Healthcare: Prevention efforts can be costly
Preventive healthcare has been touted by politicians as a sure-fire method to slash healthcare costs by saving on future treatment expenses. And it’s easy to believe them -- surely, we reason, it’s better to treat high cholesterol before it turns into a heart attack or catch cancer early on.
Better it may be, but economists present a different picture as far as costs go: Although preventive medicine is certainly desirable, it will not necessarily ease the healthcare budget, they say.
Only 20% of preventive medical measures -- meaning those that take place in the doctor’s office -- actually cut costs, according to a 2008 paper in the New England Journal of Medicine. The remaining 80% of preventive measures cost more than waiting and then providing treatment after a disease has appeared.
“The good news is that there are cost-saving and cost-effective measures,” says study coauthor Joshua T. Cohen, deputy director of the Tufts Center for Evaluation of Value and Risk in Health at the Tufts Medical Center in Boston. “The bad news is that we can’t make generalizations.”
The study, by researchers at Tufts and the Harvard School of Public Health in Boston, looked at 279 studies analyzing the cost-effectiveness of various preventive measures, which economists do by comparing the price tag of procedures to years of healthy life gained from them.
The exact costs vary from study to study, Cohen says. They include medical costs, such as doctor’s fees and lab tests, regardless of who foots the bill. But some analyses may also include secondary costs, such as when a person has to stay home and take care of a sick spouse.
Many measures, while not actually saving money, are still cost-effective in that the health value they provide is worth the extra expenditure. After all, saving money, many would say, is hardly the point. “The goal of healthcare is to make us healthy,” Cohen says.
Still, the hard-dollars data contradict what many Americans believe and what they want more of from their healthcare providers. The U.S. spends 8% to 9% of its healthcare dollars on prevention, according to the Altarum Institute, a nonprofit health research organization headquartered in Ann Arbor, Mich.
Three-quarters of American voters supported increasing spending on preventive care in a poll last May funded by Princeton, N.J.-based philanthropy the Robert Wood Johnson Foundation and the Washington, D.C.-based nonprofit Trust for America’s Health.
Studies do show that some preventive measures cost less when diseases are prevented rather than treated when they appear, making their implementation, at least, a no-brainer.
For example, for men at high risk of heart disease, taking aspirin costs less than the treatment they might need without it. One-time colonoscopies for men in their early 60s is another cost-saver, compared with the price of treatment some would need if their colon cancer wasn’t caught early.
Childhood vaccines bring savings too, according to some studies, but that depends on how you crunch the numbers, says Louise Russell, a research professor at the Institute for Health, Health Care Policy and Aging Research at Rutgers, the State University of New Jersey in New Brunswick.
Vaccine studies typically include non-medical savings, such as the wages of parents who don’t have to miss work to stay home with a sick kid. Other studies don’t. Considering only medical costs, Russell says, many vaccines don’t save money.
In fact, the majority of preventive interventions, according to the Tufts report, do cost society as a whole more money than treatment would -- costs that range from tens of dollars per healthy year gained to $1 million or more.
For example, prescribing cholesterol-busting drugs such as statins is very costly, because not all of the people taking them would go on to have expensive health problems without the medications. In a 2007 paper, Russell estimated that the cost of cholesterol medication ranged from $85,000 to $924,000 per healthy person per year, depending on the population targeted.
Lifestyle changes can cost money too, Russell has found, if the medical community gets involved. For example, a program to prevent diabetes in people at high risk for the condition included personalized diet and exercise plans, consultations with a nutritionist and physical training. The program slashed diabetes rates in half, compared with people who did not participate -- at a cost of $192,000 per healthy year gained.
Other expensive measures, with bills totaling more than $100,000 per healthy year, include left ventricular assist devices for some patients with heart failure, MRIs to detect breast cancer in women with genes that make cancer likely and screening for proteinuria in people who have normal blood pressure and don’t have diabetes.
Though healthcare isn’t just about cost-effectiveness -- it’s meant, after all, to help keep people well -- we don’t have unlimited funds to do that.
“The question that we need to be addressing in healthcare, right now, is how do we stretch the dollar,” says Dr. Steven H. Woolf, a professor of family medicine at Virginia Commonwealth University.
One way to maximize value on the dollar is to focus prevention efforts on the people at the highest risk for disease. For example, authors of a 2004 report in the Annals of Internal Medicine found that screening all 35-year-olds for diabetes costs $130,000 per healthy year, compared with $32,000 to screen only 75-year-olds with hypertension, whose risk for diabetes is much higher.
The frequency of intervention also makes a difference. In her 2007 paper, Russell calculated that Pap smears for cervical cancer screening every three years costs $41,000 per healthy year, compared with no screening. Screening every two years adds $1.3 million to the tab, and annual Pap smears cost an additional $3.3 million per healthy year gained. The cancer is slow-moving, so more frequent screens do not catch many more cases.
In the U.S., healthcare providers don’t often take cost-effectiveness analyses into account, Russell says, and she thinks that is unlikely to change in any upcoming healthcare programs.
What you think about cost-effectiveness depends, of course, on who you are: Insurance providers want the lowest costs; politicians want the happiest constituents. Should these numbers matter when it’s you on the examining table?
“There’s no reason why individuals should take this point of view,” Russell says.
Patients, experts say, should look to their personal and family health histories and the recommendations of their doctors in choosing a plan of preventive care.
