Healthcare vs. disease management

disease management In a recent post, The Myth of Evidence Based Medicine, I explained that conventional medicine is based not on evidence, but on profit.

So how’s this working out for us?

The U.S. spends far more than any other country in the world on healthcare – a whopping $2 trillion per year. 1

Considering this enormous expenditure, we should have the best medicine in the world. We should be reversing disease, preventing disease, and doing minimal harm.

But that’s not what’s happening at all. The U.S. ranks just 34th in the world in life expectancy and 29th for infant mortality. Of 13 countries in a recent comparison, the United States ranks an average of 12th (second from bottom) for 16 available health indicators. 2

Even worse, a study published a few years back in JAMA suggested that medical care may be the leading cause of death in the US. (For more on this, read my article The Failure of U.S. Healthcare).

Yes, you read that right. Medical care kills more people than heart disease, strokes or cancer.

How can it be that we spend nearly 16% of our GDP on healthcare, but have one of the worst health care systems in the industrial world?

The answer, in short, is that we don’t have healthcare in the U.S.. We have disease management. And there’s a world of difference between the two:


Wellness care is what we need. Disease management is what we have.

Wellness care would save insurance companies billions of dollars each year. But it would devastate the bottom lines of the pharmaceutical industry.

Wellness care is what I will offer my patients. And it’s the vision I have for what medicine could be here in the U.S. and elsewhere.

I’m just not holding my breath. Until we can lessen the influence of Big Pharma, disease management will rule.

  1. Park, A. America’s Health Check Up. 11/20/2008. Time Magazine Online.
  2. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.

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  1. jme’s avatar

    Awesome article. I really appreciate the chart too.

  2. hans keer’s avatar

    We don’t even have disease management. We have a system in which the food, pharma and medical industry are optimizing their profits. First they breed patients by feeding unhealthy food. After this they sell these patients the drugs and medical “care” to keep them sick but alive. When the patient is worn out, a last expensive surgery, chemotherapy or hospitalization will be “given” before he is allowed to go to the happy hunting grounds. The strange thing is that almost nobody seems to be aware. Humans are lead to the slaughtering-table more easily than lambs.

  3. Tuck’s avatar

    I agree with the thrust of your article, but one needs to exercise care when comparing health across countries.  There are three great examples of how this can be problematic:

    Life expectancy:  The US has a very high rate of auto-related deaths, since we all drive everywhere. This lowers life expectancy, but has nothing to do with the health-care system.

    Infant Mortality: The US counts infant deaths more rigorously than a lot of European countries do, which makes us look worse and them look better.  If we count a death, and they don’t count it at all, it makes our life expectancy worse, and our infant mortality worse, while not actually reflecting relative quality of care.

    Survival rates:  The US has the best cancer-survival rates in the world, which reflects that our health-care system is pretty good at treating you once you get sick, it just doesn’t do well at keeping you healthy.

    Keep up the good work, and make sure you pass those boards! ;)

  4. James’s avatar

    I am not sure why you assume a correlation between “spending” and “best medicine”?

  5. Tuck’s avatar

    @James: I think Chris, like most of us, would like it to be the case that we are getting what we’re paying for. 

  6. Tom Passin’s avatar

    I agree that I’d like to get what we pay for. But it’s too facile to use this recent report to claim by implication that the other countries studied do “wellness care” better than the US. Big Pharma operates in other countries. Medical literature and conventional wisdom travels around the world. Where is the evidence that these other countries do wellness care significantly better, *and* that this leads to better outcomes and longer life expectancies?

    From what I know (not that much!), the other countries have better access to medical care for more people, better and cheaper medical records, in some cases non-profit medical insurance, and so forth. IOW, lower administrative costs, more effective and efficient records, and more widespread access to care seem to be the big differences.

    If anyone has good information that wellness care is being done better in the studied countries and that it is effective, well, quick, let us know – that would be great news!

  7. Chris Kresser’s avatar


    Where did I say wellness care happens in other countries?

    Big Pharms’s influence is indeed global, and many other industrialized countries have the same problems we do.  We just have more of them.

  8. Maria’s avatar

    Thank you for all the wonderful info you provide on the Healthy Skeptic Blog.  I have shared the videos and certain articles with many of my family members and friends.  May your readership grow a hundred fold.  Keep up the great work!

