the University of California, Los Angeles gets directly to the essence of the problem.

Many, if not all, of the priorities of positive health activity on the national agenda can be substantially influenced
by access to professional health care. To cite just a few examples, the detection of and intervention against
hypertension and cancer, immunization against preventable infectious diseases, control of obesity, or the
preventive management of depression require the services of physicians or other skilled health personnel. Yet
some 35 to 40 million Americans do not have economic access to doctors through voluntary health insurance,
Medicare, or Medicaid. A larger number lack economic and physical access to primary health care, although they
may have insurance for hospitalization.

Access to professional care may have very broad impacts on health promotion. Education and advice from a
doctor can affect lifestyle— smoking, alcohol use, contraception, exercise, diet, stress—more effectively than the
most skillful messages of mass media. We have long ago learned that almost any person is more receptive to
advice on changed behavior, if this advice is offered by a health care provider who is giving treatment for a
specific symptom. Prevention is more effective if it is integrated with the delivery of medical care. (#277)

The Medical Care Section of the American Public Health Association (APHA) agrees with this assessment: “The
goals for the year 2000 will not be attained unless all Americans have access to high quality health care.” This is true
across the broad range of national objectives—whether the health problem being addressed is heart disease and stroke
through the control of hypertension; cancer through screening and early detection; or infant mortality through the
provision of prenatal care. Consequently, the APHA Medical Care Section suggests that the Public Health Service add
an additional goal for the year 2000 that “all Americans will be assured adequate access to quality health care.” (#755)

Senator Chet Brooks, Dean of the Texas State Senate, sums up the political view.

From my perspective as a state legislator, our success in achieving the national health objectives for the year
2000 will depend to a large extent on improving access to programs and services we already have in place and on
increasing the availability of information regarding disease prevention. For example, perhaps the greatest success
in a preventive health effort with significant effect on the nation’s health status was the discovery and uniform
administration of vaccines. The diseases we faced were so frightening and widespread, we took immediate and
definitive action. Every child had access to immunizations to prevent these diseases. The results: almost a virtual
elimination of debilitating and life-threatening diseases such as polio, diphtheria, and smallpox. The undisputed
key to this success was access. As we begin to formulate our goals for the year 2000 and beyond, we must
determine why certain objectives for 1990 were not achieved. I suggest we look closely at our policies and
programs to see whether they are accessible to the persons for whom they are intended. (#234)

Clearly, the Year 2000 Health Objectives can not be achieved without full participation of health professionals and the
organizations in which they work. This chapter summarizes testimony on two interrelated issues: the great potential

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 2/16

value of providing health promotion and disease prevention services through the health care system, and the serious
problems faced by many in gaining access to that system. Access to health care in general, and to preventive services
in particular, is primarily a problem of specific populations, especially the poor and minorities, so the problems
confronting these groups are discussed first. Testimony on potential contributions of the various health professionals
and the settings in which they work is next, along with suggestions on strengthening their roles as providers of health
education and preventive services. The next section discusses problems and solutions in the financing of health
promotion and disease prevention programs, including changes in existing federal funding programs and in the
insurance system. The last section discusses four issues in the implementation of health promotion and disease
prevention in health care settings: coordination of services, training health professionals, underserved areas, and the
need for minority practitioners.

Problems with Access to Health Care
Access to health care is very unevenly distributed in the United States. As discussed in Chapter 6, the poor, the
homeless, and many racial and ethnic minorities have severe problems gaining access to preventive services and even
basic health care. People with disabilities have access problems of a different sort (Chapter 7). To set the stage for the
interventions and changes called for in the latter part of this chapter, testimony on the problems faced by the poor,
minorities, and the disabled is presented first.

Poor and Homeless

According to many who testified, today’s poor and homeless represent special populations that both are large enough
and include enough of America’s most vulnerable citizens to warrant particular concern in the Year 2000 Health
Objectives. The difficulties these people face in maintaining their health and attaining access to the medical system go
beyond the obvious economic ones and include the horrendous physical and social conditions in which they must live.
For these disadvantaged, issues of preventing disease and promoting good health often are secondary to the problems
associated with everyday survival.

According to Mary Sapp of the San Antonio Health Care for the Homeless Coalition, the number of homeless people
is growing, and their ranks include families and people at the highest risk for health problems. Their needs are
exacerbated by special health risks inherent in their lifestyles: exposure to the elements, poor nutrition, inadequate
sanitation, lack of a place to recuperate from minor illnesses, vulnerability to violent acts, psychological stress, and
alcohol or substance abuse. This group needs access to every preventive measure available to the general population
and would benefit more from them than the average person. (#507)

According to Harold Shoults, the Salvation Army works with the most “down-and-out,” the working poor and those
who “fall through the cracks” in public welfare programs. Their experience, revealed in reports from Salvation Army
officers around the country, is enlightening. The “barriers to health care for our clients might be summed up in three
words: access, understanding, and conditions,” says Shoults. The Memphis and Dallas offices discuss access:

One of our biggest problems is lack of medical insurance among the unemployed, temporarily employed, and
those working for temporary labor providers. These people would have to apply for Medicaid if they got into a
crisis. There is nothing for minor problems. They must present themselves to an emergency room and take what
they can get there.

Preventive health service is only able to take life-threatening cases. As an example, this past winter our local
public hospital had to refuse inpatient care unless an individual had pneumonia in both lungs.

Others deal with understanding:

Barriers to access include a fragmented system and not understanding the treatment or instructions.

https://www.ncbi.nlm.nih.gov/books/n/nap1627/ddd00092/

https://www.ncbi.nlm.nih.gov/books/n/nap1627/ddd00114/

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 3/16

There is no continuity of service, they probably see a different physician every time, never develop a relationship
with a doctor or nurse and get little in the way of health education.

Finally, there is the question of condition:

The socioeconomic condition of clients creates, perpetuates, and exacerbates major health problems.

Particularly in the case of a homeless family, there are multiple needs that must be addressed. Stress related
problems of the families we see today may be due to (1) unemployment or underemployment, (2) inadequate
public assistance programs, (3) substandard housing, (4) exorbitant utility costs, (5) poor health care, (6) lack of
transportation, (7) inadequate support systems, and (8) lack of experience and education about good parenting.

