This past year’s health discussion has been remarkable for the narrow range of ideas and opinions that have floated down to the man on the street. Journalists have sought out the same organizations and sources for their stories, offering up what has become the conventional wisdom for reform. To bring more voices into the conversation, our series, Excluded Voices, will intermittently feature health care experts who aren’t on the media’s A-list of sources. This is the fifth entry in the series, which is archived here.) We want to offer journalists more options for their stories and encourage a deeper conversation. To that end, we’ve asked the experts featured in each post to respond to questions from Campaign Desk readers.
Ask any pol or business exec how to lower the cost of medical care, and most will reply “preventive care.” Average Americans apparently agree. A new poll by the Robert Wood Johnson Foundation and Trust for America’s Health found that more than three quarters of Americans believe funding for preventive care should increase. The reasoning goes like this: if you catch illness early, it saves treatment costs in the long run. What can be more straightforward? Problem is, there’s oodles of evidence that prevention costs more than it saves.
Few in the media have cast a skeptical eye on preventive care as a magic wand that will make expensive medical care disappear. More should. To help those wanting to give audiences the complete story on preventive care, Campaign Desk talked to Rutgers research professor Louise Russell, whose work is well known in academic circles but less well known in the popular press.
Trudy Lieberman: What exactly do we mean by preventive care?
Louise Russell: Primary prevention, such as vaccines, completely prevents the disease. Secondary prevention either treats a risk factor for disease or detects disease in an early stage, when it can be treated more effectively. Blood pressure medicines and statins to lower cholesterol and pap smears are good examples. Tertiary prevention means someone already has a disease but wants to prevent further consequences. An example is treating diabetes by controlling blood sugar and blood pressure, and conducting eye exams and foot checks to prevent blindness and amputations.
TL: Do people confuse risk factors with disease?
LR: Sometimes. People often think that if they have high blood pressure or high cholesterol, they have a disease—when, in fact, they are being treated to reduce the risk of diseases associated with those conditions.
TL: Why does prevention seem like such an easy answer to the cost problem?
LR: It just seems so logical, since if you prevent the disease, you avoid the cost of treating it. And people tend to focus on the cost per person, which can look low, not on the aggregate costs of mounting a preventive intervention.
TL: Can you amplify that a bit more?
LR: In order to get the benefit of prevention, you have to treat lots of people, often for a long time, and the cost of that treatment adds up. The cost to treat one person may look small, but the cost for everyone is large. And prevention isn’t perfect. Some people will get the disease in spite of preventive care. Others would not get it even without preventive care. The upshot is many people incur costs for prevention, but only some experience savings.
TL: Can you still go further?
LR: For example, you may have to give prevention, say blood pressure medication, to 100 or 1000 people for years to prevent one death from stroke or heart disease. All of those people incur the costs of prevention, but savings accrue only for the one whose death is prevented. That’s why, most of the time, prevention does not produce savings.
TL: Then it is not a panacea, right?
LR: It’s touted as one, but it is not. In fact, prevention has contributed to our rising medical costs.
TL: Can you give an example?
LR: Statins are widely used for millions of people. They do not save money and are enormously expensive, costing thousands of dollars—in some cases hundreds of thousands of dollars—for every year of life that they save.
But "medical spending" is a vague term.
How do you get a number for the cost of our private insurance system? It's been reported that the U.S. spends far more on administration of healthcare than do Canada and other indistrialized nations.
Don't we need to isolate "cost of administering and operating private insurance" and pull that out of "medical spending"? When a 1- or 2-physician office has to hire 2-3 staff people just to handle insurance claims, including repeat submissions and appeals (not to mention the insurers own staffing, administration, advertising, etc.), each with multiple plans and levels -- I suspect this cost might be a big part of medical spending. How can we isolate the cost of our for-profit medical insurance system?
#1 Posted by SB, CJR on Tue 16 Jun 2009 at 05:19 PM
Interesting interview but both parties are speaking from a strictly one sided viewpoint. Numbers. Neither works in the medical field and this should be made very clear.
Prevention, like solar panels, will save money, save lives and possibly save the planet, it just wont do it, on an epidemilogical scale in the near future, certainly not in the short attention spans of those studies quoted.
Any cardiologist will tell you that they rush in to the ER or cath lab so much less often for the mid night heart attack today than when they were in training a short 10 years ago, ditto for diabetic coma, status asmaticus, full blown eclampsia, ARDS and many other preventible emergencies. Thes are generic examples and in each case the admission and weeks of hospital in intensive care would have cost hundreds of thousands of dollars. Cost savings up front!! These are only a few examples of daily events prevented around the world that dont enter those studies. Where I agree with the professor is that the extant system of prevention is subject to much misuse, over use and mostly inappropriate use. Any criticism of preventive care should include a recognition of why prevention gets so expensive, the greed and malfeasance of the Health In dustry, Big Phrma with DTCA, careless media (in a great hurry to make copy with the latest miracle drug) and unscrupulous doctors. Anything less is indeed throwing out swimming pool when all you need is to remove a few floating leaves and a good vacuuum.
#2 Posted by Dr Wilbur larch, CJR on Tue 16 Jun 2009 at 10:28 PM
To SB: "Medical spending" means the goods and services valued in the National Health Expenditure Accounts, which are produced by the US Department of Health and Human Services. Their estimates have been the definitive information on how much the US spends on medical care for more than 50 years and can be found at http://www.cms.hhs.gov/nationalhealthexpenddata/. The administrative costs of our system are a fair point, but not an issue on which I have any special expertise .
Dr. Larch may be thinking of 'business case' analyses when he refers to the "short attention spans" of studies. He will be glad to know that cost-effectiveness analyses (CEAs), on which I base my conclusions, estimate costs and savings over the lifetimes of a cohort of patients, from the beginning of a preventive intervention until all the patients have died, often a span of 60-80 years or more.
CEAs do count those hundreds of thousands of dollars of savings, but they also count the drip-drip-drip of the millions of doctors' visits, millions of prescriptions, millions of monitoring tests, and whatever else is necessary to prevent disease. Added up, those individually-small costs are greater than than the more impressive savings for some patients.
And the savings don't come up front. They can't. Prevention has to start years before the person would develop heart disease. It would be nice if it could start the day before that expensive admission and prevent it then, but we're not there yet.
#3 Posted by Louise Russell, CJR on Wed 17 Jun 2009 at 12:50 PM
It's "preventive," not "prevenative."
You can take the copy editor out of the newsroom, but he stays a copy editor forever.
#4 Posted by Stephen G. Esrati, CJR on Wed 17 Jun 2009 at 01:48 PM
Societal health care costs are typically calculated as a percentage - 100 x health care costs/GDP. Some preventable illnesses not only incur medical expenses but also contribute to a loss of productivity, and thus presumably reduce GDP to some discernible extent. To what extent would many elements of preventive care that increase costs in absolute terms reduce them in relative terms by amplifying the denominator of the fraction more than the numerator?
#5 Posted by Fred Moolten, CJR on Wed 17 Jun 2009 at 09:06 PM
Although the concept of disease causation ergo prevention is ancient, prevention as an epidemiologic stratergy is not. I am curious as to what proven preventive approach has been studied over a 60 to 80 year period (Prof Russell). To the lay reader all they need to do is to follow the various battles of the last few U.S. Surgeons General nearly all embraced their own favourite prevention of the day. Tobacco, Obesity, HIV, lack of Exercise etc. Keep in mind that prevention is a cornerstone of Public Health and clinical medicine, which, whether cost analysis approves or not, has always worked.
Prevention in medicine as a universal medical concept has to be effective, cheap, widely applicable and acceptable to the public (from an old medical text book), the same with screening (if you talk of secondary prevention). I dont believe that this has been tested and shown to be cost ineffective.
