Why prevention is the missing link in health care policy [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

We’re joined by Anand Parekh, internal medicine physician and author of Prevention First: Policymaking for a Healthier America. We dive into the lessons of the COVID-19 pandemic, exploring the pivotal role of prevention in health policy. Anand discusses the urgent need for stronger public health leadership, effective crisis communication, and investment in community-based prevention programs. He also shares insights on bridging bipartisan divides to prioritize health care prevention for a healthier future.

Anand Parekh is an internal medicine physician and author of Prevention First: Policymaking for a Healthier America.

He discusses the KevinMD article, “Prevention is the key to saving lives: What the pandemic taught us.”

Our presenting sponsor is DAX Copilot by Microsoft.

Do you spend more time on administrative tasks like clinical documentation than you do with patients? You’re not alone. Clinicians report spending up to two hours on administrative tasks for each hour of patient care. Microsoft is committed to helping clinicians restore the balance with DAX Copilot, an AI-powered, voice-enabled solution that automates clinical documentation and workflows.

70 percent of physicians who use DAX Copilot say it improves their work-life balance while reducing feelings of burnout and fatigue. Patients love it too! 93 percent of patients say their physician is more personable and conversational, and 75 percent of physicians say it improves patient experiences.

Help restore your work-life balance with DAX Copilot, your AI assistant for automated clinical documentation and workflows.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://www.kevinmd.com/cme

I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://www.kevinmd.com/learnerplus

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Anand Parekh. He is an internal medicine physician and is the author of the book Prevention First: Policymaking for Healthier America. There’s an excerpt from that book on KevinMD, “Prevention is the key to saving lives: What the pandemic taught us.” Anand, welcome to the show.

Anand Parekh: Kevin, great to be on with you.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Anand Parekh: Yeah, Kevin, I’m in Washington, D.C. I work at a place called the Bipartisan Policy Center. So we are a think tank that tries to take the best ideas from both sides to promote health, security, and opportunity. I’m the chief medical adviser there, so I provide the clinical and public health expertise. I must say that in an election year, it’s a bit lonely waving the bipartisan flag, but that’s really what we try to do: try to ensure that both sides of the aisle and Congress work together. And health is the area that I focus on.

But in short, my career of the last thirty years has really been: I started with political science and moved to public health, moved to medicine, moved to public service, and now in public policy. So I’ve come full circle there over the last thirty years and really focused my attention on how you improve the population’s health. And what I’ve concluded, and it’s really what the excerpt is about, is you have to focus on three things, which are prevention, primary care, and public health.

Kevin Pho: All right. So before I talk about that, I just want to ask what you do from a bipartisan standpoint. We’re speaking on November 1. It’s a few days before the election. This episode is going to be published sometime after that. So when taking that bipartisan path and ideas from both sides, how do you get those ideas to resonate in a Congress, in an electorate, that is so polarized today?

Anand Parekh: Yeah, it’s not easy. So we try to identify issues in three ways. One, it’s got to be an issue that we think is incredibly important from a health perspective. Two, an issue we think both sides need to be educated on. And then three, the issue has to have some sort of political window or policy window, so someone cares about it. So both sides are, let’s say, setting appropriation levels or authorizing a health program, or the administration is focused on an issue. And then we try to convene experts and get Republicans and Democrats in the same room, and we come up with policy recommendations and send them to Congress, on a wide variety of issues.

Now, some issues are hyperpolarized, as you can imagine. Think about reproductive health and gun violence and others. But many others, from telehealth to rural health to behavioral health to physician payment, these are issues. Yes, there are differences of opinion, but there are issues that we can make traction on. So selecting those issues where there is some space between the two parties, at least for discussion and negotiation, being strategic about those, that’s how we go about our work at the Bipartisan Policy Center.

Kevin Pho: All right. So let’s talk about the excerpt from your book. It’s titled “Prevention is the key to saving lives: What the pandemic taught us.” Now, for those who get a chance to read that excerpt, tell us what it’s about.