Many children are being raised in a state of sheer survival. As a result, they are faced with some serious malaise:
malnutrition, long-term sleep deprivation, depression, developmental lags, educational deprivation, dental and
other chronic health problems; these can only bring perpetuation of the homeless syndrome. (#579)

Stephen Joseph, New York City Commissioner of Health, writes that “the health problems of New York inevitably
reflect the conditions of poverty in which too many families live. Confronting these environments means confronting
the failures of our formal and informal education systems, chronic unemployability, the too-frequent drift into a
lifetime of crime and drugs, the collapse of the nuclear family, and a worsening housing crisis.” (#437)

As an example of what needs to be done to prevent disease and promote the health of the homeless, consider the
situation of New York City. In 1987 the city provided room for over 27,000 homeless people, including more than
5,000 families, in shelters, temporary apartments, and hotels. For homeless families living in hotels the infant
mortality rate is twice the city average. According to Joseph, the Homeless Health Initiative is being expanded to
provide essential health screening and referral services to homeless individuals and families. New York City has 2

public health nurses working in 37 hotels that house approximately 90 percent of the city’s homeless; these nurses
refer residents to medical or social service agencies, and teach them about proper nutrition and prenatal or pediatric
care. To reduce the infant mortality rate and reach women who traditionally have not sought prenatal or pediatric care,
the Department of Health is implementing a plan in which 30 public health nurses and 35 public health advisers will
work with community groups to refer pregnant women and infants to local providers of medical and social services.
(#437)

Racial and Ethnic Minorities

The problems that minorities face in attaining access to health care are severe and complex (see Chapter 6). They are
caused not only by socioeconomic factors, but also by different cultural attitudes and beliefs about health and
medicine.

According to Daniel Blumenthal of the Morehouse School of Medicine, millions of Americans—especially Blacks—
lack adequate access to quality health services. The reasons for this include (1) lack of insurance (even “adequate”
insurance does not cover preventive services); (2) living in rural or inner-city areas that are poorly served by
physicians; and (3) the shortage of Black physicians. Although 12 percent of the U.S. population is Black, fewer than
3 percent of U.S. physicians are Black. (#255) The APHA Medical Care Section reports that a substantial portion of
the disparities in Black and minority health “may be attributed to differences in access to health care, both preventive
and curative between the two population groups.” (#755)

Osman Ahmed of Meharry Medical College writes that “Blacks are known to delay seeking health care within the
traditional health care system, preferring to rely upon family, friends, and even spiritualists and healers, during
periods of economic and emotional stress.” Unique value systems, together with medical care expenses, may prevent
Blacks from utilizing the health care system. Since different “loci of control are operating in Blacks, different health
promotion strategies should be used to reach them. Eliminating barriers to care seeking and behavior change will

https://www.ncbi.nlm.nih.gov/books/n/nap1627/ddd00092/

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 4/16

require new, culturally sensitive approaches to information dissemination, health planning and resources management,
and may even require the institutionalization of new health policies.” (#269)

As an example of what should be done to improve access to preventive services, Ahmed cites Meharry Medical
College’s “Community Coalition on Minority Health.” This coalition, led by Meharry, consists of local governmental,
professional, voluntary, community, and religious organizations and tries to “bring together the knowledge, expertise,
and resources to provide solutions.” The coalition’s objective is to decrease diet-and nutrition-related cancer and
cardiovascular disease risk factors and hypertension in the Black community. (#269)

Other minority groups have similar difficulties with access to health care. The National Coalition of Hispanic Health
and Human Services Organizations says that Hispanics are more than twice as likely to be without either public or
private health insurance than non-Hispanic Whites or Blacks. Hispanic mothers are more likely than non-Hispanic
Whites or Blacks to begin prenatal care in the third trimester or not at all; Hispanics are less likely to have a regular
source of health care; 30 percent of Hispanics lack this, compared to 20 percent of Blacks and 16 percent of Whites.
Hispanics are also less likely to receive public health messages. (#193)

”Hispanics, in particular Puerto Ricans, continue to have poorer health status, and excess morbidity and mortality
compared to the majority population,” according to Eric Munoz of the Long Island Jewish Medical Center in New
York. Munoz suggests that this disparity is due in part to less access to health care and preventive services in
particular. For example, fewer Puerto Rican women undergo breast exams and mammography, or Pap smears and
gynecological exams. Puerto Ricans also have inadequate detection and treatment of hypertension. (#431)

People with Disabilities

“Adults with chronic disabilities,” write Alfred Tallia, Debbie Spitalnik, and Robert Like of the University of
Medicine and Dentistry of New Jersey, “either those who have developmental disabilities or chronic mental illness,
individually and as a collective group, have a history of inadequate health care and a lack of access to quality medical
services, including preventive health services.” They say that deinstitutionalization of the chronically disabled from
large, congregate institutions assumes the availability and accessibility of health services in the community, but
services are not being delivered adequately to this population. Chronic disabilities are accompanied by complex needs
for an array of preventive health, social, educational, vocational, and other supportive services; health services for the
chronically disabled, however, tend to be targeted to specific problems, and general preventive health needs tend to go
unattended or are poorly “coordinated.” Furthermore, Tallia, Spitalnik, and Like say that the nature of chronic
disabilities may create barriers to participation in a primary care setting with preventive health measures; problems
include economic disadvantages due to difficulty in sustaining employment, physical access issues, difficulties in
obtaining adequate health histories, and negative prejudicial attitudes from health care workers. (#209)

Health Promotion and Disease Prevention in the Health Care System
Implementation of the national objectives for health promotion and disease prevention in medical and health care
settings depends on the participation of physicians, other health professionals, and the organizations in which they
work. Those who testified had many recommendations about how to make better use of health professionals in
disease prevention and health promotion programs. The suggestions generally included changes in training programs,
compensation and reimbursement systems, and recruitment.

Physicians

Many who testified felt that physicians can play a much larger role in health promotion and disease prevention than
they currently do. The evidence of their effectiveness is strong, according to witnesses. Testimony, therefore, called
for enhanced training opportunities and changes in insurance payment policies to allow physicians to become more
active.

According to the American Academy of Family Physicians:

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 5/16

1.
2.

Physicians in primary care can have a positive effect on health behaviors in very cost effective ways. For
example, the simple offering by a general practitioner of advice to stop smoking to patients who come to the
doctor for some reason other than smoking, results in a 5 percent quit rate at the end of one year.

To take advantage of the opportunities presented by physicians, the American Academy of Family Physicians makes
four recommendations:

Insurance should cover scientifically supported disease prevention and health promotion interventions in the
doctor’s office and other outpatient settings.

Office-based systems for health risk assessment and longitudinal tracking for both screening examinations and
health behaviors should be developed and adopted.

Disease prevention and health promotion curricula must be developed in medical schools and residencies and put
on a par with other medical education topics.

Research to determine appropriate assessments and interventions, as well as their frequencies and effectiveness,
needs to be funded. (#072)

Donald Logsdon reports on a series of studies funded by the insurance industry under the banner of Project INSURE,
which he directs. These studies have shown that (1) physicians are interested in clinical prevention; they will
effectively provide preventive services, including patient education in their practices, if they receive practice-based
training and if the financial barriers to preventive care are removed; (2) such interventions can be effective in
changing risk behaviors; and (3) their costs can be controlled. Therefore, Logsdon suggests that the Year 2000 Health
Objectives include clinical preventive services provided by physicians. He also sees a need for continuing medical
education programs and incentives for physicians to become more effective at preventive health services and health
promotion. (#463)

According to Michael Eriksen, Director of Behavioral Research at the University of Texas M.D. Anderson Hospital:

The potential impact of health professionals, especially physicians, in furthering our disease prevention and
health promotion goals is vast. However, they were rarely included in the 1990 Objectives. The Year 2000 Health
Objectives should stipulate specific health promotion objectives for each patient encounter, consistent with the
guidelines being developed by the U.S. Preventive Services Task Force.