  9. Jesse’s avatar

    So do other countries that rank better in health care and infant mortality (like Sweden and Iceland) practice evidence-based medicine and the “wellness care” side of that table? How do they do things differently in those places?

  10. Chris Kresser’s avatar

    Other industrialized countries aren’t necessarily practicing “wellness care”, as I defined it.  But they tend to be a bit less drug crazy and a bit more open to other methods of care.  For example, herbal medicine is often prescribed by MDs in Europe.  The US and New Zealand are the only two countries in the world that allow direct-to-consumer drug advertising, and that makes a huge difference.

  11. Jesse’s avatar

    Interesting. Direct-to-consumer drug advertising does seem useless and counter-productive and possibly harmful. What countries would you rank as being closest to practicing “wellness care?”

  12. Chris Kresser’s avatar

    Jesse, I don’t think any country in particular is doing this.

  13. kathleen’s avatar

    Really nice post.  And blog.

  14. Cindy Black’s avatar

    I appreciate the call to health care, and the stumbling blocks to it that you have pointed out so well in this post.  I would add that in addition to providers making this change in attitude, consumers also need to work on changing their approach to health, medicine and wellness.
    I have been immersed in holistic health as both a provider and a consumer for 20 years- and I still need to remind myself to pay attention to what is right, to wellness, harmony and ease.  I think those of us raised in the midst of the disease management mindset need to pay particular attention to how we are thinking everyday in order to be a part of the change you are calling for.

  15. Matthew Morrison’s avatar

    It’s not surprising that people are not getting sufficient medications. If people are healthy and not sick, there is less money being made.

  16. Ben’s avatar

    Along the same lines, this new 2010 data was just released and shows the continuation of this trend (i.e., higher spending, lower quality healthcare): 

  17. Christian W’s avatar

    Re profits as a cause of the problem:
    I don’t think that the profit motive is the problem. One of the essential features of life itself is to take in more than what’s taken out. Same goes for an individual making a living, or a corporation attempting to provide value back to its investors by making products that people want to buy.
    The problem in the area of healthcare is that the corporate interest isn’t aligned with what’s health promoting for its customers. However this is not an inherent effect of profit-seeking, which is only natural, proper, and moral.
    The core reason for today’s problems is that the American public, out of ignorance, intellectual confusion, and distracted by other priorities, have not demanded anything better than disease-management from the medical profession and industry.
    For most of the 20th century Americans in general have wanted to do whatever they feel like to their bodies (including eating junk that no one else in the world would even consider food) and then pop a few pills to fix problems as they come up.
    They got exactly what they wanted. And this with the same precision and efficiency as they get iPods and flat screen televisions provided by extremely productive corporations.
    Furthermore, the medical profession has out of ignorance of basic proper medical principles (such as the necessity of a holistic approach) been applying a reckless engineering approach to the practice of medicine. Not only dubious pharmaceuticals have played a role here. At root, it’s the entire philosophy of trying to fix things in the body as if it were a machine.
    The situation is made vastly worse by the the government attempting to regulate alternative medicine out of business to the advantage of big pharma, and by attempting to make the practice of medicine exclusive to those who have been trained according to conventional, deeply flawed methods.
    What needs to happen is a grassroots revolution among Americans such that the people begin to demand proper wellness care.
    Let’s continue educating people!

  18. John Smith’s avatar

    I hear you, Christian, but isn’t that a bit like saying the kids were at fault and so the pied piper should be forgiven.
    I like Cindy Black’s posting.  That change of attitude and the daily and constant vigilance is what it will take to turn the culture around painlessly.  Without it, the culture will be self eliminating.  The latter is more likely to be the outcome.

    The real challenge will be to save ourselves as individuals, whatever our station or situation.



  19. Christian W’s avatar

    John, corporations are made up of people, don’t forget that.
    Corporations, consumers, and shareholders, are in the game together. There is no pied piper -there is only us (the people).
    People are also responsible for the type of government that they get. Americans have wanted an increasingly fascist, more paternalistic, more controlling state, and they got it.
    I agree with the rest of your comment. We who dissent have to teach the others while also saving ourselves. It’s going to be a fight of epic proportions.
    The new USDA guidelines show that the gloves are coming off as far as the thugs are concerned. The implicit message is “We don’t care about the facts and neither should you. Eat our corn, soy, and wheat, or else… ”

  20. John Smith’s avatar

    Thanks, Christian, for the response.

