John La Puma, M.D.

A respected young physician appeared on Oprah earlier this year to offer some common-sense advice about preventive medicine. But the advice wasn't called disease prevention or health promotion. It wasn't couched in health plan terms of coverage, copayments, primary providers, or capitation. It barely mentioned the "health care system." No words about moral responsibility, either.

Instead, Michael Roizen talked about what America cares about: getting younger. Leading a life of quality, not just longevity. Simple changes to make. Today. Tomorrow. For you and your family.

Oprah loved Roizen's book, Real Age. So did her audience. The same audience that managed care insures, and finances, and delivers care to. Managed care pays dearly for these people because they don't know how to do what they should be doing.

Here is my disclosure: I have logged on to www.realage.com, read the book, and calculated my own real age. I'm 37 by Roizen's calculation — if only I'd get married, I'd get two years younger. I don't own a bit of Real Age Inc., and actually, I don't even own the book. I do practice clinically much of what it recommends, because it is strongly evidence-based and sensible.

What Roizen insists on, in language bold for a man who heads the University of Chicago's department of anesthesiology and critical care, is that we can influence how long we live and how well we live by looking at health as more than organ function and diseases. That's a message for the ages, and it's one that managed care should heed as its patients expect more of their providers, and providers look for ways to motivate their patients to take better care of themselves.

Despite the message on Chicago billboards, patients don't care that their health plan "wants to be your health plan, not your doctor." They do care that they can see who they want to see and get the answers they need. Otherwise, they'll go elsewhere: to the vitamin aisles at Sam's Club, and to the nice fitness club near the health food store. Or, they might go online for information they can't routinely get in their doctor's office about vitamins, minerals, and supplements.

Where we've been

In 1948, what was for breakfast on the American table? Fried eggs sunny side up or over easy. In the middle of the plate, underneath or just to the side, was bacon or ham. Toasted white bread was spread with creamy butter. For dinner was steak, pot roast, or meatloaf. Creamed tuna and chicken a la king came along in a jiffy.

Deep fryers were the countertop appliance of Christmas choice. Housewives collected milk bottles in the morning delivery, and skimmed the cream for coffee. Many people smoked — 70 percent of men and 30 percent of women. Couch potatoes were few, and the only people who went to the gym to exercise were competitive athletes.

Doctors thought that arteriosclerosis was a natural result of aging. Women were not thought to have the same risk for heart disease as men. No one measured cholesterol levels with an eye towards therapy; in 1938, Osler's Principles and Practices of Medicine noted that a relationship between blood plasma levels and heart disease "seemed improbable in man." The same text, though, notes that diabetes mellitus "is on the increase in all civilized countries, due partly to overnutrition and less exercise, in which the motor car plays a part." The prevalence of obesity was below 20 percent.

Where we are

Now, the picture looks different. We know that smoking is associated most closely with the leading causes of mortality, and that a high-fat, low-fiber diet and a sedentary lifestyle are close behind. We know that neither high blood pressure nor heart disease must come with aging, and that both can be prevented with diet, exercise, stress management, and psychosocial interventions. We know that certain cancers are associated with specific lifestyle measures, and that millions of Americans have turned to alternative practitioners to learn about them.

We know to floss our teeth and buckle our seat belts and wear our bike helmets and take our antioxidants and quit smoking and exercise regularly and eat five vegetables and four fruits daily. But do we?

Some of us do. We smoke less and have better treatments than ever — bupropion pills, nicotine patches, support groups. Our average cholesterol levels are down, and so are our blood pressures. The mortality rate from myocardial infarction is declining. Cereals and breads are now fortified with folate to help prevent neural tube defects, though the resulting levels probably will be too low to affect heart disease.

But the prevalence of overweight is 55 percent, and even higher among Hispanic and African Americans. The incidence of heart disease is not declining — it's level, or even rising.

Managed care is responsible for some of the progress made in prevention (though it cannot take credit for the death of creamed tuna). Managed care was, after all, promulgated with prevention in mind, in 1973. The fact that it has forced measurement where there was only anecdotal evidence, and discussion about systems where the focus had been only on individuals, is to the public good. That it ignores obesity treatment in favor of treatment of obesity-related diseases is criminal.

Where we're going

We are aiming toward food as medicine, and the myriad ways in which people can prevent the diseases that clinicians spend so much time trying to treat, once developed. Can you imagine prescribed meals on the formulary? Nutraceuticals next to beta-blockers? A reduced-fat soybean with improved flavor? HCFA or NCQA grading plans and physicians on percentage of patients with a BMI of less than 30?

Most of managed care is nowhere close to this — many patients depend on their next-door neighbor and on Oprah for their everyday preventive medical advice.

What should be done is this: Turn managed care from a health insurance program into a health program. Especially for the Medicare population. What does this mean? Not moving away from vaccinations, Pap smears, mammography, and colorectal cancer screening. It means adding programs to them.

Surveys of managed care patients and providers show that it's chiropractic, acupuncture, and massage that need coverage, and need to be held to peer-reviewed standards.

Managed care should pay for exercise, nutrition, and smoking-cessation programs delivered in communities and offer financial incentives for enrollment. People with low risk profiles should pay less.

Is this feasible? Is it cost-effective? These are the questions of the managed care age. They have to be answered. In the meanwhile, I'm going to work on my real age.

John La Puma, M.D., is a Chicago-based internist and author of Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics, Hatherleigh Press, New York, 1998. He is director of the C.H.E.F. Clinic at Alexian Brothers Medical Center in Elk Grove Village, Ill.

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