Eriksen offers this example: “Smoking patients should be counseled by their physician to stop smoking during 75
percent of routine office visits.” (#309)

Other Health Professionals

Witnesses discussed the roles that a wide range of health professionals can play in implementing health promotion and
disease prevention objectives. The professional groups include pharmacists, nurses, midwives, public health
professionals, and allied health professionals. In many cases, these groups are oriented to disease prevention and
health promotion and are reportedly effective at it, so that minimum changes in training and funding patterns can have
important effects.

The American Pharmaceutical Association (APhA), for instance, urges recognition of the important role pharmacists
play in health promotion and disease prevention. Their testimony addresses the following matters:

The pharmacists’ role as health educators and medication counselors: Pharmacists provide education and
information to patients regarding the control of high blood pressure, family planning, sexually transmitted
diseases, poison prevention, smoking and health, nutrition and weight control, and the control of stress.

The role of pharmacists in promoting rational prescription drug therapy: The 1990 Objectives focus on adverse

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 6/16

drug reactions, but counseling should be much broader and should emphasize the correct use of all medication to
avoid complications. Pharmacists also play a role in assuring the quality of drug therapies on the regulatory level.

The need to pay all health care providers for counseling that fosters health promotion and disease prevention:
Unless there are economic incentives for pharmacists (like other care providers) to provide health education, the
APhA feels that their maximum effort will not be brought to bear on the problem. (#564)

Many witnesses testified about the contributions that nurses already make to health promotion and disease prevention
efforts and stressed the role that they can play in implementing the Year 2000 Health Objectives. Patty Hawken, Dean
of the School of Nursing at the University of Texas Health Science Center at San Antonio, says that because nurses
have traditionally been the constant care giver in the community and in the home, they are well prepared to assist with
health promotion and disease prevention. (#501)

Sharon Grigsby, President of the Visiting Nurse Foundation in Los Angeles, reports that the initial efforts of visiting
nurses a century ago concentrated on the prevention of disease through education on the rudiments of good hygiene
and helped reduce maternal and infant mortality, as well as the spread of infectious diseases. Visiting nurses have kept
up with technological advances in medicine, she reports, but their historical commitment to community-based care
has not lessened. Grigsby still sees a role for visiting nurses in preventing illness and disability through education.
Their efforts would be most effective for vulnerable populations such as the elderly, pregnant women, and infants.
(#074)

Sapp reports on her coalition’s goal of promoting the utilization of nurse practitioners to the fullest extent of their
training and skills in all programs targeting the homeless. (#507)

However, according to Hawken the number of new nurses is declining. The current shortage of professional nurses
has a critical impact on health care in the country. (#501) As the population ages, the shortage of nurses to care for the
elderly will become particularly acute, says Anita Beckerman of the College of New Rochelle in New York. She
suggests that federal and state governments develop programs to facilitate the entrance of prospective nursing students
into the profession, perhaps through full tuition payments with service payback provisions, scholarships, grants, or
capitation payments to nursing schools. (#436) Hawken suggests that encouraging groups in health care to highlight
the importance of nurses in meeting national health care objectives would help ease the shortage. (#501)

Mary Mundinger, Dean of the Columbia University School of Nursing, says that the major reasons for the
unavailability of nurses are their low status within the medical system, low salaries, and shift work. To prevent a
nursing shortage and restore nursing to a viable and useful profession, funding changes must be initiated at the federal
level. These would include transferring federal resources for training physicians (who are in oversupply) to nurse
training programs; using National Health Service Corps funds to bring nurses into underserved areas; finding ways to
bring nonworking nurses back into the work force; and changing credentialing practices to recognize and reward
nurses at the highest levels of education and practice. (#589)

A number of testifiers discussed the preventive services that midwives can provide, especially high-quality prenatal
care and obstetrical services. Representatives of the American College of Nurse-Midwives believe that nurse
midwives can deliver quality services at low cost and would be particularly effective for low-income populations.
Thus, they urge the removal of barriers to practice, such as noncompetitive salaries, restraint of trade by physicians,
and the malpractice crisis. (#268; #292; #690)

Allan Rosenfield, Dean of the Columbia University School of Public Health, reports on a shortage of well-trained
public health professionals. “Only a small percentage of the people working in city, county, and state departments of
health and in other parts of the public health infrastructure have been formally trained in public health.” (#633)
Bernard Goldstein of the University of Medicine and Dentistry of New Jersey notes that one impediment to reaching
the important goal of a sufficient number of trained public health professionals is the ‘poor geographical distribution
and relative lack of outreach of our existing accredited graduate training facilities in public health.” He suggests the
development of easily accessible, rigorous graduate education programs. (#625)

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 7/16

According to Keith Blayney, Dean of the School of Health-Related Professions at the University of Alabama at
Birmingham, allied health professionals engage in millions of patient interactions each week and thus represent a
tremendous potential for disease prevention and health promotion efforts. (#258) According to John Bruhn, Dean of
the School of Allied Health Sciences at the University of Texas Medical Branch at Galveston, physician’s assistants,
physical and occupational therapists, dental hygienists, and other allied health professionals are in positions to provide
one-on-one patient education regarding lifestyles and habits that can prevent illness. ‘Teachable moments’ are not
limited to the physician-patient dyad.” (#235)

To make them a potent force for implementing the Year 2000 Health Objectives, Blayney feels that every allied health
professional in the country should be cross-trained to provide patient and public education and services in the area of
health promotion and disease prevention. (#258)

Lisa Fleming, President of the Alabama Dental Hygienists’ Association, wants to “emphasize the role that dental
auxiliaries can play in the Year 2000 Health Objectives. As education and prevention professionals, dental hygienists
can have a significant role in meeting these objectives. With proper education, hygienists can actively participate in
educational and preventive programs to reduce dental caries, apply preventive procedures to periodontal patients, and
educate the public about the prevention of accidents and oral cancer.” (#262)

Health Care Settings and Organizations

Health professionals, especially nonphysicians, generally work in organizations, and the policies and structure of
these organizations have an important effect on access to preventive services. Along these lines, witnesses discussed
health promotion and disease prevention activities in hospitals, community health centers, health maintenance
organizations, group practices, and long-term care facilities. The general feeling is that these facilities are interested in
providing more preventive services and health promotion programs, but funding patterns inhibit their ability to do so.