Anand Parekh: Yeah. So the first edition of the book came out in 2019, and the second one just a couple days ago. Obviously, what was in between was the COVID-19 pandemic. And so I do talk about the overarching takeaways and some of the lessons learned from COVID. The two overarching ones that I talk about in the excerpt: number one, that the majority of the one million deaths or so that we saw in the United States were preventable if we were able to better build trust and confidence in the public to take many of the public health interventions that were recommended. And two, had we done nothing, then millions more would have died. And that’s sort of trying to counter some of the revisionist theory saying that we shouldn’t have done anything or we did too much.

And then I get into some of the critical lessons learned. Leadership matters. Crisis communication is critical. Resources and tools, both the workforce as well as medical interventions, are critical. Public health actions have economic consequences. We need to mitigate those in a targeted way. Some of those just critical lessons: data, the importance of having real-time data for situational awareness. Some of those lessons learned, because, as you know, Kevin, it’s not a question of if, when we face the next pandemic or public health emergency. We’re already seeing H5N1 avian influenza in a variety of different mammals: cows, now pigs. So we have to be prepared.

So the excerpt in the book focuses on that, but then it takes a broader look at, as you said, how do you make prevention the most important health policy priority in the United States. And it outlines half a dozen ways, many of which focus on, again, shoring up the public health system, shoring up the primary care system, trying to increase uptake of clinical preventive services, a number of different ways that we can try to make prevention the top priority.

Kevin Pho: So you mentioned public health. And like you, I’m an internal medicine physician. I do primary care. In my exam room, I’m seeing that trust in our public health institutions is at an all-time low, and I think that has worsened during the pandemic. What are you seeing from a Washington, D.C., standpoint? Are you also seeing trust in our public health institutions at a low? And if so, why do you think that is?

Anand Parekh: Yeah, I am seeing that. I think it’s unfortunate. I think we’re also seeing the politicization of issues that were traditionally bipartisan. Public health had often been anonymous, but where we talked about public health when it came to emergency preparedness, it was always bipartisan. Vaccinations, another concerning area, always bipartisan. And now we’re seeing more traction and spillover effects from COVID to differences in flu uptake, differences in how parents perceive the importance of childhood vaccinations and the school schedule.

So it is concerning. And what I do, and I talk to both sides of the aisle about this: Public health, at the end of the day, is really about kitchen-table issues. It’s sort of gotten framed in, I think, the COVID light, Kevin, and I think that’s why we are where we are. But at the end of the day, public health is really about keeping our communities safe. It’s about making sure that harmful substances don’t get in our communities, infectious diseases are held at bay, that we get help for chronic disease prevention, the roads are safe, our food, air, and water are safe. Public health allows us to live every day the way we want to live. Nobody raves about it. People take it for granted, but it’s saving lives every single day.

And we have to get back to that idea that public health is part of our nation’s infrastructure and it’s supporting the lives of people in every community in the United States. I think if we can broaden that message out, people understand that public health isn’t just about vaccine mandates or mask mandates; it’s about much more. I think we’ll be able to help build trust again.

Kevin Pho: One of the things that I think damaged trust in public health was the fact that, especially during the pandemic, the science was changing so quickly, almost on a weekly to monthly basis. And you mentioned crisis communication. During that time, I guess, in terms of regaining trust in public health, any communication mistakes or failures that you think our public health institutions can improve on going forward to regain trust in those institutions?

Anand Parekh: Yeah, I think we need to do exactly that: how you communicate, particularly where you’re learning as the crisis is ongoing, and ensuring that, you know, the science continues to change, but we need to act on the best science to date. That could certainly have been done better during the pandemic. Just think about masks. We started with, first, no masks, and then went to cloth-based masks, and then surgical masks, and then realized that N95s and higher-quality masks were more effective. And some of that you learn as you go, but you need to communicate that to the public, that this is what we know, and as soon as we know more, we’ll share it with you.

