Suggest this concept be costed by someone who can do the actual numbers -- suspect the outcome may be the opposite. No numbers/no one knows.

Read the linked piece, there's a chart with numbers.

Ezra,

I don't get it. I mean, it is true that if you make the choice between a dead guy or a guy who's alive but in the hospital due to a heart attach and costing society money, the dead guy is 'cheaper'.

But what about the productivity gains from all of those people who would have gotten sick but are instead working? Isn't that a net gain for society from the economic point of view, even without thinking about the question of "value"? Or are these gains offset anyways by the cost of preventive medicine?

Cheers.

Is this thing on? (tap, tap)

Contrarian Wednesday!

Someone should argue (if not me, who else?) that some high-tech monitoring and precautionary care - that costs a good deal of money (CT Scans, Ultrasound, beta blockers, etc.) - are really a good investment, because if not done, the ultimate costs of, say, a liver transplant, will be super expensive and very predictably necessary (unless we are willing to just those people DIE (like we have in the past).

This subject is way to tricky to argue globally, IMO. I'm for doing what can be done medically now to prevent future high-probablity events later - but we need to find a workable way to mitigate none-medical issues from intruding on the care decisions. For instance, CT scan equipment is very expensive, but is over-purchased in major population centers (every facility needs their own very-latest tech version asap) and underutilized on a daily 24 hour basis. The machine doesn't get tired, and doesn't have to sleep. Make it earn its keep.

Besides, once people get acclimated, the peace of mind that flows from knowing exactly what, if anything, is out-of-kilter, is way much better than facing the constant fears and denials from not being aware but still fearful. Peace of mind is a liberal value too. (freedom from fear).

Insightful, but off by just a touch, I think

Its true that preventive care doesn't save money, for the reasons you describe. But that doesn't mean it should not be the focus of a rational health policy -- the question is not the capacity to reduce the overall health spending, because we could truly spend as much as we desire and still see some marginal return on the last dollar. Rather the question is the net increase in health status produced by the dollars we choose to spend. People dont die of lung cancer will have to spend money on other interventions that accompany aging, but the smoking cessation package has nonetheless cheaply prevented death and misery.

I have noticed a tendency to try to see ways to save money without really "hurting" the patient care aspect at all. Hence the repeated arguments that we can save money by scrapping various clerical parts of health insurance or by focusing on prevention, even though we don't have very good studies on the efficacy of some types of prevention we advocate.

That's quite natural and human, of course, because nobody likes to think that we might actually have to make some types of care (of unknown or minimal value but with high costs) unavailable. I don't see any way around addressing that problem, however, especially as concerns the last year of life and the very high costs that occur then because of the "do-everything-possible" kind of care.

Not to go all OT but I see the discussion somewhat differently. First, the primary reason we ought to invest more money in preventative care is not to *save money* but to save lives and the quality of life for larger numbers of human beings. It may also be the case that (some) money is going to be saved for (some) people. It is also the case that (some) grief and pain is going to be saved for (some) people. But no plan is going to save lots of money, plus lots of pain and suffering, for all the people all the time.

But this doesn't, in fact, differ from the current state of affairs. Under the current state of affairs catastrophic and end of life needs are catered to and paid for for (some) people who get that far and who have insurance or medicaid or medicare while lots of people lack daily, primary, preventive medical care because...well, because the costs of the care are born by insurance companies but the benefits acrue to individuals who may or may not be customers of the insurance companies by the time the pay off arrives. In addition, the cost of the preventive care is invariable but the "reward" can't be taxed--the insurance company neither loses money when it loses a client (since premiums are never as large as the cost of the medical care) nor gains significantly more money when the patient is saved from a debilitating disease.

We're just talking about lots of different variables and too many actors and costs to be evaluated on a purely cost/benefit scale.

But we know, as J. Goodrich points out, that "end of life" care when we are, at best, talking about prolonging life by a few months is the costliest. We could definitely save a mint of *wasted money* (as opposed to saving a mint of unwasted but hard to value money on children's vaccines and teeth) by trying to have better metrics for estimating liklihood of death and paying for patients and families to have hospice care rather than one more medical intervention.

aimai

And yes, I have lived through the deaths of several grandparents and elders and would happilly accept hospice care for myself over mindless prolongation of death in life.

I agree with the post but want to add that some preventives can have some negative health effects.

aimai has it, but let me add one point. The reason we should compare the cost of preventive care to the cost of end of life care is not that the former prevents the latter -- quite the contrary -- but because there is a finite amount of money we can spend on health care. The trade-off is not a natural consequence of preventing illness, but the natural consequence of our inevitably limited tolerance for expanding the share of health resources within our GDP.

Ezra,

Great post. A few additional thoughts:

-- A system based on value will for the most part, put preventative care at the top. So its not "Preventive care should also be pursued"-- its that under a cost/per impact metric (e.g. $/QALY), many elements of preventive care will rise to the top of that list.