For instance, the American Hospital Association (AHA) reports:

As chronic disease has replaced acute infectious disease as the major cause of morbidity and mortality, as the
locus of care has shifted to the outpatient setting, and as the research base for broadly defined health
promotion/disease prevention services has solidified, hospitals have expanded the range of services they offer.
During the 1980s, hospitals across the United States became major providers of health promotion services and
active partners with other local organizations in addressing community health problems. Historically, patient
education has been the primary focus of hospital health promotion services as a complement to acute medical
services. A 1979 policy statement recognized hospitals’ responsibility ”to take a leadership role in helping to
insure the good health of their communities.”

According to the AHA, hospitals now have a wide variety of health promotion activities such as cardiac rehabilitation,
care giver education, wellness programming, and occupational health services. Increasingly, hospitals are recognizing
the limits of their acute inpatient and outpatient services in meeting the needs of patients with chronic conditions, and
are establishing linkages with self-help/mutual aid groups. (#576)

However, AHA reports that changes in hospital are—more outpatient services, shorter inpatient stays, and more care
of chronic than acute illness—mean hat hospitals have less opportunity to offer prevention or health promotion
education to patients. Also, work force shortages, especially in nursing, and inadequate resources or reimbursement
may prevent health care professionals from offering the range of educational efforts called for in the 1990 Objectives,
such as counseling in safety belt use, nutrition education, physical fitness regimens, and stress-coping kills. Given the
lack of progress toward some key objectives such as infant mortality among minorities and the lack of access to
private health insurance, “it s perhaps time to elevate financing for preventive services to the status of an objective if
risk reduction and health status objectives are to be achieved for all populations.” (#576)

The National Association of Community Health Centers reports that these centers present a good opportunity for
implementing the objectives in poor and minority communities. Clients of these centers are largely poor, minorities,

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 8/16

1.
2.
3.

women, and children, and he illnesses reported are preventable if diagnosed early. For example, among the top 10
diagnoses reported at community health centers around the country were hypertension, upper respiratory infections,
pregnancy, and diabetes. (#635)

Health maintenance organizations (HMOs) have “several distinct advantages” that enable them to efficiently deliver
preventive and health promotion services, according to David Sobel of the Permanente Medical Group in Oakland,
California. (#780)

Their financial incentives are such that the organization benefits from the implementation of efficient, cost-
effective preventive services.

Large HMOs and group practice models can achieve economies of scale and efficiency in delivering these
services through such mechanisms as health education centers, group classes, and telephone tapes or advice
nurses.

Centralized medical records and patient profiles provide outstanding opportunities for evaluation of health
promotion initiatives.

But, Sobel cautions that even the physicians who work in HMOs may not be skilled or comfortable in providing
health education and counseling. Thus, to be successful, HMOs must

define and specify a basic benefit package of prenatal, immunization, and age-related periodic health evaluation
services to assure consistency;

use nonphysician health professionals, such as nurses, nurse practitioners, dietitians, and pharmacists, to
provide health education and prevention services; and

include self-care education to help people understand when to seek medical and preventive care, and when or
how to use self-treatment safely. (#780)

Financing Health Promotion and Disease Prevention Programs in the Health Care
System
Many testifiers identified problems with financing health promotion and disease prevention programs as an obstacle
to implementing the national objectives. Robert Black of Monterey, California, states, “Health promotion and disease
prevention have been the stepchild of the American health care system and there is no incentive or reward for keeping
people healthy. The financial structure needs complete revision and arrangement differently than it is presently
conceived.” (#796)

Some saw the problem in the context of a larger concern about overall health expenditures in the United States, and
proposed changes in Medicare and Medicaid or in already existing federal grant programs. Most of those who
testified on these issues, however, proposed major changes in the financing of health care, including a national health
insurance policy.

According to the APHA Medical Care Section, “Access to health care for those most in need of care has actually been
reduced since the Surgeon General’s goals were first published. This is because of cutbacks in the several programs
that have been established to increase access for the underprivileged and because of increasing corporatization of
health care.” (#755)

William Hagens, a senior research analyst for the Washington State Legislature, said that the number one health
problem facing Olympia and all other state capitals is the question of financing. At a time when access to health care
for low-income people is declining and costs are rising, there is the feeling that all the money spent is not contributing
to happier, healthier people. Therefore, it is important that no new program be added, but that those already on the
books be implemented more aggressively. Hagens feels that people must to be taught to be more responsible for their
own health, and that prevention activities by businesses should be expanded. (#694)

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 9/16

1.
2.

Federal Funding Programs

Many witnesses suggested that already existing federal funding programs could do more to finance health promotion
and disease prevention, and to improve the access to health care generally. In particular, testifiers addressed the
possibilities of changing Medicare reimbursement policies for preventive services; increasing the coverage of
Medicaid to include more poor people and more services, especially maternal health services; and better coordinating
block and categorical grant programs with the national objectives.

Medicare

A number of speakers suggested that Medicare should cover more health promotion and disease prevention services.
Paul Hunter of the American Medical Student Association/Foundation, for instance, says that Medicare should
reimburse at least 50 percent of the costs of the following preventive services: “health screenings, health-risk
appraisals, immunizations, nutrition counseling, stress reduction, injury prevention, alcohol and drug abuse
counseling, smoking cessation, and medication use.” (#612)

Medicaid

A number of witnesses suggested changes in the Medicaid system to improve access to preventive services for the
poor. These proposals ranged from changes for specific services, especially prenatal care, to an overall expansion of
the number of people insured and the services covered.

Milton Arnold of the American Academy of Pediatrics, for example, says that adequate prenatal care is the single
most important factor in reducing infant morbidity and mortality, and he calls for more complete Medicaid
reimbursement for it. With better prenatal care, he says, many of the 40,000 deaths that occur annually to babies in
their first year of life can be prevented. However, he cites a General Accounting Office (GAO) report that found
insufficient prenatal care for women of all races, ages, and economic groups, but especially for low-income
minorities. According to the GAO report, 81 percent of privately insured women surveyed received adequate
prenatal care compared to 36 percent of those who qualify for Medicaid and 32 percent of uninsured women. The
American Academy of Pediatrics would like to see prenatal care made available to all pregnant women early in
pregnancy; Medicaid can help meet this goal by providing a regularly updated list of approved and reimbursable
services and procedures and by improving reimbursement and paying claims promptly. (#678)

Other witnesses complained that Medicaid is not realizing its potential. The APHA Medical Care Section says that
“the Medicaid program still does nothing to improve access to health care for the majority of low-income Americans.
The program actually covers less than half of all persons living in poverty; even those who are technically covered are
often unable to find a physician who will accept Medicaid patients.” (#755)