And so yes, I think, absolutely, there are lots of lessons learned with regard to communication. But being honest with the public, again: “This is what we know now. This is what the science is telling us. It may change, and as soon as we learn more, we’ll let you know.” And providing that guidance, that two-way communication, having public health leaders have that daily dialog with the public, all of that is important. All of those are areas where we fell short, and we’ll need to do better next time.

Kevin Pho: So you talked to both sides of the political aisle. Now, for those who have lost trust in our public health institutions, do you think that they can be persuaded back to trust them, given how polarized our society is? Has there been any historical precedent where those who have lost trust have been brought back?

Anand Parekh: I hope so, and we have to, because what we’re seeing, Kevin, is if you look at some of the critical health indicators in this country, we are falling behind. Even prior to the pandemic, we had stagnation of life expectancy in the United States. The pickup post-pandemic compared to other OECD countries and others has been slower. Wide variations and disparities: racial, gender, geographic. We are not going to be individually able to achieve our goals, nor as a society, whether it’s economic, whether it’s national security, whether it’s other societal goals, if we’re not a healthier nation. And just like medicine contributes to individual health, public health contributes to population health.

So I think we have no choice. And with empathy, we’re going to have to have these conversations with the public to shore up confidence in vaccination, to shore up confidence in what local health departments do. So I really think that it’s so critical to the fabric of the nation that I think we really have no choice. As well as to remind the public that the reason life expectancy increased from forty-seven to seventy-seven in the 20th century was largely because of public health advances: vaccinations, the introduction of antibiotics, and prevention in public health-related issues related to tobacco. And so helping the public understand what public health is, what it has done in the future, and what it can do, I think that’s got to be part of the mission moving forward.

Kevin Pho: Now, one of the other areas of focus you mentioned, of course, is prevention. I’m a primary care physician, so that’s what I do every day. What do you think currently are the biggest obstacles to realizing your vision of prevention first?

Anand Parekh: Yeah, well, there are a number. I mean, we talked about the politicization of public health. In terms of preventive services, as you know, Kevin, clinical preventive services, there are dozens of important services, not just immunizations but cancer screenings, cardiovascular screening, and substance use and mental illness counseling, where these are evidence-based services. They’re free of charge now, essentially, given the Affordable Care Act, and all private insurers have to provide these, but uptake remains quite low. The pandemic even put us further behind. So really helping the public catch up with those services is critical. We recently launched with AHIP a twenty-member-organization nationwide preventive services campaign to do just that, to remind the American public that these clinical preventive services are important. They’re of no cost, no cost sharing, and it’s really important that we catch up with those. So that’s one.

The second, I would say, is broader than prevention, but it’s primary care, something that you and I both do. Fifty years ago, half of physicians in this country were primary clinicians. Now we’re down to about 10 to 20 percent are primary care clinicians. Primary care has to be the bedrock of any health care system. It is the one essential resource that’s associated with better health, better care, and lower costs. And primary care is in crisis in this country, as you know, both from a workforce as well as a reimbursement perspective. And so I talk about that in the excerpt, as well as in my book: the importance of shoring up the primary care system.

And there are some positive signs among policymakers in Washington, D.C., over the last few years, but we really need a concerted effort to shore up our primary care system. They’re the backbone of our health care system. They’re also sort of the best connectivity to our public health system as well. So, multiple reasons why we need to focus on primary care.

Kevin Pho: So, two things that I want to break down. The first is the lack of uptake when it comes to these preventive health services, cancer screening and whatnot. What are some of the reasons why that uptake is so low? Is it a resistance of the public to get these things, or the fact that they’re not as accessible as they should be? What are some of the reasons why that uptake is so low?

Anand Parekh: Yeah, so there are barriers both on the patient side as well as the provider side. On the patient side, one, it’s education, so ensuring that they understand. And it can be confusing. There are dozens and dozens of services, and it can be overwhelming, so how we communicate that is important. Secondly, many patients have barriers, social needs, transportation, and others, and might not be able to get to these services.

