Health economics: why European and OECD systems reward treatment over prevention, and why seeing that structure clearly changes how you use them.
A particular sequence keeps repeating for people who take their health seriously. A doctor measures something, reads the result, and says it looks fine, and then some months later it is plainly not fine. A carefully run programme of training, food and recovery stops producing results for reasons the effort cannot explain. The guidelines are followed exactly, and the outcome still refuses to move. It is natural to read this as a personal failing, a matter of insufficient discipline or of not yet finding the right plan.
The more accurate explanation sits underneath the individual, in how healthcare systems are paid and measured, because those systems are organised almost entirely around treating illness that has arrived rather than preventing the illness that has not. Once that incentive structure is visible, you can use these systems for what they genuinely do well and stop expecting from them what they were never built to give.
This is an educational and strategic perspective, not personal medical advice.
What a system measures becomes what it does
Healthcare systems understand prevention perfectly well. What they lack is a dependable way to measure it and to pay for it, and inside a large organisation the measured and reimbursed things are the things that actually happen. The plainest sign of this is where the money goes. Across OECD countries, prevention has taken up around three percent of total health spending, rising briefly to roughly six percent during the pandemic before settling back, which leaves well over ninety percent directed at treating conditions that are already present (OECD, 2023). That is not a judgement that prevention is unimportant. It is a reflection of what the system is set up to recognise and reward.
Payment models are the mechanism beneath the pattern. Fee-for-service pays for the volume of services, and the Diagnosis-Related Group systems used across Germany, France, Spain and much of Europe pay hospitals per classified case, which rewards throughput and careful coding of the work done (Busse, Geissler, Quentin and Wiley, 2011). A hospital that optimises for case mix and reimbursable interventions is simply staying solvent under the rules it was handed. Michael Porter and Elizabeth Teisberg described the general form of this, noting that systems tend to compete on service volume and cost-shifting rather than on value delivered to patients, and prevention sits awkwardly in that logic because a disease that never occurs produces no billable volume and shows up on no quarterly report as a success (Porter and Teisberg, 2006).
Why careful personal effort meets the same limit
It is worth being exact about how this reaches a person, because it is so easily misread as bad luck. Someone can track their markers, manage their load, follow the guidelines and protect their sleep, and still find that the system around them measures less what improved their health than what justified a billable intervention. This is not cynicism. It is the recurring finding of health quality research, which is that what a system chooses to count ends up shaping what its organisations produce, more reliably than good intentions ever do (Berwick, 2002). Systems of this kind count procedures, compliance and hospital activity well, and count avoided disease and preserved years of health poorly, for the simple reason that the first group has billing codes and the second does not.
The result is not careless care by careless people. It is that even well-run systems deliver inconsistently the things they are not built to measure. A landmark American study found that adults received the recommended standard of care only about fifty-five percent of the time, and the authors traced this not to incompetent clinicians but to systems that fail to implement what is already known (McGlynn et al., 2003). European systems are financed and governed differently, yet they share the same measurement problem, so a person doing everything right is still working inside an environment aimed at a different goal than their own.
The same incentive runs through every model
A fair objection is that Europe holds several different models, and surely one handles prevention better. The Bismarck systems of Germany, France and Belgium fund care through social insurance, the Beveridge systems of the United Kingdom, Spain and Scandinavia through taxation, with hybrids in between. These are real differences in how cost and access are shared. What they have in common is the direction the money flows, because in each of them reimbursement follows the diagnosis and treatment of illness that has already appeared rather than its prevention (OECD, 2016).
A hospital paid per case is pushed toward managing case mix and throughput, so prevention stays invisible in its revenue. A provider on a fixed budget is pushed toward managing demand within it, so prevention, which lowers future demand without raising present income, offers no near-term reward. A mixed system inherits both logics and the same outcome. The details differ, and a patient in Berlin does not experience the same thing as a patient in Madrid, but the orientation toward treatment over prevention is shared, which is why switching country or model does not solve the individual's problem.
Why prevention stays underfunded, and why it is not a conspiracy
None of this is a plot against patients, and it is worth saying so, because an incentive structure is easy to mistake for bad faith when it is really just economics behaving normally. Treatment is easy to measure and to pay for. A procedure has a code, a diagnosis has a reimbursement, a hospital stay produces recorded revenue. Prevention resists all three. You cannot bill for the heart attack that did not happen, cannot report on the illness that never developed, and cannot code for a decade of preserved health, so the whole category slips outside the machinery a system uses to recognise its own work.
The gap matters more than it seems, because medical care is only a modest contributor to health to begin with. Work on the determinants of population health has put shortfalls in medical care at roughly ten percent of premature death, with behaviour, social circumstances, genetics and environment carrying far more of the total (McGinnis, Williams-Russo and Knickman, 2002). The Marmot Review arrived at a compatible conclusion from the other side, showing that the conditions in which people live and work shape health to a degree clinical care alone cannot offset (Marmot, 2010). Systems therefore concentrate their spending and their measurement on the small share of health that medical intervention directly controls, while most of what determines long-term health, and most of what is open to prevention, sits outside what they count or fund. Individual choices matter enormously within that majority, but they are made inside a structure whose incentives point elsewhere.
Seeing the structure clearly
The point of understanding this is not to assign blame, and certainly not to blame clinicians, most of whom understand prevention and want to help while working inside structures they did not design and cannot easily change alone. The point is to see the structure accurately, because someone who sees it can stop asking the system to do the one thing it is not organised to do. A few quiet questions make any given system's orientation legible.
Does it measure prevented disease or only treated disease. Does staying healthy and needing fewer services return any benefit to the patient or the provider. Can a clinician explain the reasoning behind what they measure, since a reasoned framework adapts where a fixed protocol does not. Is prevention funded as its own infrastructure or treated as secondary. For most people inside a European system the honest answers point the same way, toward an environment built around treatment, and there is no shame in noticing that, because the incentives stay close to invisible until you look for them.
Changing this at the level of a whole system is genuinely hard, since it means altering how success is measured and how resources are allocated across an entire institution, which is a slow collective project rather than an individual one. What a person can do is more modest and more immediately useful, which is to stop treating a treatment-oriented system as though it were a prevention-oriented one, to use it well for the acute problems it handles ably, and to build the prevention layer deliberately somewhere else instead of waiting for the system to supply it.
Where Atlas Cove fits
This is close to the reasoning behind Atlas Cove. The week is built to supply the prevention layer that the surrounding systems are not structured to provide, starting from a person's own numbers and turning them into decisions that are measured again before they leave, so that health is maintained on purpose rather than only attended to once something has already gone wrong. The intention is not to replace medical care, which stays the right choice for genuine illness, but to occupy the long stretch of ordinary life where prevention is where almost all of the return actually is. Personal health rarely fails for want of individual effort. It more often meets the limits of a system that measures treated disease well and prevented disease hardly at all, and the useful move is to understand those incentives clearly enough to use each part of the system for what it does well, and to build the rest yourself.
Tom Wuerden · Co-Founder
Engineer turned Ironman