Judith Glazner of the Denver Department of Health and Hospitals says that federal and state cutbacks in the early
1980s resulted in some of the poor becoming ineligible for Medicaid; she recommends that all states be required to
use the same Medicaid eligibility standards. (#377) The Health Policy Agenda for the American People, a
collaborative effort of nearly 200 health, health-related, business, government, and consumer groups to promote
health sector change, recommends that

Medicaid be revised to establish national standards that result in uniform eligibility, benefits, and adequate
payment mechanisms for services across jurisdictions; and

Medicaid eligibility standards be expanded to include the medically indigent and payments be related to their
ability to pay. (#583)

Block Grants

A number of state and local health officers suggest that federal block grant funds should be an important tool in
financing prevention activities called for in the objectives. Mark Richards, Secretary of Health for the Commonwealth

5
6

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 10/16

of Pennsylvania, says that all recipients of block and categorical grant funds should demonstrate clearly how they will
help meet the appropriate objectives. (#387)

Thomas Halpin and Karen Evans of the Ohio Department of Health say that federal preventive health and health
services block grants were crucial to the success of the objectives in Ohio and should continue with the Year 2000
Health Objectives. (#129) Diana Bonta suggests using Title X family planning grants to implement family planning
objectives. (#024) Maternal and child health block grants and the Special Supplemental Food Program for Women,
Infants, and Children (WIC) can help improve access to early prenatal care and other services for pregnant women,
infants, and children. (#044)

Health Insurance

Many witnesses called for some form of national health insurance system that would pay for preventive services,
saying that without major changes in the current system, from which many are disenfranchised and which provides
little preventive care for those who are covered, it will be difficult to make progress in the Year 2000 Health
Objectives. Although some witnesses felt that a national health system or at least a national health insurance system is
the only answer, others proposed changes in the existing private insurance system.

According to Rosenfield:

There should be a much greater emphasis on disease prevention/health promotion as a number one national
health priority with adequate funding at federal, state, and local levels. Health care financing in this country
remains a tragic problem for an unacceptably large percentage of the population. As the only Western nation
without some form of national health insurance or health service, a sizable percentage of our population is either
unserved or under-served. The problem is greatest for the uninsured working poor, the homeless, and the poor
generally. A national health insurance program remains an urgent, if misunderstood, national priority. (#633)

Derrick Jelliffe of the University of California, Los Angeles goes further:

Until the country has some form of national health insurance coverage or other national health system enabling
preventive and curative health services to be available to all economic levels in the country, the rest of the
deliberations on the objectives border on the farcical. Unless one is careful, a potpourri of fragmented programs
of limited extent and coverage may emerge in the usual sort of way. There is no way that the country can move
from being a second-class nation as far as health services are concerned until a national health coverage has been
achieved. (#271)

“Millions of people are going without needed medical care, both therapeutic and preventive, because of financial
barriers,” writes Marjorie Wilson of Olympia, Washington.

It is time for us to stop Band-Aiding a sick medical system. It is time now to start implementing a comprehensive
national health plan. In addition to preventing serious conditions caused by neglect of early diagnosis and
treatment, the national health plan should provide other preventive services such as: (1) primary prevention of
mental conditions, early screening, and tertiary prevention for symptom control; (2) age-related health screening
for all citizens with emphasis on the very young and the very old; (3) mammograms, Pap smears, and cholesterol
and diabetic screening, as risk related; (4) health education in the community, the workplace, and the schools for
healthy living; and (5) environmental and personal changes for injury prevention. (#346)

Members of the Society of Teachers of Family Medicine at a hearing on the national objectives suggested the
following objective: “The number of Americans not covered by health insurance, currently 37 million, should be
reduced by at least half—and preferably more; alternatively, more than 95 percent of Americans should have health

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 11/16

insurance that covers 90 percent of hospital and 80 percent of outpatient costs, including primary and secondary
prevention, as recommended by the U.S. Preventive Services Task Force.” (#143)

According to Glazner, insurance coverage is a key factor in gaining access to preventive health care, and lack of
insurance particularly affects the young, the old, and the poor.

Without health insurance, low-income families must rely on a frequently fragmented and difficult-to-use public
system of health care. Regular preventive care, including prenatal care, immunization, and well-child care, is
sometimes difficult to get, and its availability may not be well understood. Only when families do not have to
make a choice between food on the table and a visit to the doctor or clinic will adequate care for those most at
risk be provided.

Because health insurance in the United States is largely employment based, ‘the practical focus of increasing
insurance coverage at this time must primarily be on employers that don’t provide health insurance and on the insurers
themselves.” (#377)

Thus, Glazner suggests adding a new category to the objectives, “Improvement of Economic Access to Health Care.”
Its aim would be to reduce the number of Americans not covered by public or private insurance programs, including
Medicare and Medicaid, to less than 7.5 percent (a reduction of 50 percent), and she suggests a number of specific
changes in legislation and regulation to achieve this goal. (#377)

The Health Policy Agenda for the American People also is addressing the current insurance system, especially its
coverage. The Health Policy Agenda has developed a “basic benefits package” to serve as the foundation for private
health insurance plans and for public programs that finance health care. The package includes the following
prevention and health promotion activities: maternal and child care, dental examination and teeth cleaning,
immunizations, and periodic medical examinations. (#583)

Implementation within the Health Care System
Witnesses also identified four interrelated implementation issues especially relevant to assuring access to preventive
services: coordination of services, training of health professionals, underserved areas, and the lack of minority
practitioners.

Coordination of Services

Helen Farabee, representing the March of Dimes Birth Defects Foundation, suggests as an objective that “by 2000, all
pregnant women and infants should have access to and at least 95 percent shall receive quality care and case
management from a coordinated and comprehensive system of public and private health-care providers.” According to
Farabee, recent efforts in Texas have (1) expanded services, to make prenatal care available in every county; (2)
instituted a comprehensive managed care program for pregnant women with high-risk conditions; and (3) tried to
better coordinate services that should be targeted toward the poor, such as the WIC program, family planning
programs, infant care programs, and early childhood intervention programs. (#289)

George Silver of Yale University writes of the need “to focus on the inadequacies, inefficiencies, uncontrollable
inflation of cost, and evidence of poor quality plaguing the U.S. medical care system” in order to meet the Year 2000
Health Objectives. However, in implementing programs, he emphasizes the need to start with a state, rather than a
full-scale national, program because the “national tradition in connection with social policy has always been to start
with a state model.” (#510)

Training of Health Professionals

Many testifiers identified training issues as key in realizing the potential of health professionals, especially physicians,
in implementing the objectives. One issue is the necessity for more specialists in preventive medicine. Other

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 12/16

witnesses called for better integration of the knowledge and skills needed for health promotion and disease prevention
in the basic education of all health professionals.