And then on the physician side, it’s less of an education side for physicians, providers more broadly, but within the workflow, the number of things that providers are trying to track can also be overwhelming. And with quality metrics being the currency for value-based health care transformation, we haven’t prioritized those quality metrics that are linked to providing clinical preventive services. So we need to ensure that these are a priority, work with the provider community to ensure that they have the team-based care, the workflow design, the supports they need to remember and to provide these services, to connect their patients with it.

So I think we need to elevate the importance among providers. They already know that this is important, but through quality measures and incentives. The provider side, we need better education. We need to facilitate the provision of these services.

Kevin Pho: And of course, the second thing is shoring up our primary care system. It sounds like we’ve been talking about that for decades, and there have been multiple attempts by various medical societies to do that. What is it really going to take to move the needle when it comes to shoring up our primary care system? Is it just simply money? Is it the will? Is it the fact that clinicians are so divided? What’s it really going to take to move the needle? Because it sounds like we’ve been talking about this for decades now.

Anand Parekh: Yeah, you’re absolutely right. One of the things that we’re working on, I talk about it in the book as well, is this idea that if you don’t measure something, it’s not important. And right now, when you look at the federal government health insurance programs, Medicare, Medicaid, there is no measurement or tracking of primary care spend among these programs. The reason why that’s important: In the United States, it’s estimated that about 6 percent on the dollar, or 6 cents on the dollar, about 6 percent of the $4.5 trillion we spend on health care, goes to primary care. That’s about half of other OECD countries that have better health outcomes. And about 19 states now across the country are first, at least initially, tracking and then setting targets for what that primary care spend should be.

And so one of the things that we’ve been advocating at the federal level: At least, let’s start tracking and measuring how much we are spending on primary care, perhaps setting targets as well, trying to move some of those resources upstream into primary care. So I think that’s one.

I think how you pay primary care clinicians is also very important: moving away from fee-for-service to what we call hybrid payments, where they’re capitated payments to allow primary care providers to do all the things that they don’t get reimbursed for on a service basis, plus fee-for-service. So reimbursement is critical. But then workforce, Kevin, I think is also very important, to the extent that there is still, for whatever reason, stigma out there that as you proceed in medical school and you select a residency, you ought not to go into primary care because maybe it’s not as prestigious or not. We have to break through that stigma.

Reimbursement is a part of that as well. Clinicians obviously are coming in with loans, and they want to repay that. They see the differential in income between primary care and specialists. So there are a whole lot of reasons there. It’s not just public policy, but I think we have to tackle all of these.

Kevin Pho: So that primary care urgency, do you find that resonant with both sides of the political aisle?

Anand Parekh: You know, I do. I really do. And one of the things: We were able, early this year, to resurrect the Congressional Primary Care Caucus. So now there are four members, two Democrats, two Republicans, in the House who are working together. There’s a flag planted in the House saying, you know, primary care is really important. We’re seeing, on the Senate side, Kevin, Senators Whitehouse and Cassidy put forward bills, the Pay Primary Care Act, to try to shore up primary care payments. So I think we are starting to see signs on both sides of the aisle. Thankfully, primary care hasn’t been politicized yet compared to public health. It’s going to be really important that we continue that bipartisan push on primary care. It’s just too important to be politicized.

Kevin Pho: We’re talking to Anand Parekh. He’s an internal medicine physician and author of the book Prevention First: Policymaking for Healthier America. Anand, we’ll end with some take-home messages that you want to leave with the KevinMD audience.

Anand Parekh: Well, I just want to thank your audience, clinicians, and all of you who are doing great work taking care of patients and keeping Americans healthy. Whatever we can do to support all of our colleagues, but particularly primary care colleagues; whatever we can do to increase uptake of clinical preventive services; whatever we can do to support and defend our public health colleagues, who are baguer; I think all of that is going to help us keep our patients healthy. And that’s why it comes back to each of us individually. So I hope this message, that prevention needs to be our nation’s health policy priority, I know it resonates with many clinicians who are listening in. We have to make sure policymakers understand that as well.

Kevin Pho: Anand, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Anand Parekh: Thanks so much.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes