With an hour to spare Saturday while in Cincinnati, I visited a local bookstore where I picked up the Saturday Wall Street Journal, an edition I rarely read. It caught my eye because the inside section had this headline across its top: "The Myth of Prevention." Ye gads, I thought, not another screed on how helping people live healthier lives will only cost the health care system more money in the long run because healthier people wind up consuming more health care services by reaching a ripe old age.

It turned out that the article had but three paragraphs devoted to prevention, and they actually endorsed active intervention to promote healthier lifestyles!

It's worth reviewing the article in depth, since I have rarely read a more honest appraisal of what is wrong with our health care system, or a more dishonest headline compared to what the article actually said.

The article's author was Abraham Verghese, a professor at Stanford Medical School, who's also a novelist and a blogger at The Atlantic.com. And after a long opening that linked Sir Luke Fildes' famous portrait "The Doctor" to the frayed patient-physician relationship, the writer segued into an analysis of President Obama's speech to the American Medical Association. 

The speech was a model of clarity, full of the kinds of truths we in medicine have managed to dodge and distort for years. . . 

President Obama pointed to the problem of "a system of incentives where the more tests and services are provided, the more money we pay." As if to rub it in, he added, "And a lot of people in this room know what I'm talking about."

Noting that the president's remarks at that point were greeted with "stony silence," Verghese turned to analyzing his colleagues in the medical profession.

Yes, Mr. President, a lot of people inside and outside that room know exactly what you are talking about. A skewed reimbursement scheme set up by Medicare, a system that pays generously when you do something to a patient, but is stingy when you do something for a patient, is largely to blame. Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more.

Verghese did take a shot at the president's insistence that focusing on prevention would help pay for health care reform. But his "myth" of prevention barb wasn't aimed at wellness programs. Just the opposite. It was aimed at costly medical interventions made in the name of prevention. 

It is true that if the prevention strategies we are talking about are behavioral things-eat better, lose weight, exercise more, smoke less, wear a seat belt-then they cost very little and they do save money by keeping people healthy.

But if your preventive strategy is medical, if it involves us, if it consists of screening, finding medical conditions early, shaking the bushes for high cholesterols, or abnormal EKGs, markers for prostate cancer such as PSA, then more often than not you don't save anything and you might generate more medical costs. Prevention is a good thing to do, but why equate it with saving money when it won't? Think about this: discovering high cholesterol in a person who is feeling well, is really just discovering a risk factor and not a disease; it predicts that you have a greater chance of having a heart attack than someone with a normal cholesterol. Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc).. But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)-I don't see the savings there.

But this was a mere sidebar in the context of the whole article. Verghese immediately returned to his main theme: the conflicts of interest at the heart of out-of-control medical costs:

I recently came on a phrase in an article in the journal "Annals of Internal Medicine" about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us-doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others-are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not?-it's hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman's plan and scuttled Hillary Clinton's proposal.

Verghese's solution?

We may not like it, but the only way a government can control costs is by wielding great purchasing power to get concessions on the price of drugs, physician fees, and hospital services; the only way they can control administrative costs is by providing a simplified service, yes, the Medicare model (with a 3% overhead), and not allowing private insurance to cherry-pick patients (some of them operating with 30% overheads, the cost passed on to you).

You're probably wondering how it can happen that an article that attacks fee-for-service medicine and calls for government price negotiations and a government plan to control runaway administrative costs winds up with a headline that misrepresents even the small section of the article to which the headline refers. It's no conspiracy. Copyeditors are among the least powerful people in a newsroom. They are anonymous. But they get to write the headlines. And this would appear to be a case where the anonymous copyeditor decided to add his or her editorial two cents.