William Scheckler of the University of Wisconsin, for instance, notes a decline in choice of primary care careers by
medical students, despite an increasing need for such specialists. He suggests that training grants in these areas be
increased, residency programs in primary care be promoted, and medical schools be encouraged to emphasize primary
care. (#194)

The American Occupational Medicine Association (AOMA) makes a similar suggestion about training more
specialists in occupational medicine. (#071) The Society of Teachers of Family Medicine (STFM) calls for a 25
percent increase in the number of residency graduates in family medicine and general preventive medicine who plan
to emphasize clinical preventive medicine in their practice, as well as development of a clinical preventive medicine
fellowship to meet this objective. (#118)

The Association of Preventive Medicine Residents agrees with this approach and recommends creation of a specific
objective dealing with the training of health professionals in disease prevention and health promotion, with emphasis
on training physicians in preventive medicine. Although shortages of preventive medicine specialists are predicted,
the federal government has cut funding for preventive medicine residencies in recent years; thus, the association
recommends that this funding be restored at least to the earlier level. (#560)

The other approach suggested in testimony is incorporation of health promotion and disease prevention material into
the general medical curriculum. Sue Lurie of the Texas College of Osteopathic Medicine points to the importance of
prevention in the training of physicians and physician’s assistants. She feels that integration of specific topics into the
existing curriculum is the most effective approach and that increasing the clinical training of physicians in outpatient
settings would increase their focus on preventive health care. (#136) The AOMA recommends that broad-based
orientation courses in occupational medicine be established in the curriculum of all schools of medicine and
osteopathy. (#071) The STFM calls for a 25 percent increase in the curriculum time spent in medical schools and
primary care residency programs on health promotion and disease prevention. (#118) The National Board of Medical
Examiners sets certification standards for practicing physicians and develops tests to evaluate current medical
education and practice. It reports that the major priority areas of the 1990 Objectives are covered in the examination
and that the “educational imperative” of the Year 2000 Health Objectives will be reflected in new examinations. Thus,
setting appropriate objectives will have some impact on medical practice. (#221)

The National Council for the Education of Health Professionals in Health Promotion (NCEHPHP) suggests that

students of medicine, nursing, dentistry, and the allied health professions be adequately prepared to intervene
effectively with those patients at risk and to organize health promotion/disease prevention services. Therefore,
those responsible for the education, training, and certification of health professionals must develop goals and
objectives to assure that health promotion and disease prevention becomes an integral part of the repertoire of
skills of those charged with the responsibility of providing health care.

The NCEHPHP also addresses specific recommendations for the health professions curriculum, academic institutions
and faculty, accreditation, certification and licensure, and continuing education. (#169)

Underserved Areas

According to some witnesses, the problem is not a shortage of health professionals but rather their distribution. Many
inner cities and rural areas have few physicians or other health professionals; furthermore, according to witnesses, the
primary federal program for addressing this problem, the National Health Service Corps, is insufficient. The solutions
proposed involve the medical education system, reimbursement, and substituting one kind of professional for another.

According to the APHA’s Medical Care Section, “Millions of Americans who live in rural or inner-city areas lack
access by reason of living in these areas. The National Health Service Corps, which offered one approach to this

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 13/16

1.
2.
3.

problem, has been all but phased out over the last several years.” (#755)

Donna Denno, representing the American Medical Student Association, says that the health objectives cannot be
attained without a consistent health care work force available to implement them, particularly to serve the indigent in
health manpower shortage areas. Despite reports of a physician surplus, the manpower shortage is increasing,
particularly of primary care physicians in underserved regions. The steps Denno lists to address the problems include
funding the National Health Service Corps, exposing medical students to health manpower shortage areas during their
training period, and recruiting minority medical students. (#717)

In a more specific case, according to Lisa Kane Low and colleagues from the Michigan chapter of the American
College of Nurse-Midwives:

The distribution of health care providers is a main contributor to the problem of patient access to maternity
services. While major urban and resort areas have long had ample numbers of physicians, there are many areas
of Michigan that have far fewer physicians than necessary, and despite the ample number of providers, all
women are not provided equal access to these resources. Many of the underserved areas are rural, geographically
removed from the social and professional benefits of large urban areas. However, a number of urban areas in
Michigan contain “pockets” of underserved populations.

They offer three recommendations for dealing with these problems:

Reestablish the National Health Service Corps or provide incentives for states to develop their own programs.

Reimburse certified nurse midwives and other nurses in advanced practice for services they are qualified to
deliver.

Improve reimbursement rates for services provided to Medicaid recipients and provide parity in reimbursement
for the same services provided by various health care professionals, including nurse midwives. (#628)

Minority Practitioners

The problems of underserved areas often intersect with the lack of access for minority populations. A number of
testifiers suggested that one solution to this joint problem could be found in training more minority health
professionals at all levels.

One testifier who calls himself “a state health commissioner with a vision toward the new millennium,” says that
“ultimately, achievement of the nation’s health objectives will depend not only on clearly articulated measures, but
also on the availability of appropriately trained personnel who are representative of the communities served, and who
recognize the fact that health is the outcome of many complex factors, involving individual, institutional, and
community behavior patterns.” Objectives for the year 2000 should include training health professionals in culturally
appropriate interventions and recruiting health personnel from the communities most in need of interventions. (#599)

More specifically, the APHA Medical Care Section says that “the continued shortage of Black physicians exacerbates
access problems for Black Americans. (#755) Denno adds that minority physicians tend to work in health manpower
shortage areas more often than their White counterparts; thus, recruiting minority medical students through specific
grant and loan programs would help underserved areas. (#717)

James Young, Dean of the School of Allied Health Sciences at the University of Texas Health Science Center at San
Antonio, says that allied health professionals have an important potential role in promoting and achieving the nation’s
health goals, specifically as they concern minorities. Young’s recommendations include (1) increasing minority
representation in the allied health professions, and assessing the incentives that exist to encourage student, faculty, and
clinician entry into needed areas; (2) aggressively recruiting students from underserved communities; and (3)
developing strategies and incentives to attract allied health professionals to enter practice in underserved areas and to
increase the number of minority students who practice in these settings. (#497)

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 14/16

2.
3.

References
U.S. Bureau of the Census: Statistical Abstract of the United States, 1987 (107th Edition). Washington, D.C.: U.S.
Government Printing Office, 1986.
National Center for Health Statistics: Health United States, 1984 (DHHS Publication No. [PHS] 85-1232), 1985.
Russell MAH, Wilson C, Taylor C, et al.: Effect of general practitioners’ advice against smoking. Brit Med J
2:231-235, 1979. [PMC free article: PMC1595592] [PubMed: 476401]
Hughes D, Johnson K, Rosenbaum S, et al.: The Health of America’s Children: Maternal and Child Health Data
Book. Washington, D.C.: Children’s Defense Fund, 1988.
U.S. General Accounting Office: Prenatal care: Medicaid recipients and uninsured women obtain insufficient care.
Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on
Government Operations, House of Representatives. GAO/H D 87-137, September 1987.
Ibid.