-- A similar phenomenon is seen with two other policy favorites-of-the-moment: health IT and medical homes. Health IT could potentially lead to lower utilization (even that's questionable though), but after factoring the costs of implementation and maintenance, many in the field believe its a wash at best. Better value of dollars spent-- yes, but not cost savings. Similar for medical homes, better care coordination will lead to increased utilization of health care for those without a strong support structure today, offset by those who are accessing care today in an inefficient fashion. Again, the value of the system is better, but cost savings themselves are not likely to materialize.

Ah, so what you want are preventative strategies that keep people healthy until they acquire a quickly (and cheaply) terminal condition rather than a slow and expensive decline.

idlemind,
wouldn't that be selling cyanide laced cigarettes to smokers. A certain number of packs would be infected and then a certain percentage would die quickly, without costing the rest of us anything? I think this very argument was more or less made by the tobacco companies.

aimai

A couple points:
1) It's probably not helpful to talk about all preventive care as either cost effective or cost ineffective. Statins on moderate risk groups aren't cost effective; helping someone stop smoking may be more cost effective.
2) I don't have the time to track down the studies the Post references, but do these studies factor in value produced? That is, of course someone who dies at 80 will probably, over time, consume more health resources than a 45 year old with lung cancer. He'll also produce a lot more value. How does that get factored in?
3) I agree with Wisewon that most of the cost savings initiatives--electronic records, etc.--aren't likely to be of much use financially. I think a more realistic goal is to improve care and get medical inflation in line with inflation, at least in the short run.

as far as "preventive care" goes, where do we draw the line in terms of what constitutes preventative care.

i mean, when being told how to best take care of our health, what do we hear? we are to eat well, avoid or limit fats and sugars, exercise, get plenty of sleep, reduce our stress and/or adopt stress coping mechanisms.

we take about taking statins as preventative care, but it strikes me that the need for statins can be eliminated for most people if our diets are revised.

so where in the budget numbers do we talk about the cost of fresh fruits & vegetables compared to subsidies for corn syrup? where do we talk about providing free gym memberships to everyone who wants one? or mandating paid vacation time for all workers? &c.

this may be veering way off topic, but let's talk about preventing the conditions from the ground up, not intervening part way and calling it "preventative".

IMHO &c.

"...our inevitably limited tolerance for expanding the share of health resources within our GDP."

How limited is our tolerance assuming that new and better treatments can be paid for without crowding out really important expenditures like larger SUVs and foreign vacations -- which lucky outcome seems to be the case.

We now spend six (6!) times a much per capita on health care in ABSOLUTE terms than we did 40 years ago -- but only three (3) times as much as a share of GDP -- leaving 170% of 1968 GDP to blow on everything else (not even counting wide screen instead of black & white for the same $600 -- tech progress not even being counted in inflation numbers).

No doubt small but positive productivity increases in health care can produce cheaper care even as health care occupies higher proportions of the GDP. But that doesn't mean that health resources wont have to be limited -- look at the obscene proportion of the economy we currently spend on health and look also at how much implicit rationing pervades the system. Now imagine that everyone is insured -- that people can get care they can't get now -- care they can't pay for, dont know about, or cant get insurance for because they are sick. Yes, there is lots of bullshit we can crowd out first -- overhead, insurance profits, fee for service distortions -- and there's lots of non-health economic activity we can eventually choose to go without. But ultimately, as Ezra notes, preventive care comes home to roost when people live longer, and there is, in any case, no limit on the number of health care interventions we can envision that provide some marginal benefit (or imnagined benefit) to someone, especially at the end of life.

And, I hate to say it, but I think the total volume of economic activity is also going to shrink as we encounter environmental limits -- we haven't been managing that too well either. There are also any number of non-health priorities competing for a share of public and private dollars that are currently neglected -- global poverty, peacekeeping, crime prevention, tighter labor markets (or, if you are conservatively minded, the war, big fences, whatever).

There are limits, is all I'm saying.

Sure, it's a shibboleth that preventive care doesn't save money, but where's the evidence? Pretty much all the studies we have are in situations where the party spending the money on prevention doesn't reliably get to collect the possible rewards later in the life cycle. (Remember, that's why insurance companies typically aren't that interested in promoting health.)

You may also be looking too narrowly. Are you assuming, for example, that the folks whose lives are -- statistically speaking -- prolonged by statins are paying full retail for their drugs? Are you assuming that in future the numbers of people needing statins won't have been changed by decades of access to doctors empowered and motivated to teach them sensible behaviors?

And, as others have pointed out, are you counting just the savings in health care costs (which is all a private insurer, even a lifelong one, can count) or are you looking at total economic impact.

It's obvious that we're not going to get big immediate economic gains from prevention, but the longterm issues are far less clear.

Paul
There isnt a dispute here about whether preventive care should displace more intensive interventions -- the question is whether it will do so naturally, or whether that will have to be a conscious, managed decision. As of now, we have the opposite -- intensive interventions driving up the price of insurance and displacing preventive care.

Actually, I take that back -- I'm not disputing that preventive care should displace other interventions, others might be.