What passes for prevention today and over the last decade or two are myriad add-on, me- too, wanna be, unproven or half proven stratergies which I think have contaminated the data. I will mention some examples, keep in mind the usual suspects (perpetrators) I listed in my previous note.
A colonoscopy showing a large polyp (>1 cm) done in a person over 50 with a family history of colon cancer (first degree family) will prevent colon cancer, hospitalizations, surgery, chemo etc, cost of colonoscopy $200, but in the last 10 years the gastroenterologist found it less of a bother if he got an anesthesiologist to join in and do it under anesthesia, do it on every one once they cross 50, and repeat every few years, cost goes up to a recurring $200 +$600 and a low yield of people with the cancer (this is not medicine, its business).
Other examples are Gov Rick Perry trying to make HPV vaccine mandatory, doing stress tests, Holter monitors, and cardiac MRI's with no indication or the doctor owns the technology, carotid Dopplers in people without a stroke history, testing Vitamin D levels and indiscriminate Bone Scans, CT angiogram of the heart in low risk patients (egged on by a Dr. Gupta specials on CNN).
The same thing for prescribing expensive name brand Statins and blood pressure drugs, this is more drug rep than evidence based. Even if the JNC VII / WHO ISH and NCEP II Guidelines say so, remember the panels are replete with the Industry point men and women.
As the French General said of the Charge of the Light brigade, C'est magnifique, mais ce n'est pas la guerre." ("It is magnificent, but it is not war.") this is the buiness end of medicine, a commodified entrepreneurial abuse, it is not a failure of preventive medicine.
#6 Posted by wilbur larch, CJR on Thu 18 Jun 2009 at 12:23 AM
Louise Russell, thank you for the clarification on "medical spending."
#7 Posted by SB, CJR on Thu 18 Jun 2009 at 11:17 AM
As a followup to my brief comment yesterday, the link that follows is to an analysis that emphasizes the significant savings potentially available from effective preventive strategies aimed at common chronic illnesses - savings exceeding $1 trillion in the costs of lost productivity annually:
http://www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20080604milken-report.html
If the link doesn't work, the article is from AAFP and is entitled "Chronic Diseases Spark Dramatic Increases in Treatment Costs While Lowering Productivity, Study Says".
As I suggested yesterday, the typical means of calculating health care costs is not in absolute dollar terms, but as a percentage of GDP. This makes sense, because what is most important is how we allocate society's total capital among competing demands. Lost productivity increases costs calculated by this method by reducing GDP (the denominator), and if prevention is implemented wisely rather than wastefully, the productivity savings could substantially reduce health care costs in the sense of the term that most affects our economy.
#8 Posted by Fred Moolten, CJR on Thu 18 Jun 2009 at 09:48 PM
I've always calculated the cost of our current for-profit system at 22% of current health care costs (the 31% that we use for the insurance bureaucracy LESS the 9% that I think a single payer system would cost). Both numbers include billing staff at hospitals and clinics. We also say that a pure Medicare-for-all system would save $400 billion per year. Could that all be the elimination of the insurance industry?
#9 Posted by Jack Lohman, CJR on Thu 23 Jul 2009 at 07:47 PM
In response to Fred Moolten's point, it is important to remember that effective treatment also boosts productivity. The argument that prevention or treatment can make us more productive is true, but does not solve our cost problem. We do lots more of both now than we did 50 years ago, when we spent about 5 percent of GDP on medical care. Today we spend more than 16 percent.
#10 Posted by Louise Russell, CJR on Fri 4 Sep 2009 at 12:01 PM
If you want to buy a house, you will have to receive the business loans. Moreover, my sister always takes a term loan, which is really useful.
#11 Posted by IMOGENE23Ballard, CJR on Thu 15 Sep 2011 at 10:01 AM