Testifiers Cited in Chapter 8
024 Bonta, Diana; Los Angeles Regional Family Planning Council

044 Corry, Maureen; March of Dimes Birth Defects Foundation

071 Givens, Austin; American Occupational Medical Association

072 Graham, Robert; American Academy of Family Physicians

074 Grigsby, Sharon; The Visiting Nurse Foundation

118 Kligman, Evan; Society of Teachers of Family Medicine

129 Halpin, Thomas and Evans, Karen; Ohio Department of Health

136 Lurie, Sue; Texas College of Osteopathic Medicine

143 Martin, Robert; Society of Teachers of Family Medicine

169 Osterbusch, Suzanne; National Council for the Education of Health Professionals in Health Promotion

193 Delgado, Jane; The National Coalition of Hispanic Health and Human Services Organizations (COSSMHO)

194 Scheckler, William; University of Wisconsin

209 Tallia, Alfred, Spitalnik, Debbie, and Like, Robert; University of Medicine and Dentistry of New Jersey

221 Volle, Robert; National Board of Medical Examiners

234 Brooks, Chet; Texas State Senate

235 Bruhn, John; University of Texas Medical Branch at Galveston

255 Blumenthal, Daniel; Morehouse School of Medicine

258 Blayney, Keith; University of Alabama at Birmingham

262 Fleming, Lisa; Alabama Dental Hygienists’ Association

268 Work, Rebecca; University of Alabama at Birmingham

269 Ahmed, Osman; Meharry Medical College

271 Jelliffe, Derrick; University of California, Los Angeles

277 Roemer, Milton; University of California, Los Angeles

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595592/

https://www.ncbi.nlm.nih.gov/pubmed/476401

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 15/16

289 Farabee, Helen; Benedictine Health Promotion Center (Austin)

292 Wente, Susan; Jefferson Davis Hospital (Houston)

309 Eriksen, Michael; University of Texas Health Science Center at Houston

346 Wilson, Marjorie; Olympia, Washington

377 Glazner, Judith; Denver Department of Health and Hospitals

387 Richards, N. Mark; Pennsylvania Department of Health

431 Munoz, Eric; Long Island Jewish Medical Center

436 Beckerman, Anita; College of New Rochelle (New York)

437 Joseph, Stephen; New York City Department of Health

463 Logsdon, Donald; INSURE Project (New York)

497 Young, James; University of Texas Health Science Center at San Antonio

501 Hawken, Patty; University of Texas Health Science Center at San Antonio

507 Sapp, Mary; Benedictine Health Resource Center (San Antonio)

510 Silver, George; Yale University

560 Salive, Marcel and Parkinson, Michael; Association of Preventive Medicine Residents

564 Schlegel, John; American Pharmaceutical Association

576 Owen, Jack; American Hospital Association

579 Shoults, Harold; The Salvation Army

583 McCarthy, Diane; Health Policy Agenda for the American People (Chicago)

589 Mundinger, Mary; Columbia University

599 Adams, Frederick; Connecticut Department of Health Services

612 Hunter, Paul; American Medical Student Association/Foundation

625 Goldstein, Bernard; University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

628 Low, Lisa Kane; American College of Nurse-Midwives

633 Rosenfield, Allan; Columbia University

635 White, Francine; National Association of Community Health Centers

678 Arnold, Milton; American Academy of Pediatrics

690 Carr, Katherine; American College of Nurse-Midwives

694 Hagens, William; Washington State House of Representatives

717 Denno, Donna; University of Michigan

755 Blumenthal, Daniel; American Public Health Association, Medical Care Section

780 Sobel, David; The Permanente Medical Group

796 Black, Robert; Monterey, California

2/5/2020 Health Promotion and Disease Prevention in the Health Care System – Healthy People 2000 – NCBI Bookshelf

https://www.ncbi.nlm.nih.gov/books/NBK235764/?report=printable 16/16

Bookshelf ID: NBK235764

https://www.ncbi.nlm.nih.gov/books/about/copyright/

From “Sick Care”

o Health Care: Reengineering Prevention into
the U.S. System

Farshad Fani Marvasti, MD, MPH1 and Randall S. Stafford, MD, PhD1

1Stanford Prevention Research Center and the Department of Medicine, Stanford University
Medical School, Stanford, CA

Although the United States pays more for medical care than any other country, problems

abound in our health care system. Unsustainable costs, poor outcomes, frequent medical

errors, poor patient satisfaction, and worsening health disparities all point to a need for

transformative change.1 Simultaneously, we face widening epidemics of obesity and chronic

disease. Cardiovascular disease, cancer, and diabetes now cause 70% of U.S. deaths and

account for nearly 75% of health care expenditures.2 Unfortunately, many modifiable risk

factors for chronic diseases are not being addressed adequately. A prevention model,

focused on forestalling the development of disease before symptoms or life-threatening

events occur, is the best solution to the current crisis.

Disease prevention encompasses all efforts to anticipate the genesis of disease and forestall

its progression to clinical manifestations. A focus on prevention does not imply that disease

can be eliminated, but rather embraces Fries’ model of “morbidity compression,”3 in which

the disease-free lifespan is extended through the prevention of disease complications and the

symptom burden is compressed into a limited period preceding death. Thus, a prevention

model is ideally suited to addressing chronic conditions that take decades to develop and

then manifest as life-threatening and ultimately fatal exacerbations.

Although the need for a prevention model was highlighted during the recent health care

reform debate, efforts to expand prevention continue to be thwarted by a system better suited

to acute care. A century after the Flexner report, the acute care model and its cultural,

technological, and economic underpinnings remain securely embedded in every aspect of

our health care system.

The organizational structure and function of our medical system is rooted in fundamental

changes made at the beginning of the 20th century that emphasized an acute care approach

and marginalized prevention and public health. Breakthroughs in laboratory sciences led by

Koch and Pasteur provided powerful tools for mechanistically understanding and treating

infectious diseases. Bolstered by philanthropy and the Flexner report, U.S. medicine became

Author responsible for correspondence: Randall S. Stafford, MD, PhD, 251 Campus Drive MC 5411, Stanford, CA 94305-5411,
Phone: (650) 724-2400, Fax: (650) 725-6247, rstafford@stanford.edu.

Reprint requests will not be available from the author.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

NIH Public Access
Author Manuscript

N Engl J Med. Author manuscript; available in PMC 2015 February 24.

Published in final edited form as:
N Engl J Med. 2012 September 6; 367(10): 889–891. doi:10.1056/NEJMp1206230.

N
IH

-P
A

u
th

o
r M

a
n
u
scrip

t
N

IH
-P

A
A

u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t

http://NEJM.org

reliant on laboratory research.4 This strategy made sense 100 years ago, given the

prominence of acute infectious diseases in a young population; it makes little sense now.