    You are correct, of course, but you must be considerably younger, bolder, more hopeful and empowered than I, as I am pretty switched off from trying to save the masses in great handfuls. 

    The story goes that Jesus tried that two thousand years ago, and to this day, not even his most devout followers seem to understand his message.  I trust that is not true for his namesakes like yourself.

    Saving ourselves may yet prove to be our greatest contribution to the race, to the collective, and to the masses.

    My experience has led me to believe that the human mind is one of the most impenetrable barriers in existence.  It seems to have been engineered by the great creative force itself to resist all but that lovely music from the pipes of Pan.



  21. Bob’s avatar


    Why do you automatically blame our health care system for our problems?  Our health care system is there to provide care when we’re sick .  And the US populaion is sick because it doesn’t take care of itself.  And smoking, lack of exercise, poor nutrition, etc. are the causes of a population that’s sick.  Sick people need more medical care – hence higher health care expenses.

    Everybody knows what they should be doing to be healthy – I don’t need a “wellness doctor” to tell me these things.  That’s ridiculous – this is 2010 for crying out loud!  A doctor can tell a patient 30 times to stop smoking, give them every tool at their disposal, and yet they continue to smoke and get lung cancer.  By your logic this is the fault of the doctor?  WTF?!!

  22. Chris Kresser’s avatar

    Settle down, Bob. Where did I say I blame the health care system exclusively for our problems? Obviously I believe people need to take responsibility for their own health. That’s the entire purpose of this blog. But that doesn’t mean drug companies, insurance companies and health care providers don’t have a moral and ethical obligation to provide a high standard of care to patients. The failure of our system isn’t all the fault of the individual. There are plenty of sick people trying to get the care they need but aren’t able to. Imagine someone with blood sugar problems that goes to the doctor. They’ll get put on drugs and told to follow a low-fat, high carb diet. That is the fault of the healthcare system, not the patient. Not all patients have the education, inclination or confidence to find their own solutions. That’s the whole purpose of having a healthcare system in the first place, rather than just letting everyone do it themselves.

  23. Bob’s avatar

    If everybody in our country stopped smoking today, we’d have the healthiest country on the planet in 5 to 10 years, and costs would plummet.  Should we then pat ourselves on the back and say what a marvelous health care system we have?  

    My point is that to look at our health care costs and point the arrow of causation in one direction is misleading.  You could hypothesize that one potential cause of our poor health despite high costs is that our health care delivery systems are worse, just as you could hypothesize that there’s an as yet unrecognized environmental toxin we’ve all been exposed to, or that we’re the laziest population on the planet. etc.  To rail against our health care system because of these statistics is just hand waving propaganda.  There are lots of problems with our health care system, and we need to have honest discussions about how to fix them.

    And I disagree entirely that the whole purpose of the healthcare system is to keep people from getting sick.  The system is there to take care of me if I have a massive heart attack, or Dengue fever, or Guillain Barre syndrome.  Preventing lifestyle related illness is our responsibility.  If you reach adulthood not knowing that smoking, substance abuse, a diet based on processed foods, sedentary behavior, etc. are going to make you sick, then that’s fault of our culture and our educational system.  And I’d contend that the vast majority of the population know these things, but choose to act differently.  And I would hypothesize that that’s why we’re so sick.

  24. Chris Kresser’s avatar

    You must not have read my reply.  Once again, I’m not “pointing the arrow of causation in one direction”.  I clearly said that the fault is shared amongst patients, healthcare providers, insurance companies, drug companies (and I would add legislators).

    Nor did I say the whole point of the healthcare system is to keep people from getting sick. I’m not sure where you’re coming up with this stuff.  I said that when people do get sick, as in the case of the diabetic person I mentioned above, they should get a treatment that is backed by the latest evidence and that actually helps – not harms – them.

    I also disagree strenuously that healthcare providers don’t have a responsibility to help their patients stay healthy.  The idea that they should just wait until people get sick and then treat them is shortsighted and one of the primary reasons our healthcare (or rather, disease-care) system is so inefficient, expensive and ineffective.

    Countless studies have shown the value and cost-effectiveness of preventative medicine. It’s a complete no-brainer.

    Your viewpoint is privileged.  It assumes that all people have the same access to resources, education and time and the same ability to discern good from bad information.  I know plenty of highly intelligent people that are very motivated to live a healthy lifestyle.  They do their own research, but there’s so much contradictory information out there they look to some.