The first argument, that statins (I don't even know what that is but that doesn't matter) may prevent some illnesses but at a high price is at least comprehensible (the same is true for vaccinations and other treatments, and which of these can truly be labeled "preventive care" is debatable).

The second, I'm sorry, is nonsense. You are right that the guy who quits smoking may get a heart attack instead of lung cancer but that's beside the point. He might as well have gotten both if he continued smoking. He might have developed cancer, survived it for a couple years thanks to very expensive, and very hurtful, treatments, and still gotten other diseases as well which may cost even more money. You have to take that into account when trying to assess the financial impact of preventive care. To conclude that not getting lung cancer is more expensive than not getting lung cancer is obviously nonsensical and you should take that back if your reputation is dear to you.

Oh dear. Again:

To conclude that *not* getting lung cancer is more expensive than *getting* lung cancer is obviously nonsensical and you should take that back if your reputation is dear to you.

I have taken a look at the referenced article and I think there is a misunderstanding.

"In 1986, a health economist named Louise B. Russell published "Is Prevention Better Than Cure?," in which she concluded that prevention activities tend to cost more than they save. Since the book's appearance, her observation has been borne out by studies of hundreds of interventions -- everything from offering mammograms to all women and prescribing drugs to people with high cholesterol to requiring passenger-side air bags in cars and shortening the response time of ambulances."

I suspect that the real question to ask is whether these prevention activities are *effective*. Mammograms, for example, are known to be notoriously unreliable and there is serious debate whether they may even do more harm than good.

Another example given is that of doctors reading a self-help booklet to patients. I think it isn't terribly difficult to predict that this activity, while not very expensive and probably not harmful, is also not likely to have much of an impact. Prevention through education may have great potential but probably it needs to be a concerted, well-planned effort (implicating schools, insurance providers, etc.), not just an isolated activity that is soon forgotten.

Or - maybe not. I may be wrong but this has to be tried and tested. I am sure that with preventive care, as with everything else, there are things that work and others that don't. Generalizations about how "expensive" "preventive care" can be are not helpful. Instead, we should focus on finding out what works and what doesn't.

The question to ask, then, is not "does preventive care save money", the question should be "what can we do to *effectively* promote healthy living and prevent illness?"

Piglet--
How is the person who doesn't get lung cancer going to die? What kinds of injuries and illnesses might he or she need between the time he or she would die but for the intervention and the time he or she will die after he or she decides not to smoke? For this reason, I think you can meaningfully assess the tendency of preventive care to increase or decrease total health spending in and of itself.

RW, please explain yourself. "How is the person who doesn't get lung cancer going to die? What kinds of injuries and illnesses might he or she need between the time he or she would die but for the intervention and the time he or she will die after he or she decides not to smoke?"

We don't know but there is no reason to assume that smokers would have fewer ilnesses than non-smokers *except for lung cancer*. It is more likely that they have at least as many illnesses, probably more, than non-smokers plus some of them also get lung cancer. It is therefore beyond me how anybody could seriously suggest that lung cancer saves money (apart from it being rather cynical). You could make that *cynical* case for not helping accident victims, but certainly not for smoking!

In case that wasn't clear enough, lung cancer patients don't drop dead immediately.

Piglet -- note that I am not arguing that we shouldn't divert health resources to preventive care. I am just saying that we need to anticipate that it will not in and of itself save money and we will need to establish some mechanism to limit costly interventions down the line. We agree that the care we should fund should be evaluated based on "what works" or at least "what works"/cost, and probably agree that preventive care meets this test. I am just saying that we can't add preventive care to the mix and expect to be able to magically afford more of everything else because there will be fewer costly, preventable, interventions.

There is in fact reason to believe that lung cancer sufferers will develop fewer illnesses or at least utilize less health care -- they will not die immediately, but they will die before they use a lot of health care that they would if they had lived longer lives. Most people, moreover, develop chronic ailments, sometimes terminal ones, later in life as a matter of course. There might be kinds of preventable care or preventable illnesses for which this analysis does not hold (cost of preventable illness - average cost of all health care derived from an extra years lived = positive number). But the point is that when most people say preventive care saves money they just mean (cost of preventable illness > cost of intervention).

"they will die before they use a lot of health care that they would if they had lived longer lives. Most people, moreover, develop chronic ailments, sometimes terminal ones, later in life as a matter of course."

I disagree with that line of argument. First, not all lung cancer patients die young, and smoking has other adverse health effects. What you are suggesting - that smokers will use less health resources over their lifetime because they die younger - seems to me an extraordinary claim that would need extraordinary evidence to be credible.

But even if you had that evidence, I would answer that the whole line of argument is absurd. The purpose of (almost) any health care intervention is to prolong life. We measure the success of any intervention by whether it achieves that goal. Your argument amounts to saying that health care cannot be cost effective and sucessful at the same time. Any successful intervention, even if it happened to be cheap, will cause more cost simply by virtue of allowing the patient to live longer. The reasoning here becomes circular. You cannot reasonably make a cost-benefit analysis if you equate any benefit automatically with additional cost. Do you see what I mean?