With the aging of the population, the shift in the burden of disease toward chronic

conditions has accelerated. The most prevalent preventable causes of death are now obesity

and smoking, which result in delayed but progressive disease.5 Even in the developing

world, increases in the prevalence of chronic disease are outstripping reductions in acute

infectious diseases.1 Such epidemiologic evolution demands a focus on public health and

prevention.

Yet economic and technological factors dating from the early 20th century remain strong

barriers to effective disease prevention. A key feature of U.S. health care is its use of a

piecemeal, task-based system that reimburses for “sick visits” aimed at addressing acute

conditions or acute exacerbations of chronic conditions. Economic incentives encourage

overuse of services by favoring procedural over cognitive tasks (e.g., surgery vs. behavior-

change counseling) and specialty over primary care. The current model largely ignores

subclinical disease unless risk factors are “medicalized” and asymptomatic persons are

redefined as “diseased” to facilitate drug treatment. These mismatched economic incentives

effectively preclude successful prevention through health maintenance.

Moreover, our reliance on ever newer, more advanced technology has perpetuated an

expensive system in which costly new technology is widely adopted in the absence of

comparative advantage. When combined with economic incentives for patenting devices and

drugs, these technological factors become self-reinforcing. Although many preventive

strategies may be cost-effective, they unfortunately have limited potential for wide adoption

because they cannot be patented or made profitable. Therefore, the primacy of patentable

therapies impedes research on prevention and diffusion of prevention approaches that could

cost-effectively address the burden

of chronic disease.

The cultural and social underpinnings of our system also inhibit optimal disease prevention.

Faith in reductionism, which was infused into medicine in the 20th century, has empowered

medical research to pursue only isolated problems and to yield targeted, immediately

deployable solutions. Consequently, the model for treating acute infectious disease is being

misapplied to the treatment of chronic disease. For example, cancer chemotherapy is

modeled after antibiotic therapy; coronary revascularization is modeled after abscess

incision and debridement. Societal expectations of a “magic bullet” and a focus on symptom

relief also reflect and reinforce the reductionist approach. These scientific and societal

values emphasize discovering a “cure” for the major causes of death. With the advent of

direct-to-consumer advertising for pharmaceuticals and surgical procedures, these cultural

expectations of immediate, simplistic solutions have been bolstered by consumerism and

fully exploited to generate demand for therapies that are marginally indicated and potentially

unsafe. Our very culture thus devalues disease prevention.

Changing the system requires recognition of these cultural, technological, and economic

obstacles and identification of specific means for overcoming them through alterations in

medical education, medical research, health policy, and reimbursement. For example, to

Marvasti and Stafford Page 2

N Engl J Med. Author manuscript; available in PMC 2015 February 24.
N
IH
-P
A

A
u
th

o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t

combat the primacy of technical knowledge and the profit-based system for medical

technology, medical schools must teach prevention strategies alongside treatment

approaches, and emphasize motivational interviewing with a focus on lifestyle modification.

Payers and the federal government must fully reward use of appropriate non-patentable

therapies and support research on the development and dissemination of prevention

strategies.

To change our reductionist way of thinking, we must teach aspiring physicians about

systems science that addresses psychological, social and economic determinants of disease.

Taking a patient-centered, whole-person approach focused on long-term functional status

will also help to address the current fragmentation of care and allow for standardization of

prevention strategies.

Medical school curricula should emphasize homeostasis and health, rather than only disease

and diagnosis, and provide training in the science and practice of cost-effective health

promotion. In turn, payers will need to reimburse for health maintenance and prevention

activities, primary care physicians will have to act as health coaches; and all health care

professionals will need to embrace a coordinated multidisciplinary team approach.

Systematic steps must also be taken to change the culture of medicine so that primary care is

valued. Renewing primary care will require increasing ambulatory care training in

community settings and reallocating funding for residency training away from hospitals to

reimburse appropriately for innovative models such as medical homes. Furthermore, we

must compensate primary care physicians for their work as care coordinators by establishing

reimbursement parity for cognitive and procedural care and accounting for long-term costs

and benefits.

The new approach to medicine endorsed by the Flexner report succeeded because it was

based on sound science and a radical restructuring of the way medicine was taught,

organized, and practiced. Today, we face a similar challenge that requires another

fundamental reordering of our health care system. Although the need for acute care will

remain, centering our efforts on prevention is the only way to thwart the emerging pandemic

of chronic disease.

Current health care reform efforts will bring incremental improvement, but reengineering

prevention into health care will require deeper changes, including reconnecting medicine to

public health services and integrating prevention into the management and delivery of care.

Though change is painful, the successful transformation of medicine at the turn of the last

century demonstrates that it is possible. Ultimately, embedding prevention in the teaching,

organization, and practice of medicine can stem the unabated, economically unsustainable

burden of chronic disease.

Acknowledgments

Grant Support

This project was supported by a grant from the National Heart, Lung, and Blood Institute (K24-HL086703).

Marvasti and Stafford Page 3

N Engl J Med. Author manuscript; available in PMC 2015 February 24.
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t

References

1. Fuster, V.; Kelly, BB., editors. Promoting Cardiovascular Health in the Developing World: a critical
challenge to achieve global health. Washington, D.C.: The National Academies Press, Institute of
Medicine; 2010.

2. Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services; 2010.
(Accessed June 14, 2012 at http://www.healthypeople.gov/2020/default.aspx)

3. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980; 303:130–
135. [PubMed: 7383070]

4. Fleming, D.; William, H. Welch and the rise of modern medicine. Boston, Massachusetts: Little,
Brown; 1954.

5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States,
2000. JAMA. 2004; 291:1238–45. [PubMed: 15010446]

Marvasti and Stafford Page 4

N Engl J Med. Author manuscript; available in PMC 2015 February 24.
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t
N
IH
-P
A
A
u
th
o
r M
a
n
u
scrip
t

http://www.healthypeople.gov/2020/default.aspx

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Explain the focus of the U.S. health care system on treatment of disease compared to disease prevention /health promotion. ”

Get high-quality paper

NEW! AI matching with writer

Hire a Writer

Client Reviews

4.9

Sitejabber

4.6

Trustpilot

4.8

Our Guarantees

100% Confidentiality

Information about customers is confidential and never disclosed to third parties.

Original Writing

We complete all papers from scratch. You can get a plagiarism report.

Timely Delivery

No missed deadlines – 97% of assignments are completed in time.

Money Back

If you're confident that a writer didn't follow your order details, ask for a refund.

New to Your Trusted Assignment Help Service? Sign up & Save

Calculate the price of your order

Type of paper needed:

Pages:

You will get a personal manager and a discount.

Academic level:

We'll send you the first draft for approval by at

Total price:

$0.00

Power up Your Academic Success with the
Team of Professionals. We’ve Got Your Back.

Power up Your Study Success with Experts We’ve Got Your Back.

Order Now Order Now