Everything else I write here is about a body: how it answers training load, what it does with fuel, what a very long race exposes. This one is about the room all of that is happening in, because the room turns out to explain a lot of what looks like personal failure.
There’s a version of this essay that names a villain. Greedy pharma, cynical insurers, doctors who stopped caring. It reads well, and I’m not going to write it, because if the problem is somebody’s character then the fix is finding better people, and better people won’t touch this.
So, the narrow claim. European health systems are genuinely good at finding and treating illness that has already turned up, and close to structurally blind to the illness that hasn’t arrived yet, and the reason sits down in the plumbing rather than anywhere near anyone’s motives. Keeping a person well produces nothing an institution can bill for, and institutions do what they can bill for.
That’s an accounting problem, and it changes what it makes sense to walk into a doctor’s office and ask for.
This is an educational and strategic perspective, not personal medical advice. The views are the author’s own and not statements by Atlas Cove Lda.
I trained as an engineer, so my instinct with any system I don’t understand is to go and look at what it spends. Strategy documents describe intentions. Budgets describe behaviour.
Across OECD countries, spending classified as prevention has sat at around 3 percent of total health expenditure, and it lifted toward 6 percent during the pandemic before settling back near where it started (OECD, 2023). Which leaves well over 90 percent pointed at illness that already arrived. I’d read that as a description of what the apparatus can see, fund and account for, and not as a statement about what anybody inside it believes.
The mechanism sits in how providers get paid, and the two dominant models push the same way for opposite reasons. Fee-for-service pays per service delivered, so billable volume sets the revenue, and anybody responding sensibly to that signal does more of whatever can be coded. Case-based payment was built to stop that. The Diagnosis-Related Group systems now underpinning hospital finance across most of Europe pay a fixed tariff per classified case, set by diagnosis, procedure and complexity (Busse et al., 2011). Germany, France, Spain and Portugal all run on them. Inside the hospital it works, because a fixed tariff turns each admitted case into something to handle efficiently rather than expansively, and restraining the volume incentive was the whole point of bringing it in.
No version of it generates revenue for the case that never arrived.
Porter and Teisberg described the general shape of this twenty years ago, arguing that health systems compete on the volume of services they deliver and on shifting costs onto each other rather than on what a patient actually gets across a whole cycle of care (Porter and Teisberg, 2006). Prevention fits that competition badly. An illness that doesn’t happen produces no volume, no code and no line in any quarterly report anyone is answerable for.
The structure reaches all the way down into a single appointment, which is where it stops looking structural and starts feeling like bad luck or a personal failing.
You walk in with a question about direction rather than about a symptom. Where is this going, over ten years, given what you can see? That room is built to produce one output, which is whether a diagnosable illness is present and what’s indicated if it is, and a slow drift across several markers that are each still sitting inside their reference range is an interesting signal to anyone thinking about a decade and a complete non-event for that decision.
Nothing went wrong in the room. The room did its job.
Berwick made the general point back in 2002, writing about the Institute of Medicine’s quality work: what a health system produces follows from how it was designed and from what that design measures and rewards, so expecting different output out of the same structure by exhorting people harder was never a serious plan (Berwick, 2002). Systems count procedures performed and cases coded. They count avoided illness and preserved years of good function very badly, because the first group has identifiers attached to it and the second doesn’t.
The gap turns up even inside what systems fully intend to do. The best known attempt to measure it found that adults in the United States got the recommended standard of care roughly 55 percent of the time across a wide range of conditions, and the authors were explicit that this was systems failing to deliver what was already known rather than clinicians who didn’t know it (McGlynn et al., 2003). European systems are financed differently and would produce different numbers. They share the underlying difficulty, which is doing consistently what they aren’t structured to measure.
Two winters and two springs, I lost whole days at a time to severe migraine, aching like flu and a tiredness that sleeping didn’t touch. I’d go in, bloods would come back unremarkable, somebody would tell me it all looked fine, and I’d leave with nothing. Four times, I think. Maybe five. Somewhere in there I’d quietly filed the whole thing as a lack of interest.
I had it wrong, and I’d decided who was at fault before I’d checked anything.
Every one of those appointments answered its own question correctly. Is there a diagnosable illness here? No, there isn’t. I was walking in with a different question, about regulation rather than about any one organ, and I kept putting it to the one institution in my life that has no mechanism at all for receiving it. Part of mine does have a name, as it happens: cold urticaria, mast-cell driven, with a family history of autoimmune dysregulation sitting behind it. A name is worth having, and it still isn’t a plan.
What eventually moved things took months and would have looked like nothing on a chart. I stopped drinking, went to bed and got up at hours I stopped negotiating with, and pulled the intensity out of my training for long enough that it stopped really being training. Recovery came back well before performance did, in that order, which I hadn’t expected and didn’t much enjoy. None of it was ever going to be prescribed to me in a fifteen minute slot, because none of it is a thing you can do to a person once.
A fair objection lands here. Europe contains several genuinely different health systems, so surely one of them handles this better than the others.
The differences are real, and I’ve been a patient in two of them. Germany, where I’m from, runs a Bismarck model, care financed through social insurance contributions and a plurality of sickness funds, while Portugal, where I live and work now, runs a Beveridge model financed out of general taxation with the state as the dominant purchaser, and various hybrids sit in between the two with their own arrangements for cost sharing and waiting times. From the inside they feel nothing alike. What you pay and what you wait for are different, reaching a specialist is a different exercise entirely, and anybody claiming a patient in Berlin and a patient in Lisbon are in the same situation has not tried both.
Neither of them ever asked me a question about the next ten years.
