Last week I suggested that the road to improving health may be to keep people basically “in good health” for longer, and that one way to do this might be increased focus on preventive care through early- and late- middle age. However, it is a stretch to go from “preventive care improves health” to “preventive care reduces the cost of health care.” And, the latter point is one that more often comes up in the context of health reform.
The logic behind preventive care is straightforward. By increasing screening you identify diseases at an earlier stage. And, if diseases are identified before they become serious, they can be treated and/or managed at a lower overall cost than if the diseases are identified only later once they do become serious.
Sounds good. So, what’s the problem? The problem is that screening costs money. And, you will screen many, many people in order to identify a small number who can benefit from early treatment. Even though screening is relatively cheap, and the benefits for the small number of people are large, the sheer number of screens that must be done to convey this benefit to a small number of people can often make early screening for a population very costly relative to the benefit derived from it.
This leaves several possibilities with regard to preventive care. One: the preventive measure lowers overall cost. Two: the preventive measure increases cost, but the medical benefits associated with it justify the increased cost. Three: the preventive measure increases overall cost without commensurate medical benefits. There is widespread agreement that we should adopt measures of the first kind and avoid measures of the third kind. In the frenzy to reduce the overall cost of the health care system, measures of the second kind are often overlooked. If, compared to how we currently spend medical dollars, a particular treatment (whether it is preventive or not) has a ratio of health benefit to cost that is significantly larger than typical treatments in our current arsenal, then we should do more of the new treatment and less of the current ones. Although we are understandably reluctant to increase the cost of care, the necessity of improving the quality of our health care implies that we should make changes of this sort whenever we identify them.
Enter a 2008 study entitled “Does Preventive Care Save Mondy? Health Economics and the Presidential Candidates,” by Joshua Cohen, Peter Neumann and Milton Weinstein that appeared in the New England Journal of Medicine that looks at the costs and benefits of preventive care. The study finds that, in general, blanket statements about how preventive care can reduce cost are not justified. Taken as a whole, there is a distribution of cost/effectiveness ratios for preventive care that looks a lot like the distribution of treatments for existing conditions. In other words, preventive care in general is not superior to waiting for conditions to emerge and treating them only then.
While preventive care in general does not appear to be cost-saving, some particular treatments, such as flu vaccinations for toddlers and colonoscopies for men aged 60 – 64 do appear to reduce overall costs. Other preventive measures, such as screening newborns for certain enzyme deficiencies and high-intensity programs to prevent former smokers from relapsing, have very high cost/effectiveness ratios (i.e., they are the second type of program above) and should probably be encouraged.
So, can preventive care save our health care system? The short answer is no. In a letter in response to an inquiry by the House Subcommittee on Health, the Congressional Budget Office argues that, “for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.” A particularly compelling example is the following:
[A] recent study conducted by researchers from the American Diabetes Association, the American Heart Association, and the American Cancer Society estimated the effects of achieving widespread use of several highly recommended preventive measures aimed at cardiovascular disease—such as monitoring blood pressure levels for diabetics and cholesterol levels for individuals at high risk of heart disease and using medications to reduce those levels.4 The researchers found that those steps would substantially reduce the projected number of heart attacks and strokes that occurred but would also increase total spending on medical care because the ultimate savings would offset only about 10 percent of the costs of the preventive services, on average. Of particular note, that study sought to capture both the costs and benefits of providing preventive care over a 30-year period.
So much for the silver bullet.