But while Republicans are intent on politicizing care, there are other, far-more effective ways of lowering costs that deserve more airtime, including by revisiting preventive care and some of its excesses. Those excesses not only return higher costs to patients (through greatly increased premiums and co-pays), but also can do demonstrable harm to the same vulnerable population by needless, irresponsible overmedication.

In 2008, the Lancet ran an important article, "Is clinical prevention better than cure?," whose principal author, Dr. Juan Gérvas (Equipo, CESCA, Madrid; and Johns Hopkins, Baltimore) focused on the "daily challenge" facing doctors wanting to find "the right balance between prevention and treatment." As wealthier countries in particular move from cure to prevention, in an effort to anticipate future diseases, far too little attention was being paid, Gérvas argued, to the degree to which prevention can also do serious harm, including by overmedicating, creating unanticipated side effects, and--our focus today--massively ramping up costs. Noted Gérvas, "The potential consequences of preventive measures include possible disruption of cultural and individual capacities to cope with sickness, pain, and death; increased fear and perception of illness where none exists; and clinicians' frustration over a growing list of requirements that are impossible to accommodate within the clinical visit."

Of particular interest to Tokyo-based medical professor Yuri Sato, responding in the same medical journal three months later, was Gérvas's focus on the consequences of "individuals' wishes for immaculate health," a concept that Carl Elliot addressed in Better Than Well: American Medicine Meets the American Dream (2003). For Sato, as for Elliot and Gérvas, conscious also of the unstated dangers and basic impossibility of "immaculate health" for most populations, far more attention needed to be given to the differences between relative risk and absolute risk, as well as the "relentless ... pressure [for physicians] to do more, whether in prevention or treatment."

Just one source of that pressure is direct-to-consumer advertising, which urges the worried well to "ask their doctor about" dozens of new medications offered for conditions whose severity is often greatly exaggerated. "Not all preventive activities are of equal value," Gérvas noted, drawing on still-earlier assessments of this problem, such as Ray Moynihan and Richard Smith's 2002 editorial in the British Medical Journal, "Too much medicine? Almost certainly."

I was reminded of Gérvas's fascinating article when Marc Jamoulle, a Belgian physician, shared with me last month an article he'd co-written with Gérvas and three other European practitioners. (The article, appearing in the November 2010 issue of Primary Care, has already appeared in five languages.) Extending Gérvas's earlier arguments and those of many others sharing the same concerns about prevention often doing more harm than good, Jamoulle, Gérvas, and their colleagues developed the concept of "quarternary prevention" in a bid to eliminate the vast excesses of European and American overmedication.

Quarternary ("fourth") prevention examines the "meeting point between illness and disease," they write. Beyond primary, secondary, and tertiary prevention, quarternary prevention (hereafter QP) "encompasses the consequences of the encounter between the anxiety of the patient and the uncertainty of the doctor," where overdiagnosis can often create a "false positive, with its cohort of avoidable human, social and economic costs and suffering."

Whereas primary prevention includes such essential acts as immunization against known diseases, and secondary and tertiary prevention aim to lower risk factors by screening and early detection, QP, they write in Primary Care, "is the prevention of unnecessary medicine or the prevention of overmedicalisation."

"The principle of ‘primum non nocere' [first, do no harm] is central to the whole of medicine," they add. But "mainly in the name of prevention, there has been an explosion of new disease labels and health care measures that warrant a rethinking of the objectives and underlying philosophy of primary care. Especially in an area of high grades of uncertainty and low prevalence of severe diseases, the most difficult thing for the physician is the decision not to pursue further action and to protect our patients from unnecessary medicine."

While "the feeling of being ill does not necessarily meet the doctor's judgment that there is a disease present,... there are more and more disease labels attached to patients who feel perfectly well." "In fact," they write, "the most common so-called ‘chronic conditions,' such as hypertension, diabetes, osteoporosis and many others, are diseases without illness."

"While the patient experiences illness," they note of these and many psychosomatic and controversial disorders, and may "feel relieved from the perceived blame of a psychiatric disorder, all [such] symptoms and illnesses widely open up the doors for endless diagnostic procedures. Most of them will have normal results, but many will have borderline or false positive results. The consequences are endless further diagnostic tests and prescriptions of never-proven therapies with well-known side effects."

One of those side effects, it goes without saying, is a massive increase in general health-related costs. Another, often labeled "disease-mongering," is the deliberate exploitation of medical and psychiatric gray areas, with interested parties pushing to expand the "disorder" to fit the largest possible population because it suits them to represent the condition as graver, more extensive, and less recognized than we've hitherto known. Working often with the notion of "unmet need" and "underdiagnosis," these interested parties (including the drug companies sponsoring the research on their product in the first place), stand to gain enormously if they can expand the pool of prospective patients/clients from chronic sufferers to include also those with mild or nonexistent symptoms.