What they do share is which way the money runs, because in each of these arrangements the money follows the diagnosis and treatment of illness that already exists (OECD, 2016). Prevention is also a set of things people do, and things people do can in principle be paid for. The catch is what triggers the payment. Payment is triggered by a diagnostic or therapeutic event attached to an illness that exists, so work whose success consists of an illness never existing has nothing to trigger on.
A hospital paid per case manages case mix and length of stay. A provider inside a fixed global budget contains demand within that budget, and prevention lowers demand at some distance in the future while eating resources now, which returns nothing at all inside the period that provider gets judged on. Mixed systems inherit both logics and arrive in the same place. Moving country doesn’t solve it, and the OECD’s own review of how to pay for care still treats rewarding prevention as an open question rather than a settled one (OECD, 2016).
None of this needs anyone acting in bad faith, and it’s worth saying that flatly, because an incentive structure seen from the inside looks a lot like malice when it’s only economics behaving normally.
Treating a person is easy to define and therefore easy to pay for. A procedure has a code, a diagnosis carries a tariff, an admission produces recorded activity and recorded revenue, and a payer can audit every one of those. Prevention fails at all of them. There’s no invoice for the heart attack that didn’t happen, and no billing identifier for a decade of function maintained.
A second economic property sits underneath, and this is the part I find interesting. Medical care is a credence good, meaning the buyer usually can’t judge the quality of what they received and has to trust the seller’s judgement about what was needed, which is most of why medicine ended up regulated and professionalised as heavily as it is. Prevention is the extreme case, because its successful output is an absence, and an absence can’t be inspected or compared or pinned on anyone. A market can’t price the permanently invisible. A public payer can’t easily defend a budget line whose returns arrive in a later electoral cycle, in a different institution’s accounts, under somebody else’s name.
The gap that leaves is wider than it first looks, because clinical care was never the main input to health. Work on the determinants of population health put around 10 percent of premature death down to shortfalls in medical care, with behaviour, social circumstances, genetics and environment carrying most of the rest (McGinnis et al., 2002). Marmot arrived somewhere compatible from the opposite direction, and showed in detail how the conditions people live and work in shape health to a degree clinical care can’t offset (Marmot, 2010).
Set that beside the spending figures and the shape of the problem is obvious. Systems put nearly all of their money and nearly all of their attention on the small share of health that medical care directly determines, while the much larger share, which is also where nearly all the room for prevention sits, lies outside what they fund or count at all. Individual decisions matter enormously in there. They’re being made in a space nobody is paid to occupy.
I’d rather none of this got turned into an argument against clinicians, most of whom understand prevention perfectly well, want to help, and are working inside a structure they didn’t design and can’t move on their own. Seeing the structure is useful for a smaller reason than blame, because once you can see it you stop asking it for the one thing it isn’t organised to supply.
Four questions locate where any given system stands. Aim them at the system, not at whoever happens to be in the room.
Does this place measure prevented illness, or only treated illness?
If I stay well and use fewer services over the next decade, does that return anything to me, or to whoever treats me, or does it simply disappear?
When something gets measured in me, can somebody explain why that one and not another?
Is prevention funded here as infrastructure with its own budget, or bolted onto the budget for treating people?
For most people inside a European system the honest answers all point the same way, and it took me until my thirties to ask any of them. There’s nothing embarrassing in that. Financing structures stay close to invisible from the inside until someone goes looking for them.
Fixing this at the level of a system is slow collective work, because it means changing how success gets defined, how it gets measured and how resources move across whole institutions and several budget cycles at once. I’d like that to happen. I don’t plan around it.
What one person can do is narrower and considerably more useful. Stop treating a treatment system as though it were a prevention system. Use it well and gratefully for the acute and diagnosable problems it handles with real skill, and assemble the prevention layer deliberately somewhere else instead of waiting for somebody to provide it.
That gap is why my sister and I started Atlas Cove. The week stands in the long stretch of ordinary life where no institution is paid to be present, beginning from a person’s own measurements and ending with decisions that have the reasoning attached, and it replaces nothing, because medical care stays the right answer for genuine illness. I’m confident about the gap and a good deal less sure that one week is the right size of answer to it.
Personal health rarely stalls for want of effort, and among people who read essays like this one it almost never does, because it stalls instead at the boundary of a system that measures treated illness precisely and prevented illness hardly at all. Frustration is the wrong answer to that, and so is hunting for a better country to be a patient in. Learn the incentives well enough to use each part of the thing for what it’s actually good at, and build the rest yourself.
This is an educational and strategic perspective, not personal medical advice. The views are the author’s own and not statements by Atlas Cove Lda.
OECD (2023). Health at a Glance 2023: OECD Indicators. OECD Publishing, Paris. DOI: 10.1787/7a7afb35-en
Busse, R., Geissler, A., Quentin, W., & Wiley, M. (Eds.) (2011). Diagnosis-Related Groups in Europe: Moving Towards Transparency, Efficiency and Quality in Hospitals. European Observatory on Health Systems and Policies / Open University Press. ISBN 9780335245574
Porter, M. E., & Teisberg, E. O. (2006). Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press, Boston. ISBN 9781591397786
Berwick, D. M. (2002). A user’s manual for the IOM’s ‘Quality Chasm’ report. Health Affairs, 21(3), 80-90. DOI: 10.1377/hlthaff.21.3.80
McGlynn, E. A., et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348(26), 2635-2645. DOI: 10.1056/NEJMsa022615
McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion. Health Affairs, 21(2), 78-93. DOI: 10.1377/hlthaff.21.2.78
Marmot, M. (2010). Fair Society, Healthy Lives: The Marmot Review. Institute of Health Equity, UCL
OECD (2016). Better Ways to Pay for Health Care. OECD Health Policy Studies, OECD Publishing, Paris. DOI: 10.1787/9789264258211-en
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