By Fred Pelzman, MD

The old saying about an ounce of prevention should still hold true today.

While I don't begrudge the complexity of the work done by specialists and subspecialists, or the operations performed by our surgical colleagues, the benefits of primary care seem to argue for making a greater investment in this across our country.

In these uncertain times, as public health and science and healthcare in general are threatened in so many ways, it would seem that investing in prevention and chronic disease management and equitable access to care really would, should, and could be the way to go.

Think of a world in which, instead of managing diseases that presented in late stages, advanced cancers, severe heart failure, end-stage kidney disease requiring dialysis, peripheral vascular disease requiring amputations, we instead set up a system that afforded everyone the ability to come into care, to stay in care, to manage their health and attend to all their preventative interventions and get themselves to the healthiest lives possible.

Years ago, when the committee was formed that helped set the rates for reimbursements in healthcare, a group of specialists and subspecialists and surgeons sat around and decided how much a surgery was worth, how much a transplant should be reimbursed, and what the complex care provided by super sub-specialized folks should be valued at. This was done through a system of "relative value units," in which each procedure or intervention was given a numerical value comparing its worth to that of another procedure.

This system, which is still in use today in fee-for-service Medicare, tends to assign surgery and other specialty procedures higher values than primary care visits and interventions, so primary care doctors end up getting paid less for their services. For the most part, primary care doctors have been left out of these discussions.

It feels like only in hindsight has the committee grudgingly offered up incredibly low rates for evaluation and management, including preventive annual care visits, which has led to a system of needing to churn through patients, to pack people onto your schedule, instead of being able to thoughtfully take care of them, to listen to their complaints, to evaluate them without referring them out, to manage them on our own.

Wouldn't it be better if we turned the system on its head, and truly valued primary care's contribution to a patient's life, longevity, and health?

We know the things that are going to get and keep people healthy, getting them to quit smoking, managing their stress and mental health, providing excellent prenatal care, good nutrition, keeping hydrated, exercising, getting needed vaccines, and undergoing all your age-appropriate screenings.

If we built this solid base of a pyramid and threw tremendous resources at making sure every patient had every opportunity to get these things done, to follow through with them, and to stick with them -- to make the changes they needed to get to their healthiest selves -- think of all the things we could avoid.

If we lived in a world where every woman who needed it had cervical cancer screening, think of the untold misery we could avoid. If people had their colonoscopies and mammograms on schedule, the complex and costly and devastating care and treatment they might require when things are not detected early could be avoided.

I recognize that no matter what system we build, things will still happen. Cancers will pop up out of the blue, kidneys will fail, hearts will not pump hard enough.

And treatment of things like hypertension and high cholesterol with medication can only do so much. We need to make sure our patients are living their healthiest lives -- eating healthy diets, not smoking, and exercising as much as possible -- but even then, the contribution of family history through genetics may lead to certain things happening down the line no matter what we do.

But if we could focus on primary care, preventive care, and timely access to care in this country, and take the finances out of the picture, think of the burden of disease we could prevent, the massive suffering, all the early morbidity and mortality that we could avoid.

Sure, we're always going to need general surgeons, transplant surgeons, colorectal surgeons, neurosurgeons, and oncologists, heart failure specialists, and electrophysiologists; and nephrologists to carry out dialysis. But if in addition to a robust public health system and a government that was looking out for our health, for the health of everyone, we might be able to tip the scales away from illness and towards health.

After all, it's all relative.