    It’s disingenuous to use smoking and substance abuse as examples.  Everyone knows those activities are harmful.  But what about diet?  For decades we were told that eating a low-fat, high-carb diet was “healthy” and that a diet high in saturated fat and cholesterol caused heart disease.  Now research clearly shows that low-fat, high-carb diets contribute to cardiovascular disease, obesity and metabolic syndrome (among other things), and that saturated fat and cholesterol don’t cause heart disease.  Most people – even well-educated, “health-conscious” people still aren’t aware of this.  Why?  Because our healthcare system is hopelessly in the grip of drug companies that have a vested interest in selling people drugs – regardless of whether they’re beneficial or not.

    I could go on, but I have a feeling there’s not much point.  We’ll just have to agree to disagree.

  25. Bob’s avatar

    In your post you say:

    “Considering this enormous expenditure, we should have the best medicine in the world. We should be reversing disease, preventing disease, and doing minimal harm.”

    You didn’t say:
    “Considering this enormous expenditure, we must have the unhealthiest lifestyles on the planet.”

    “Considering this enormous expenditure, there must be something contaminating our water supply that’s making us all sick.”

    etc, etc..

    The fact that you conclude that higher costs should lead to healthier population and means we have “one of the worst healthcare systems in the world” reflects a bias in your interpretation of this data.  You could be right, but there are multiple alternative hypotheses that could account for the statistics.  You focus on one and then use it to support your argument.  (incidentally, it’s this kind of sloppy logic and biased data analysis that is the very reason the nutrition experts wrongly advocate a “low fat, high carb” diet!) 

    And you say:
    “It’s disingenuous to use smoking and substance abuse as examples.  Everyone knows those activities are harmful.  But what about diet?”

    That’s my point!  Everbody knows smoking is bad – and millions still smoke!  And they’ll get sick, and cost the health care system billions of dollars.  Our problem is not education, it’s compliance.  The people who are involved enough in their own health to come to a wellness doctor, care about preventitive health, follow the recommendations of their doctor, etc. are by and large not the ones who are getting sick from lifestyle related illnesses.  A 20 year old chain smoker who has been raised in poverty and a steady diet of processed junk isn’t poring over epidemiological studies on the internet trying to figure out proper macronutrient ratios.  The ones are that involved in their health are not the ones driving up costs.

    Also, most of the countries that beat us in overall health make the same dietary recommendations that US docs do, prescribe the exact same medications, etc.  That patient you mention with the high blood glucose will be given the same meds, the same diet guidelines in Sweden as they would here in the US.  Yet the Swedes are much healthier.  But our health cares system is “one of the worst in the world”, and theirs one of the best??

  26. John Smith’s avatar

    It is the ‘monkey’ in us that keeps us from being healthy.  We play follow the leader and the leader can’t help himself from putting on a silly hat and thinking he is now god.

    If you want to understand the primal conditions that make this true, the story of Capt. Cook is a good model.  The residents of the Hawaiian Islands had this tradition that a white god would come some day, so when Cook turned up, pink though he may well have been, they worshiped him. 

    He was only too willing to avail himself and his crew of their favours, pigs, yams, sex, labour to repair his ship etc.    However, when the natives discovered his Achilles Heel, that he was just a mortal man, same as themselves, one of them put a spear through him and his god status was sent packing.

    A similar thing happened with midwives, or maternity nurses, or witches, as they evolved to be.  You can see that same monkey-mindedness at work in this case with a multitude of people.

    Now progress that throughout a society to the entire world, and you can see that the monkeys are following the Dr. WHO (World Health Organisation) which is run by other monkeys with cute hats (flat tops and tassles), and when sufficient of the public wake up to their frailties the spears will come out again.

    Now just who is responsible for all that is rather difficult to determine, but after Cooks death, there was not much more story to record.   After the witch trials, we simply switched to male leaders, and after the next purge there will be only a few tribal customs survive (if that even, if nuclear war breaks out).

    So I blame the guy who invented monkeys.   He must have wanted it this way.  Or was he a she?  Or was IT an insect?

    What is here now is for us to sort out and few there be who want to walk the narrow pathway.   When those who want the easy life are gone, we will start all over again: Hopoefully!

    But old age and treachery will beat youth and innocence every time!



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